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experience of that clinic. She told me after the surgery severe burning pain started in her wound area. In the next day, around the 10 am, Salma begum and others who were admitted to the clinic were told, to leave the place at that time and requested to go to the roof of the clinic. When the patients and their relatives asked to the authorities about the reason they said, there was a little problem so they might leave that place. The surgery patients went up to the stairs of the roof with the help of their relatives with great difficulty, very slowly and much carefully. Later, they learned that the doctors at this clinic were allowed to see patients but not the authorized legislation to admit them, allowed to do medical surgery and operation (OT). At that time, the senior police officer came to visit the clinic and soon they are asked to leave the place. Salma begum's eyes filled with tears and she sobbing and said to me, "I have claimed the stairs on the roof with my wounded abdomen very difficult. My surgery was not done with experienced hand. I have a problem on my forehead. If I had known it before, I would not go there, done my operation by this unskilled hand." Though it was 25 days have passed since the surgery was taking and she had taken medicine properly but no changed was observed. She was broken hurt mentally. (Baer et al, 2003, p.30) --- Biomedical Error and Technical Mistakes Biomedicine is greatly relied on science and modern technology at the time of diagnosis (Woolf et al, 1999). Error may occur, all kinds of care process from diagnosis to administration of medicine. Medication error also found in clinical environments that may lead unnecessary diagnosis, various test, prolonged hospitalization and even death (Kozer et al, 2006, Paul et al, 2014). It is often observed that biomedicine gives some false report that affects women health in the studied area. Rural women sometimes, face health risks due to the mechanical failure of biomedicine. I have a female informant who is 48 years old. She was a direct victim of the mechanical failure of biomedicine. She is a patient of high blood pressure and diabetes. That is why; she often goes to the doctor's chamber to check her diabetes and blood pressure because her diabetes and blood pressure are not under control. One day after measuring her diabetes, the doctor gave her anti-diabetic medication because it has risen again. She felt physically weak for 3 days after taking that medicine. Later when she went to the doctor again, the doctor said that since the machine was technically error yesterday, so the diabetes point was not measured correctly. Then, the doctor asked to take new medicine after measuring diabetes with a new machine. After taking that medicine she felt better. Another informant of mine, who is 40 years old, told me that during an operation (OT) in a clinic in Baganchra Bazar, the patient regained consciousness. At one point the patient started screaming. It happened because the doctor could not give the anesthetic medicine to the patient properly. I spoke to a nurse at the clinic to find out more about this. "The patient was not properly anesthetized that day because the anesthetist was not present on the operation table," she told me, withholding her name and identity. As a result, the woman regained consciousness during the tumor operation. --- Mistakes in Ultrasound Report: Hastened the Killing of Fetus Very intrinsically, women in our country are eager to know whether the baby in the womb is a baby boy or a baby girl. Ultrasound is a blessing of modern science and widely accepted accurate medical technique to access pregnancy. It also identifies various specific conditions, such as: age of fetus, possible miscarriage, number of fetuses, baby movement, fetal growth, sex identification etc. The observed village women who are pregnant know about their unborn children taking the blessings of biomedicine that introduced themselves to the new technology called as ultrasound which informs about their desired subject. --- Case Study The women, 41 years old, Rahima Sultana have 4 daughters and she had also pregnant for the fifth time then. She was much anxious about her unborn baby and went to a private clinic in the nearest bazaar, to identify the sex quality of fetus receiving the ultrasound technology of biomedicine. Observing the report, the physician assumed that, she would not have a baby boy but a girl. Rahima's husband said her, "If she had a daughter this time, he would divorce her." Finally, she consulted with the physician and decided to have an abortion very secretly. Then she convinced doctor very difficult and finally received an injection of abortion from the local health care. The next day, she gave birth to a stillborn son. It was a great tragedy, for herself when she realized that it was a baby boy. She told me, "I cannot tolerate my pain and sorrow as I am a mother whether it was a boy or a girl. I got itself in my womb, but my family urged me to do this abortion." (Fieldwork, 2017) Only because of her socio-economic facts and her family condition aroused herself to do it. Also due to technical error in ultrasound report, her life was at stake. She felt very weak due to heavy flow of blood for abortion. Besides she could not accept the grief the losing of her child. Besides, due to the terrible mistakes of biomedical treatment her family members told many bad comments to her. --- Biomedicine is Preventive, Less Curative According to Alison Gray, "biomedicine has failed to effectively control some disease like tuberculosis (TB), cancer and also unable to deals with social problem that causes the disease (Gray, 1996). Doctors prescribe different medicine but ultimately, the ailments of patients are not cured. A young girl, Ashura Khatun, the key informant of this research had been suffering from chronic cough and sour throat for long time. She went to the government hospital and receiving treatment from biomedical doctor and her condition was not changed. Then she goes to a private clinic of local market and got a checkup after costing about 1200Tk. But she did not get cure. After that, on the advice of her father, she took medicine from a homeopathy doctor and about 20 days later, she recovered completely. She told me that Homeopathy treatment and its medicine kill germ forever but the in the cases of allopathy, (biomedicine) when the medicine is taken to be stopped the cough returns because it cannot exhaust the germ of cough forever. This comment is simply similar to critical medical anthropological thought that claims that it is not always right that only the biomedicine is useful but alternative medicine and ethnomedicine are also beneficial, as the efficacy are multidimensional. (Ember and Ember, 2004) --- Generational Differences of Taking biomedicine A generational gap and some differences are observed in women of the researched area for the practice and acceptance of biomedicine to them. While biomedicine has become more acceptable to the younger generation of women, it has not become much popularity to the older women. Perhaps, the elder people (58-78 years old, especially women) do not like to seek treatment from biomedical doctors, unless the disease is serious. They realize, if one goes to the allopathy doctor, he/she must have to go. But the disease is cured before repeated visit to the homeopathy specialist. There are effective treatments available at low cost. But the costs of biomedicine are so high. The older women consider the caesarean delivery of a young woman is an unnecessary waste of money. The Local hospital and clinics are full of male doctors and they dominate the knowledge of biomedicine. There are only one, two and some fewer female doctors. So, the elder women express their reluctance to hospital treatment system. They are afraid of lost their veil and worry about sacred and sin as they motivated their life style according to Islam. Purda has not only an aspect of Muslim life, but it has become an essential acceptable part of social and cultural life. The Non-Muslim older women also show aversion to take treatment from male doctors. The social and religious practices of purda are more observable among the elders rather than Youngers. They do not like the intervention of technologies and male doctors on their body, again and again. In this regard, the critical medical anthropologist M. Lock properly said, "Medicalization is a patriarchal process in which, the intervention of technologies and trained male doctors are observed over the female body. (Ember & Ember, 2004, p.118). --- The Exercise of Political Power in Hospital and Clinics The internal environment of the hospital and clinics are not free from the influence of external political power, the political leader and the economically powerful individuals enjoy especial privilege in local hospital and clinics for their power. On the other hand, the politically and economically disadvantages patients struggle to get a seat, even in emergency, in local hospital and clinics. Other time, giving some money or baksheesh to hospital staff, one can get a seat. As a result, the sick women face health risk at the time of emergency. Three beds were occupied by politically and economically powerful male. Though he had one patient but he occupied more because he will stay there with his family members. On the other hand, the sick, young girl who belonged to middle class family, broken her leg in a sudden accident did not get any seat though she was writhing in pain. Later she was laid on a mat in the floor. This case is similar to critical medical anthropological perspective (CMA) that depicts how spacious political relationship affecting individual health (Baer et al, 2003, p.27) Case Study 22 years old woman had a tumor surgery about 5 days ago and she needed 8 stitches in her abdomen. The assistant doctor was dressing her wounded area and she was mourning loudly. Two nurses were standing herself, hold her two hands and she could not move. The professor doctor kept scolding to her because she was crying. She had a lot of pain due to infection in wound. In the bed, she had completed her natural work. Most of the time, she was in tensed that when she will be able to recover, to walk normally, and there were many questions in her head (Fieldwork, 2017). When the women body undergoes biomedical treatment for a disease, they are subjugated to biomedical knowledge, technology not once but repeatedly. Drugging in women's body, injecting them and undergoing surgery are the expression of biopower of biomedicine. --- Conclusion Biomedicine is an effective treatment system as it immediately protects human health from acute manifestation of disease. Most of the cases, it is considered as lifesaving medical care. The observed women, in researched area face various problems and challenges to take this lifesaving active medicine and medical care. Beside the local nature of biomedicine and biomedical care have some rigid and inflexible aspects; those are impacted on women health. If it were possible to reduce the additional cost of biomedicine, unequal relationship between doctors and patients, the absence of doctors in hospital, clinics and other complication like the baksheesh, socio-political aspect etc, then the women did not have to face the health risk. They could properly enter the practice of biomedicine. Even it is also important for biomedical practitioners to full concentrate on patient's experiences of sickness that will improve doctor-patient's relationship. At the time of diagnosis, doctors should emphasis not only on biology, pathology, science, medical knowledge and technology, but also on patient's mind. It will bear more fruitful result in biomedicine and biomedical treatment system.

Medical anthropology, an interdisciplinary subfield of mainstream anthropology, has become the most popular and potential knowledge that receiving its brawny figure at present world. Biomedicine, a strong concept of medical anthropology includes: the scientific medicine, allopathy medicine, modern medicine and the regular medicine that basically focuses on human biology, pathophysiology, western knowledge and modern technology. It has become globally dominant during this century and wellpracticed in developed, developing and less developed countries. This study has explored, what are the local nature, practice and perception of western biomedicine in rural area of Bangladesh. This research paper systematically searches, what type of challenges have to face by the rural women to get access to biomedicine or modern medical service in local hospital and clinics. What a modern technology and scientific knowledge-based treatment system impacted on rural women's biological and mental health, this paper explores that. Applying Critical Medical Anthropology (CMA) Perspective, this paper has sorted out to identify the socio-cultural and political-economic aspects of biomedicine and what are the impacts of biomedicine on rural women health. What kinds of health problems, rural women are facing and what are the ultimate result of it as practicing biomedicine that will be analyzed here. Using Critical Medical Anthropology (CMA) this study has analyzed the power relation that is found in biomedicine and biomedical health seeking in local hospital and clinics that has become the primary area of social control. This article is a written interpretation of an anthropological fieldwork that was done in 2017, in Kaiba village at Sharsha Upazilla of Jashore district of Bangladesh.

Introduction Places of worship (POW) broadly refer to locations where people gather to practice some type of religion, such as Christianity, Hinduism, Islam, and Judaism, to name a few. In addition to religious socialization, research has shown that POW are important because they tend to facilitate social ties, mutual cohesion and trust, and a willingness to intervene for the common good [1][2][3][4][5], which In turn, can be used instrumentally to achieve a collective goal, namely minimizing crime in neighborhoods. The key implication is that social capital that originates within POW extends to other settings in the larger community [6][7][8][9], ultimately strengthening informal social control mechanisms, such as the dissemination of information, mobilization of resources, or an informal system of monitoring public spaces. This suggests that places of worship should have a crime-reducing association in neighborhoods [6,7,9,10], even after controlling for a range of factors known to be associated with aggregate crime outcomes. Although there are many reasons to expect places of worship (POW) will reduce the amount of crime in neighborhoods [6,7,9], there is a dearth of empirical work to assess this proposition [7,11]. A principal reason for this mismatch between theory and data is that geospatial information on churches is generally lacking [7,11]. Because POW have tax-exempt status, they are not compelled to report to the Internal Revenue Service (IRS) or most municipalities, thereby it is a bedeviling challenge for researchers to accurately capture POW aggregated to microgeographic units. For example, even the National Center for Charitable Statistics (NCCS) does not have a directory or listing of all POW located across the United States (U.S.) [11]. Data issues aside, the few studies to have analyzed the effects of POW have provided weak evidence of their crime-reducing behavior [6,7,9,12]. This raises the possibility that POW might signify an unintended consequence for neighborhood crime control. The crime and place literature has established the crime tends to spatially concentrate at or near risky facilities, including bars, liquor stores, check-cashing stores, retail outlets, restaurants, schools, and more [13][14][15][16][17]. This is because such facilities generally provide an opportunity structure for crime, that is, there is a tendency for motivated offenders and suitable targets to converge in space and time alongside weak guardianship [18][19][20]. More specifically, these facilities have deleterious effects because they operate as crime generators [19,21]. The latter is a foundational concept of environmental criminology and refers to the following: "particular areas to which large number of people are attracted for reasons unrelated to any particular level of criminal motivation they might have or to any particular crime they might end up committing [19:7]." Thus, the concept of a crime generator is predicated on high foot traffic (or what is referred to as a large ambient population) operating alongside emerging criminal opportunities. The implication is that potential offenders are not traveling to these areas with the specific intent to commit crime [18,19]. Rather, potential offenders will recognize situations in which there is a weakly guarded target, while going about their routine activities, and seize these opportunities to commit crime [13,19,20]. Analogous to how schools, restaurants, and retail stores have been linked to more crime in place [13,17,22,23], we propose that POW might unintentionally lead to neighborhood crime problems, mainly because of their ability to induce high foot traffic, which offers an abundance of targets, while at the same time undermining guardianship and social control capabilities [24,25]. There are competing expectations for how places of worship might impact crime in place. On the one hand, the literature rooted in social capital suggests that POW are crime-reducing because they engender social ties, common values and goals, and a responsibility for the collective good [1,3,4]. Conversely, POW might unintentionally be associated with more crime because they produce high foot traffic and undermine guardianship and social control capabilities, consistent with the environmental criminology literature [18,19]. Despite these competing expectations, there are few studies to empirically assess the POW-crime nexus in neighborhoods. Therefore, for the present study, we conduct a block group analysis of crime, places of worship, well-established criminogenic facilities, and sociodemographic characteristics in Washington, DC. --- POW and social capital A voluminous body of literature highlights how local institutions facilitate networks of effective social action in terms of crime control [7,11,[26][27][28]. Places of worship (POW) specifically have been argued to strengthen dimensions of social capital such as social ties, mutual cohesion and trust, and a willingness to intervene for the common good because of sponsored events and activities [2][3][4]. Consequently, POW can produce two types of social capital: 1) Bonding social capital builds intraneighborhood cohesion and social ties among adherents and residents, while 2) bridging social capital establishes interneighborhood cohesion and social ties among local institutions, municipal agencies, and other groups of people [4,8]. Both bonding and bridging social capital are theorized to strengthen neighborhoods' capacity for collective action against crime problems. So, when neighborhoods exhibit relatively higher levels of social capital (as a result of POW), there is a greater likelihood that residents and adherents will acknowledge crime problems, will achieve consensus on how to address these problems, and will solve the problems in a more collective fashion [2,4,8]. This leads to our first proposition: P1. Places of worship will be associated with lower counts of both violent and property crime, controlling for a range of factors known to be associated with crime in neighborhoods. The seminal work of Robert Putnam [4,29] posits that successful outcomes (in terms of education, health, crime control, family structure, etc.) are more likely in communities with high social capital, with local institutions like churches being the catalyst for the latter. Putnam's [4] analysis indeed reveals a negative effect of local institutions on crime in U.S. counties. Similarly, Lee (10) constructs an index of civic engagement, which includes an indicator of congregations, and finds that this index is negatively associated with crime in rural U.S. counties. In one of the more comprehensive examinations linking POW to crime in place, Beyerlein and Hipp (8) determine that three POW measures are largely associated with lower levels of murder, burglary, assault, and robbery in U.S. counties. Yet despite this evidence in support of proposition 1, there is also evidence to the contrary. For instance, one study failed to determine that POW are related to lower violent and property crime in New York (NY) block groups [7]. This study also failed to detect any conditional effects of their POW measure. Also, another study found that three church measures (i.e., church presence, total churches, and churches within 500 ft) had nonsignificant effects on informal social control in Louisville and Lexington (KY) block groups [9]. --- POW and criminal opportunities Environmental criminology has argued and shown that crime is spatially concentrated in neighborhoods with a high density of nonresidential activities [30][31][32]. More specifically, activity nodes refer to locations where people spend a significant amount of time conducting nonresidential routine activities (e.g., work, school, grocery, recreation, shopping, etc.), while pathways are features of the planned physical environment that connect activity nodes with one another (e.g., a road network, monorail or train system, bus lines, walking trails, etc.). Neighborhoods with a higher concentration of nodes and pathways have indeed been shown to have a disproportionate amount of crime [13,16,31] and this is because nodes and pathways yield overlapping activity and awareness spaces of large numbers of people-a recipe for crime problems [18][19][20]. Environmental criminologists have increasingly used the term crime generator, an extension of the activity node concept, to denote physical structural qualities of neighborhoods that breed crime as a result of foot traffic and anonymity specifically [13,16,33]. Stores, restaurants, and schools commonly operate as crime generators because of their ability to increase the volume of targets and undermine guardianship capabilities, that is, the ability to informally monitor and regulate public spaces [16, 17, 22-24, 34, 35]. Offenders do not travel to these locations with the specific intent to commit crime [19], rather, the key implication is that amid high foot traffic, a potential offender will notice a weakly guarded target (person or object) and seize the opportunity to commit crime. Given that foot traffic is a defining characteristic of crime generators, we argue that POW might operate in the latter capacity. In addition to religious meetings and services that occur on a weekly basis, many POW have a mission statement that involves the provision of need-based social services to its members, as well as less fortunate people in the larger community. These services include shelter and housing, food/soup kitchens, therapy and counseling, and job procurement and training [7,9,12]. When POW are effective in improving the social circumstances of people, these people may be less inclined to resort to criminal behavior [7,11], yet this remains an open question. On the other hand, high foot traffic because of the provision of need-based services will almost certainly induce criminal opportunities [6]. Analogous to how a shopping mall not only provides positive services and economic benefits but also provides criminal opportunities by increasing the presence of both potential offenders and targets [22], a place of worship has the ability to increase the number of potential offenders and targets in a neighborhood simply through the increased foot traffic (or ambient population) that results. We therefore evaluate a second proposition: P2. Places of worship will be associated with higher counts of both violent and property crime, controlling for a range of factors known to be associated with crime in neighborhoods. Two studies reveal that places of worship might unintentionally lead to crime problems in neighborhoods. Triplett, White (6) determine that neighborhood variation in street crimes and domestic assaults, respectively, are positively associated with the number of churches in Norfolk (VA) block groups. Desmond, Kikuchi (12) examine how different types of religious congregations are linked to crime in Indianapolis (IN) block groups. The authors determine that their congregation measures mainly have nonsignificant effects on violence whereas for property crime, most of these measures yield significant positive effects. Conversely, there are no instances in which the density of congregations shows a crime-reducing association (except for civically engaged organizations). However, both these studies do not control for the presence of well-established criminogenic facilities (e.g., bars, liquor stores, check-cashing stores, retail outlets), and therefore the observed criminogenic effects of POW might be attributed to the latter facilities. In the sections that follow, we explain our data and analytic strategy used to test our propositions (i.e., P1 and P2). After reporting the findings, we provide a discussion of the implications for criminological theory, urban studies, public policy, and future research. --- Data and methods --- Study area The study area is Washington, DC, the Capital of the United States. DC is an urban area with 670,050 persons according to the most recent estimate by the United States Census Bureau (https://www.census.gov/quickfacts/fact/table/DC,US/PST045221). It follows that DC is one of the most populous areas within the United States, specifically, ranking 23 rd among U.S. cities. DC also has an ethnically diverse population; 37.3% of residents self-identify as white, 45.8% as Black, 11.5% as Latino, and 4.5% as Asian. Although the median household income is significantly more than the national average ($90,842 versus $64,994), such disparity is explained by DC's high cost of living, and therefore it is not surprising to observe that DC's poverty rate exceeds that of the national average (16.5% versus 11.6%). Washington, DC, offers a favorable setting for examining the effects of places of worship (POW) on crime in place for several reasons. First, DC has recently (and historically) exhibited rather high levels of both violent and property crime among the 100 most populous U.S. cities. In 2019, for example, DC ranked 24 th and 29 th in violent and property crime rates, respectively (https://www.fbi.gov/how-we-can-help-you/need-an-fbi-service-or-more-information/ucr/ publications). Therefore, there is a need to determine the factors that affect the spatial distribution of crime problems in DC. This leads to a second reason: Washington, DC, has a large presence of facilities (e.g., alcohol stores, retail districts/centers, check-cashing stores, and metro stations) which have been theorized or shown to be associated with more crime in place [13,16,19]. The presence of various criminogenic facilities has been provided through DC's open data portal (https://opendata.dc.gov/), and therefore this provides the necessary means to minimize the possibility of obtaining spurious effects of our key independent variable (i.e., places of worship) on crime. Furthermore, DC has a large presence of POW (N = 742) with the corresponding longitude (x) latitude (y) data made publicly available through the portal. Notably, previous researchers have documented the many challenges of collecting geospatial data on POW [7,11,26,36]; most notably, there is not a census of POW in the U.S. because most of them are tax-exempt and therefore they are not accurately captured by data provided by the National Center for Charitable Statistics (NCCS). By using DC data on POW in combination with their large presence, it affords us the flexibility to test for a multitude of main and moderating effects. --- Units of analysis and sample The U.S. Census Bureau provides data on various geographic/spatial units. We draw on block groups specifically to link places of worship to crime in place, primarily because block groups have been designed to be homogenous on a range of sociodemographic characteristics, including income and poverty, educational attainment, household structure, age, and length of residence [37,38]. Thus, our selection of block groups as our units of analysis is consistent with previous empirical work that has examined "neighborhood effects" on a range of outcomes, such as ethnic and racial segregation [e.g. 39], social networks [e.g. 40], walkability and health [41], gentrification [e.g. 42], and crime [43], to name a few. The present study involves secondary data analysis of block groups from publicly existing data, and therefore did not require institutional review board approval. For our analysis, we estimate crime models using a sample of 449 block groups (out of the 450 in DC); one block group has been dropped because it is missing necessary information from the U.S. Census American Community Survey (ACS). We cannot use constituent tract information as a substitute for missing block group information, because for this block group, the tract and block group boundaries are exactly the same. We suspect missing data for some variables is attributed to the fact that this area largely encompasses Georgetown University and its affiliated facilities. --- Dependent variables: Crime counts We have collected crime data from DC's open data portal. These are official crime data coded and reported by the District of Columbia Metropolitan Police Department (MPD). MPD has provided crucial information on each crime incident from 2021, including the longitude-latitude coordinates of the crime, the date in which the crime occurred, and the type of Part 1 crime committed according to the Uniform Crime Reporting (UCR) program in the United States. Accordingly, we aggregated these data to their constituent block group and computed the number of incidents for the following crime types: murders, robberies, aggravated assaults with a gun, burglaries, larcenies, and motor vehicle thefts. Furthermore, we created an index of violent crimes (combining murders, robberies, and assaults) along with an index of property crimes (combining burglaries, larcenies, and motor thefts). Notably, our main models utilize the latter two indices as outcome measures, whereas some of the ancillary models assess each of the crime types (separately) that comprise both indices. --- Independent variables: Places of worship, criminogenic facilities, and sociodemographic characteristics DC's open data portal provides information on places of worship in 2019, most notably, the longitude-latitude coordinates of each POW. We identified 742 POW in the dataset after eliminating 32 cases with coordinates outside of the study area or with duplicate coordinates. Although some prior studies have theorized that the effects of POW differ by the religion or denomination of POW [8,9,44], DC only classifies its POW by seven religions, of which 97% of them are determined to be Christian. Denomination information was not provided for places of worship. We also determined that the name of POW was not sufficient for accurately classifying POW into denominations. Thus, we have created an index of the number of all places of worship, aggregated to block groups. One of the most enduring correlates of spatial crime patterns is the presence of facilities that provide an opportunity structure for offenders, targets, and weak guardianship to converge in space and time [18,19]. Accordingly, we constructed several variables to capture such facilities. These facilities include the number of onsite alcohol outlets (i.e., bars, night clubs, and taverns), offsite alcohol outlets (i.e., liquor stores and convenience stores), check-cashing stores, and retail districts/centers (e.g., shopping malls and plazas). We also include a dichotomous variable for the presence of a DC metro station (1 = Yes and 0 = No). It is also necessary to control for sociodemographic characteristics that have been linked to the spatial distribution of crime [25,[45][46][47]. Drawing on data from the U.S. Census Bureau we create measures of various sociodemographic characteristics. In particular, we utilize the American Community Survey (ACS) five-year estimates from 2015 to 2019, aggregated to block groups. To capture differences in economic hardship, we account for poverty (%) in block groups. We computed a Herfindahl index of five ethnic groups (white, Black, Latino, Asian, and other races) to account for the ethnic heterogeneity of block groups. The concentration of both Black (%) and Latino (%) residents are also included to account for populations that have been historically marginalized by the political economy of place [48]. Furthermore, we employ a variable of homeowners (%) as a proxy for residential stability and we control for two types of housing characteristics: the number of housing units (/100) and occupied units (%). Finally, we created a variable of the population (/100) along with a variable that specifically captures the age group with the highest rate of offending and victimization, that is, persons aged 15 to 29 (%). Descriptive statistics for all measures are shown in Table 1. --- Analytic strategy The dependent variables of crime counts are significantly skewed and overdispersed (i.e., the variance exceeds the mean). Thus, we analyze the spatial distribution of crime using negative binomial regression in Stata 17; a Poisson-based regression that effectively accounts for overdispersion via its alpha parameter [49,50]. While the Poisson distribution can be appropriately used to model certain count variables, for the present study, we find that Stata's likelihoodratio test, which tests the null hypothesis that the dispersion parameter (alpha) is equal to zero, is significant for all our models (p <unk> 0.05). Negative binomial regression is therefore needed to account for overdispersion [49,50]. Yet at the same time, we acknowledge that ordinary least squares regression (OLS) is a viable alternative for modeling the spatial distribution of crime, especially given that a large majority of block groups do not have zero crime incidents, and therefore we have estimated ancillary models using OLS. To be clear, we are concerned with using the appropriate model(s) to analyze the spatial distribution of crime, however, it should be noted that negative binomial and OLS regression models are not representative of spatial regression. Therefore, we estimate ancillary spatial error models as a final robustness check (described in more detail below). Geographic units such as block groups are not islands unto themselves [51], in fact, the conditions of spatially contiguous/adjacent units can very well shape what occurs in the focal unit -what is often referred to as a spillover effect. What this means for the current study is that crime in the focal block group is likely impacted by the amount of crime in nearby block groups [52][53][54]. To account for this spatial dependence, we constructed a spatially lagged measure for each crime outcome using GeoDa software with first-order queen contiguity. Such a measure captures the average number of crime incidents among contiguous block groups in relation to the focal block group. We include a spatially lagged measure of crime (as a predictor) in our full models. A general expression of the (full) negative binomial regression models that we estimate is as follows: y 1<unk>4 B 1 POW <unk> B 2 SD <unk> B 3 CF <unk> B 4 SLy <unk> a;<unk>1<unk> where y is the number of crime incidents, POW is the number of places of worship, SD is a matrix of the sociodemographic characteristic measures, CF is a matrix of the criminogenic facility measures, SLy is the average number of crime incidents in block groups adjacent to the focal block group (a spatially lagged measure), and <unk> is an intercept. While one approach for modeling crime across geographic units is to specify the population count as an exposure term (thereby estimating the outcome as a crime rate), we have instead modeled crime counts by including the population count as a predictor, given growing concerns over population count being the denominator of a calculated crime rate [e.g., see 18, [55][56][57][58]. As anticipated, we detected minimal evidence of spatial autocorrelation in our full models as a result of including the spatially lagged measure of crime. Although the Moran's I value was statistically significant in all instances, the maximum value was.08 (which is rather weak given that positive spatial autocorrelation ranges from 0 to 1). Furthermore, we assessed and found no evidence of multicollinearity issues based on variance inflation factors (VIF). The maximum VIF was 4.68, which does not exceed the commonly used cutoff of 10 [59,60]. In the results section, we present two models for both the violent and property crime outcomes (Table 2). We first estimate a baseline model that features our places of worship measure along with the sociodemographic characteristic measures, consistent with the modeling approach undertaken by certain prior studies [for example, see 6,8,12]. We then estimate a full model that additionally includes the measures of well-established criminogenic facilities and the spatially lagged measure of crime in order to determine the extent to which places of worship maintains a significant effect on crime (if at all). Crime and place researchers have called for analyses to integrate measures associated with social disorganization and routine activities theories simultaneously [for example see, 33,61]; therefore, our full model is consistent with this call. In addition to discussing the observed effects in terms of their direction and statistical significance, we highlight the magnitude of these effects in relation to one another. We draw on an approach that determines the percent change in the expected crime count for a one standard deviation increase in the variable of interest using the following formula: (exp(<unk> SD)-1) 100. This is a preferred approach because some of our independent variables drastically differ in terms of their scales [49: 492-493, 514-516.], most notably, the POW and facility measures are counts whereas the sociodemographic characteristic measures are percentages. Similar to previous crime and place studies [62][63][64][65] we utilize this approach to effectively compare the effect sizes of variables with substantively different scales. On the other hand, we recognize that another common approach is to assess the magnitude of the effects using incident rate ratios (IRR). Specifically, an IRR denotes the percent increase or decrease for every one-unit increase in a predictor by multiplying the difference between the IRR and one by 100 where positive values yield a percent increase and negative values yield a percent decrease [49]. In Table 3, we compute the effect sizes using both approaches, although we base our inferences on the first approach because for the second approach, a one-unit increase may represent a very large increase for one predictor (e.g., DC Metro Station) and a very small increase for another predictor (e.g., population). --- Results --- Violent crimes Model 1, a baseline model, shows that places of worship (POW) is significantly and positively associated with violent crime counts, controlling for sociodemographic characteristics that are commonly accounted for by crime and place researchers [45]. A 1 standard deviation (SD) increase in places of worship implies a 27.6% increase in the expected number of violent crimes based on the following formula: (exp(<unk> SD)-1) 100. We also find that ethnic heterogeneity is positively associated with violent crime, albeit at the marginally significant threshold (p <unk>.10), while the percentage of Black residents also shows a positive association with the outcome. The percentage of homeowners is significantly and negatively associated with violent crime, whereas the number of housing units exhibits the opposite relationship. This baseline model suggests that POW might have an unintended consequence, consistent with proposition 2. To minimize the possibility of obtaining spurious effects of POW, it is necessary to account for physical structural qualities of neighborhoods that have been linked to crime. In model 2, we therefore include measures of various facilities as well as the spatially lagged measure of violent crime counts. Although ethnic heterogeneity is found to be no longer related to violent crime, the positive relationship between the percentage of Black residents and violent crime persists. Moreover, the negative relationship between homeownership and violent crime remains as well. On the other hand, the positive effect of housing units becomes nonsignificant, whereas population is now related to more violent crime (albeit at the marginally significant threshold). Most of the facility measures indicate significant relationships with violent crime in the hypothesized direction, that is, violent crime in block groups is positively linked to the presence of alcohol outlets (both onsite and offsite establishments), check-cashing stores, and the presence of DC metro stations, respectively. We also determine a positive relationship between the spatially lagged measure and the outcome. What this means is that violent crime in nearby block groups is related to higher numbers of violent crime in the focal block group. Similar to model 1, we observe that POW maintains its significant and criminogenic effect in block groups. Yet, the size of the coefficient from model 1 to model 2 has decreased by more than half (from.121 to.059). Thus, the effect of POW on violent crime is much weaker as well: There is a 12.6% increase in the number of violent crimes for a 1 SD increase in POW. Although the inclusion of the facility and spatial lag measures naturally reduces the POW effect in terms of magnitude, the latter has one of the strongest effects among the variables in the full model (see Table 3). The magnitude of the effect of POW, specifically, rivals or even outpaces those of on-premise alcohol outlets, off-premise alcohol outlets, check-cashing stores, and the presence of a DC metro station. All of this is to say is that the full model of violent crime reinforces the notion that POW appear to operate as crime generators (not social capital organizations). --- Property crimes Model 3, a baseline model, reveals that places of worship is significantly and positively related to higher numbers of property crime in block groups, controlling for sociodemographic characteristics that have been linked to crime in place. The magnitude of this effect is quite strong: Notes: SD Effect size refers to the percent change (%) in the expected crime count using the formula [exp(<unk> X SD)-1]100, on an all other things equal basis. IRR refers to the incident rate ratio effect size. Empty cells denote non-significant effects. https://doi.org/10.1371/journal.pone.0282196.t003 A 1 SD increase in places of worship implies a 31.4% increase in the expected number of property crimes, consistent with proposition 2. While most of the sociodemographic characteristic measures have nonsignificant effects, we do find some instances in which they do indeed affect the spatial distribution of property crimes. For instance, we detect positive effects for ethnic heterogeneity, number of housing units, and the percent aged 15 to 29. On the other hand, percent homeowners exhibits a (marginally significant) negative effect on property crime. In model 4, we additionally include the facility measures along with the spatially lagged measure of property crime. This provides a conservative test of the effect of POW on property crime in block groups. We find that the effects of ethnic heterogeneity, the percent homeowners, and the percent aged 15 to 29 are no longer significant in the full model. Conversely, the number of housing units maintains its positive effect, while the population measure now shows a marginally positive association with the outcome. Consistent with environmental criminology [18,19], each of the facility measures have a positive effect on property crime (except for the presence of retail districts/centers). We also find evidence of property crime being spatially clustered, as the spatially lagged measure indicates a positive effect. The coefficient estimate for POW has decreased by more than half from the baseline to the full model (from.136 to.066), which is similar to what we observed for violent crime. Nonetheless, the criminogenic effect of POW remains strong; there is a 14.2% increase in the number of property crimes for a 1 SD increase in POW. Moreover, the magnitude of this effect is stronger than all the other predictors in the model (Table 3) with the exception of housing units and the spatially lagged measure of property crime. Because POW have strong positive effects on both violent and property crimes, this suggests that POW may need to be reconceptualized as a crime generator rather than a source of social capital that is leveraged to reduce crime. --- Ancillary results An alternative analytic strategy is to model the violent and property outcomes using ordinary least squares regression (OLS) instead of negative binomial regression. Thus, we have estimated OLS models of violent and property crimes using the same model specifications as those implemented for negative binomial regression (i.e., Table 2, M1-M4). Table 4 shows the results of the OLS models, and it is apparent that the pattern of results is very similar to those produced by negative binomial regression. Although the criminogenic effect of POW weakens in magnitude between the baseline and full model for both violent and property crimes, it nonetheless remains statistically significant and crime-producing. Also, the measures capturing sociodemographic characteristics and well-established criminogenic facilities yield effects that are virtually the same as those produced by negative binomial regression (in terms of both direction and statistical significance). Another line of inquiry that is necessary to investigate is whether POW affect certain crime types differently. We therefore estimated separate models for each crime type that comprises the violent and property crime indices. From Table 5, we determine that POW is significantly and positively associated with the number of robberies (14.5% more for a 1 SD increase), burglaries (12.2% more for a 1 SD increase), larcenies (13.8% more for a 1 SD increase), and motor vehicle thefts (15.3% more for a 1 SD increase), while demonstrating a marginally significant association with murders in the same direction (18.5% more for a 1 SD increase). So, aggravated assault is the lone instance by which POW fails to have a statistically significant relationship with a form of crime. Finally, we did test for moderating effects between certain independent variables (e.g., POW X poverty and POW X percent Black), but in all instances these interaction terms were found to be nonsignificant. A final consideration is to determine whether the pattern of results remains unchanged when estimating spatial regression models, given that negative binomial regression and OLS regression do not explicitly account for spatial autocorrelation. We therefore estimate a spatial error model for both the violent and property outcomes, thereby mimicking the full model specifications illustrated in Table 2. Specifically, we draw on GeoDa software to conduct maximum likelihood estimation of spatial error models that include a spatial autoregressive error term. Table 6 shows the results of the two spatial error models, and it is apparent that the pattern of results is very similar to those produced by negative binomial regression and OLS regression. Not only is POW significantly and positively related to violent and property crimes, but also the Moran's I of the spatial error residuals are very close to zero. This means that including the spatially autoregressive error term has in effect removed all the spatial autocorrelation from these models. --- Discussion Physical structural qualities of neighborhoods have been argued to have consequences for crime [2,18,20], yet there is a dearth of research investigating how places of worship shape spatial crime patterns [6,9]. What's more, there are competing theoretical arguments for how POW would impact crime in neighborhoods, with social capital and environmental criminology perspectives arguing that POW have negative and positive associations, respectively. Accordingly, we examined the spatial distribution of violent and property crime in Washington (DC) block groups as a function of places of worship, well-established criminogenic facilities, and sociodemographic characteristics. We highlight three key findings. The first key finding was that we consistently found POW to be associated with more violent and property crime, consistent with the results of two previous studies [6,12]. This coupled with the fact we failed to detect a single instance of POW having a significant and crimereducing effect suggests that POW do, in fact, operate as crime generators in neighborhoods. That is, the presence of outsiders lessens familiarity and makes it more challenging for insiders (i.e., members and residents) to identify potential offenders and detect suspicious, crimerelated activity [18,19,24]. For insiders, there may be ambiguity concerning whom they should direct territorial behavior at, but also, the situational contexts by which it is acceptable to do so [24,66,67]. Recent studies have drawn on social media, cell phone, and transportation data to measure various properties of the ambient population and have indeed determined that the size of the ambient population is associated with more crime in place [56,58,[68][69][70]. Thus, we propose that a significant increase in the volume of potential offenders and targets is enough to disrupt (or completely negate) a process whereby social capital is formed in POW and later used to instrumentally prevent and solve crime problems. The second key finding was that places of worship exerted strong criminogenic effects, even after controlling for well-established criminogenic facilities and sociodemographic characteristics. We found that the effects of POW were stronger in magnitude than most of the other predictors in the violent and property crime models (Table 3), including alcohol outlets with onsite consumption, check-cashing stores, and the presence of a DC Metro station. Moreover, ethnic heterogeneity and poverty, two predictors often equated with social disorganization [45,46], were not significantly related to more crime. Because POW are important local institutions insofar as they promote education, steady employment, marriage, drug and substance avoidance, and friendships among members, our findings should not be interpreted as an indictment on religion or POW. Rather, it highlights POW as an (unexpected) ecological risk factor for neighborhood crime, similar to how shopping malls, central business districts, restaurants, and retail stores have been deemed to operate as crime generators [13

Places of worship (POW) have traditionally been argued to have crime-reducing effects in neighborhoods because of their ability to produce social capital. Yet, the evidence for this proposition is surprisingly weak. Consequently, an alternative proposition, rooted in environmental criminology, suggests that POW might unintentionally operate as crime generators in neighborhoods insofar as they induce foot traffic and undermine guardianship and social control capabilities. Because of these competing propositions in combination with the limited number of studies on this topic, we conduct a block group analysis of crime, places of worship, well-established criminogenic facilities, and sociodemographic characteristics in Washington, DC. We estimate negative binomial regression models of both violent and property crime and find strong evidence for only one of the propositions, with the effects of POW being relatively strong in comparison to other predictors in the models. The implications of these findings for criminology, urban studies, and public policy are discussed.

(or completely negate) a process whereby social capital is formed in POW and later used to instrumentally prevent and solve crime problems. The second key finding was that places of worship exerted strong criminogenic effects, even after controlling for well-established criminogenic facilities and sociodemographic characteristics. We found that the effects of POW were stronger in magnitude than most of the other predictors in the violent and property crime models (Table 3), including alcohol outlets with onsite consumption, check-cashing stores, and the presence of a DC Metro station. Moreover, ethnic heterogeneity and poverty, two predictors often equated with social disorganization [45,46], were not significantly related to more crime. Because POW are important local institutions insofar as they promote education, steady employment, marriage, drug and substance avoidance, and friendships among members, our findings should not be interpreted as an indictment on religion or POW. Rather, it highlights POW as an (unexpected) ecological risk factor for neighborhood crime, similar to how shopping malls, central business districts, restaurants, and retail stores have been deemed to operate as crime generators [13,16,22,35]. Our results have implications for both researchers and policymakers. When modeling crime across geographic units, crime and place researchers importantly control for factors that induce criminal opportunities (i.e., liquor stores, bars, check-cashing stores, and transit stops). We suggest additionally controlling for POW to minimize the possibility of obtaining spurious effects with regards to the independent variables of interest. Relatedly, for crime policy, we encourage researchers and city officials to account for the presence of POW in determining the risk of crime across areas within a city. This could be accomplished via two data driven approaches: 1) combine regression analysis and the mapping of predicted outcome variables [e.g., see 71], and 2) implement risk terrain modeling [e.g., see 72]. Many policing strategies and intervention efforts are predicated on identifying areas with a disproportionate amount of crime; therefore, the incorporation of POW may provide more accurate profiles on which areas would benefit the most from increased (fair and consistent) policing, or municipal resources, services, and partnerships. --- Limitations and directions for future research Although the current study provides crucial insight into places of worship and crime in neighborhoods, we acknowledge certain limitations and directions for future research. First, because of data limitations we were unable to test the theorized mechanisms that may link POW to violent and property crime in neighborhoods (although this is true of nearly all prior studies on the topic). Thus, we encourage future research to collect neighborhood level data on social capital, civic engagement, foot traffic (or the ambient population), and anonymity in order to test whether these factors do, in fact, mediate the effects of POW on crime. Second, our key independent variable captures the presence of places of worship, and therefore it does not capture the differential capacity of POW to impact crime. A natural extension is for future studies to assess variation in neighborhood crime as a function of more fine-grained characteristics of POW, such as the number of adherents/members, employees, income/donations, and years of operation. A few studies have explored this line of inquiry [6,11,27], yet it remains to be seen whether measures that account for the differential capacity of POW provide additional knowledge beyond what can be gained from the standard measurement approach (i.e., the number of POW in a neighborhood). Also, it is an open question the extent to which DC's data on POW is exhaustive and accurate, though we have no reason to suspect that these data are any less valid than other POW sources (e.g., Yelp, the phonebook, Google, etc.). And, there is no reason to think that any missing data is not random or systematic. Third, the analysis is crosssectional; and therefore, it is unable to test how changes in the number of POW influence changes in the number of crimes. While this does not repudiate the findings of the present study, as understanding the spatial distribution of crime at a single timepoint offers an important baseline, future research may want to perform a longitudinal analysis using a fixed-effects approach. Finally, the analysis and findings pertain to neighborhoods of a single city. It is therefore possible that the observed effects might operate differently across U.S. cities. Accordingly, future work needs to examine potential relationships between places of worship and crime across a diversity of ecological settings, including cities beyond the United States. --- The data on crime, places of worship, and well-established criminogenic facilities can be found on Open DC (https://opendata.dc.gov/). The data on sociodemographic characteristics can be found on the United States Census Bureau website (https:// www.census.gov/programs-surveys/acs.html). --- Author Contributions Conceptualization: James C. Wo.

Places of worship (POW) have traditionally been argued to have crime-reducing effects in neighborhoods because of their ability to produce social capital. Yet, the evidence for this proposition is surprisingly weak. Consequently, an alternative proposition, rooted in environmental criminology, suggests that POW might unintentionally operate as crime generators in neighborhoods insofar as they induce foot traffic and undermine guardianship and social control capabilities. Because of these competing propositions in combination with the limited number of studies on this topic, we conduct a block group analysis of crime, places of worship, well-established criminogenic facilities, and sociodemographic characteristics in Washington, DC. We estimate negative binomial regression models of both violent and property crime and find strong evidence for only one of the propositions, with the effects of POW being relatively strong in comparison to other predictors in the models. The implications of these findings for criminology, urban studies, and public policy are discussed.

Introduction Epidemics are considered to be a prominent source of psychological and social disorders, e.g., fear, anxiety, and reluctance to communicate with others [1]. It is common during epidemics and pandemics for people to suffer from stress and anxiety, including the fear of infection and death, avoiding receiving medical treatment at health facilities, fearing the loss of relatives, and fearing isolation because of quarantine, which causes boredom, loneliness, and depression [2]. There is a psychoneurotic connection between acute inflammations of the respiratory system and psychological disorders, as occurred with SARS decades ago. People in quarantine suffer from boredom, anger, and loneliness. Symptoms such as cough and fever can increase anxiety, intrusive thoughts, and the fear of COVID-19 infection [3]. The world is currently experiencing the COVID-19 pandemic that spread to all countries in a short amount of time. The WHO declared the novel coronavirus outbreak a pandemic in March 2020, and predicted it to spread to all countries, urging countries to take the necessary steps to control it [4]. The number of people who have had a coronavirus infection is in the millions. It is, therefore, a threat that invokes anxiety, depression, and indignation in people. To protect themselves, people now adhere to social distancing so as to not catch the infection from close contact with others [5]. Being at home all the time can affect the mental health of both children and adults. Children and adolescents have therefore been advised to focus on home activities to forget about the negative effects of the coronavirus [6]. Middle Eastern countries have also been affected by the pandemic. By 7 July 2020, 214,000 confirmed coronavirus cases and 1968 deaths had occurred in Saudi Arabia. In the United Arab Emirates, 520,068 infected cases and 324 deaths were reported. In Egypt, 760,222 infected cases and 30,422 deaths were reported. A total of 1167 infected cases and 10 deaths were reported in Jordan [7]. Several studies have reported on the negative effects of epidemics and pandemics on the psychology of infected people and their caregivers [8,9]. Those studies reported a high level of psychological stress among people providing care to infected cases. In many studies, people with acute respiratory syndromes (Ebola, MERS, and SARS) were reported to have psychological disorders such as anxiety, depression, and other forms of mental illness [10][11][12]. In the Saudi context, in terms of the effect of MERS on psychological stress, female students had a higher level of psychological stress than that of male students [13]. In the Omani and Bahraini contexts, the coronavirusinduced anxiety among families was average, and no significant differences were found by country. However, there was a significant difference in favor of females, people aged over 40 years, people with lower educational levels, and unemployed people. Retired people were reported to experience the lowest level of anxiety [14]. In terms of the psychological impact, depression, anxiety, and stress at the beginning of the coronavirus pandemic in a sample of 1210 participants from 194 Chinese cities, 53.8% of the participants suffered an acute psychological impact because of the pandemic, whereas about 28.8% of the participants were found to suffer from average to acute anxiety [15]. In a study conducted in Italy, the percentage of people having high and severe coronavirusrelated anxiety ranged between 2.89% and 7.43% [16]. The WHO also asserted that some populations, such as people working in health and security, had infection fears and suffered from stress due to dealing with infected people, work pressure, and changed sleep and eating routines. Ministers and leaders in authorities confronting the pandemic suffer from similar psychological effects [17]. Two surveys were also conducted by the British Academy of Medical Sciences via the Internet. The results of the first survey revealed that the majority of the sample suffered from problems with mental health. Participants reported fears about their health and access to support and services during the pandemic. The second survey reported anxiety among participants about social isolation and economic difficulties resulting from the pandemic. With expectations of the increased occurrence of anxiety and stress during the pandemic, researchers expect an increase in the number of depressed people and people who are prone to commit suicide. In 2003, during the SARS epidemic, the rate of suicide in people over 65 years witnessed a 30% increase. Researchers asserted that actions taken at that time to eliminate the spread of SARS had serious effects on people's mental health, as unemployment rates and feelings of financial insecurity and poverty increased [18]. Research results concerning gender differences in epidemic-related anxiety are inconsistent, with some studies reporting higher levels of anxiety among females [15,16,19,20] and others reporting higher levels of anxiety among males [21]. Some studies have reported differences in anxiety about the future by gender in favor of females, and by social status in favor of the unmarried. No differences were found by profession [22][23][24]. Low-to-average anxiety levels were found between participants. The frequency of mild, average, and severe anxiety among participants was 7.7-78.8%, 5.6%, and 2.7-5.2%, respectively. The study did not find gender differences in depression and anxiety. On the other hand, it found differences in favor of the unmarried [25]. The authors in [15] found higher levels of anxiety among students than those among employeesworking personnel. The level of anxiety did not correlate with social status, the size of the family, or age. Similarly, social status, having no children, and workplace did not significantly contribute to anxiety or depression [16]. Smartphone use has been globally widespread during the coronavirus pandemic, which has induced feelings of isolation, social distancing, and a need for leisure, recreation, and shopping [26]. With this intensive use, smartphone addiction has become a universal concern [27]. It is a recent phenomenon in human behavior that can adversely affect the mental health and social functioning of people who overuse smartphones [28]. Smartphone addiction is the overuse or compulsive use of smartphones, resulting in negative consequences in social, behavioral, and emotional functioning [29]. It is a form of behavioral addiction that makes the individual unable to control the strong desire to use the smartphone and its applications, with the loss of productivity, the denial of negative effects, preoccupation, and feelings of annoyance and even panic when deprived of the smartphone [30]. Some studies have shown a connection between smartphone addiction and psychological adjustment problems, e.g., anxiety and depression. A Korean study found that smartphone addiction can be predicted by depression [31]. A similar finding was also reached in a Chinese study [32], where loneliness, which relates to depression, was found to be a strong predictor of smartphone addiction. In an American study, social interaction anxiety was found to predict smartphone addiction [33]. Another study found a positive correlation between anxiety and depression and smartphone overuse [34]. Smartphone addiction could be predicted by anxiety and depression. Anxiety as a major symptom of smartphone addiction emerges once the person is deprived of their smartphone [35,36]. This shows that the smartphone itself is a source of anxiety [37]. Smartphone overuse is a factor leading to mental health problems. They also found that gender was the strongest predictor of depression. Symptoms of anxiety were more frequent in younger people [38]. A positive correlation between smartphone addiction and psychological stress was also found. Research also revealed a weak relationship between age and hours of use on the one hand, and smartphone addiction on the other [39]. More than one study did not find a correlation between age and smartphone addiction [40,41]. Meanwhile, a positive correlation was found between daily use hours and the problematic use of smartphones [42]. However, differences in smartphone addiction in favor of individuals using a smartphone for more than four hours a day were found [43]. This same finding was reported by Haug, who reported a correlation between smartphone addiction and daily use hours [44]. Facebook addiction and state anxiety could be predicted by an increased use rate. The interaction of gender and trait anxiety predicted Facebook addiction [45]. As mentioned above, and the increase in cases of COVID-19 infection around the world in general and in Middle Eastern countries in particular can lead to increased levels of anxiety with negative behavioral effects, such as smartphone addiction. The present study aimed to identify the level and frequency of anxiety about COVID-19 infection in some Middle Eastern countries, and differences in this anxiety by country, gender, workplace, and social status. The study also aimed to identify the predictive power of anxiety about COVID-19 infection variables, daily smartphone use hours, and age in smartphone addiction. --- Method 2.1. Participants This study comprised a total of 651 participants (222 males and 429 females representing 34.1% and 65.9%, respectively) from four Middle Eastern countries: Jordan (n = 271, 41.6%), Saudi Arabia (n = 179, 27.5%), the United Arab Emirates (n = 108, 16.6%), and Egypt (n = 93, 14.3%). Their age ranged between 18 and 73 years (M = 33.35, SD = 10.69). Of the 651 participants, 246 (37.7%) were single, 378 (58.1%) were married, and 27 (4.22%) were divorced. The number of participants working for the government, the private sector, and students were 242 (37.2%), 243 (37.3%), and 166 (25.5%), respectively. --- Instruments 2.2.1. Anxiety about COVID-19 Infection Scale The authors developed a scale to measure anxiety about COVID-19 infection. To develop the scale, the authors surveyed scales in the relevant literature, e.g., the State-Trait Anxiety Inventory [46] and scales of social anxiety and general anxiety [15,[47][48][49][50][51]. The authors also used anxiety indicators, including the WHO's reports about prevention and the health guidelines for dealing with the virus. The scale had 40 items with 5-point Likert scales ranging from 5-'to a very high degree' to 1-'to a very low degree'. The preliminary version of the scale was face-validated by five professors who specialized in psychology, measurement, and evaluation. They were asked to judge if items represented the measured trait, and if the wording of items was sound and clear. This resulted in modifying some items, but no deletions were made. Correlations among items and the total score were computed. These ranged from 0.628 to 0.842, all of which were high and statistically significant. The unilaterality of the scale was established by factor analysis. The results revealed that all items were significantly loaded on the first factor. The first eigenvalue was 22.025, and the second eigenvalue was 2.345. The explained variance of the first factor was 55.63%. This is consistent with Rechase's [52] suggestion that the unilaterality condition is met if the first factor can explain at least 20% of total variance. The reliability of the scale was then checked by computing the alpha Cronbach coefficient of participant scores. The scale yielded an alpha coefficient of 0.978, which indicates that the scale was highly reliable. Participant scores on the scale ranged between 40 and 200. Scores were categorized by range into high anxiety (146.8-200) with a weighed mean ranging from 3.67 to 5, average anxiety (93.4-146.7) with a weighed mean ranging from 2.34 to 3.66, and low anxiety (40-93.3) with a weighed mean ranging from 1 to 2.33. --- Smartphone Addiction Inventory After surveying the literature on smartphone addiction and the instruments used in relevant studies, we used the Smartphone Addiction Inventory (SPAI) that was used in the studies of Pavia, Cavani, Blasi, and Giordano [53] and Lin et al. [54]. It is an inventory developed on the basis of the Chinese Internet Addiction inventory (CIAS) [55]. Items of this inventory assess several dimensions of smartphone addiction: compulsory use, withdrawal, tolerance, and problems in relationships with others, and time and health management. The reliability examination of the inventory was originally performed on a Chinese sample of 283 university students. Another examination of its psychometric characteristics and factor structure was performed in Italy [53]. The sample consisted of 485 male and female students whose ages ranged between 10 and 27 years. Exploratory and confirmatory factor analyses revealed that the items of the inventory were loaded on five factors: time spent, compulsivity, daily life interference, craving, and sleep interference. The alpha Cronbach reliability coefficient of the whole inventory was 0.94. The English version of the inventory was translated into Arabic by two bilingual researchers. The accuracy of translation was verified by back translation, which was performed by a third researcher. The retranslated version was then compared with the original English version, and differences were very few. Very few adaptations were made to make the inventory suitable to the Arab environment. As a result, the version used in the study originally had 24 items, measuring 5 dimensions with a 4-point rating scale ranging from 4-'strongly agree' to 1-'strongly disagree'. Thus, a respondent's score on the inventory ranged from 24 to 96. The higher the score of a respondent was, the higher their level of smartphone addiction. The inventory was validated by having it refereed by specialists and by establishing its construct validity. For construct validation, correlations among items and the total score were computed, and they ranged between 0.63 and 0.85, which were all statistically significant. The unilaterality of the inventory was established by exploratory factor analysis. The results revealed that all items significantly loaded on the first factor. Eigenvalues were 12.632 for the first factor and 1.460 for the second factor. The explained variance of the first factor was 52.635 (90% of the total variance before rotation) and 31.299 (53% of the total variance after rotation). This indicates that the inventory was unilateral. The reliability of the inventory was then checked by computing the alpha Cronbach coefficient of the participants' scores. The inventory yielded an alpha coefficient of 0.982, which indicates that it was highly reliable. --- Procedures The authors developed an electronic questionnaire, including the scale on anxiety about COVID-19 infection, the smartphone addiction inventory, and demographic data. The link to the questionnaire was then sent to participants via WhatsApp (Facebook Inc, Menlo Park, CA, USA) and Twitter with the help of authors who live in the four countries included in the study. Completion of the questionnaire took three weeks (the last two weeks of May and the first week of June 2020). The application of the questionnaire coincided with the application of strict health procedures, imposing social distancing and quarantining. Movement between cities was also prohibited in the four countries. Other procedures included the prohibition of gatherings, distant learning, school closures, and restricted travel. The aims of the study and instructions for completing the questionnaire were provided with the electronic questionnaire. Participants were told that the completion of the questionnaire was voluntary, and that data collected from the completed questionnaires would only be used for research purposes. For this reason, they were not required to write their names or give any information about their identities. They were also told that the honest completion of the questionnaire would be the key for the successful completion of the study. Following this, the authors scored and codified the received completed questionnaires, and categorized the data according to the study variables. --- Data Analysis The obtained data were statistically analyzed using IBM SPSS Statistics-25 (IBM, Armonk, NY, USA). To answer the research question about the frequency of anxiety about COVID-19 infection, descriptive measures (frequencies, percentages, means, and standard deviations) were used. The t-test for independent samples was used to identify gender differences in anxiety about COVID-19 infection, and the ANOVA test was used to identify differences in anxiety about COVID-19 infection by country, social status, and workplace. Pearson's correlation was used to explore relationships among variables. Lastly, the multiple stepwise regression test was used to explore the predictive power of the anxiety about COVID-19 infection scale, daily smartphone use hours, and age in smartphone addiction. --- Results --- Frequency of Anxiety about COVID-19 Infection among Participants Table 1 shows means, standard deviations, and percentages of anxiety about COVID-19 infection by country. Table 1 shows that the country with the highest anxiety about COVID-19 infection was Egypt (M = 106.22), followed by Saudi Arabia (M = 98.31), the United Arab Emirates (M = 96.53), and Jordan (M = 93.45). --- Differences among Countries in Anxiety about COVID-19 Infection To identify differences among the four countries in anxiety about COVID-19 infection, the ANOVA test was performed. These results are listed in Table 2. The data in Table 2 reveal that there were significant differences among countries in anxiety about COVID-19 infection (p = 0.033, a <unk> 0.05). The effect size was partial eta squared = 0.13. The country variable explained 13% of variance in anxiety about COVID-19 infection. After performing post hoc analysis using the Scheffe test, differences were found to be significant only between Jordan and Egypt (p = 0.037, a <unk> 0.05) in favor of Egypt, of which the mean was higher. --- Gender Differences in Anxiety about COVID-19 Infection The t-test was performed to explore gender differences in anxiety about COVID-19 infection in the four countries. Table 3 presents these results. Table 3 shows that there were no statistically significant gender differences (a = 0.05) in anxiety about COVID-19 infection in Saudi Arabia. However, there were significant differences in Jordan (p = 0.007, a <unk> 0.05) and Egypt (p = 0.018, a <unk> 0.05) in favor of females, and in the United Arab Emirates (p = 0.013, a <unk> 0.05) in favor of males. The effect size according to Cohen was small in the Jordan sample (0.363), and average in the Egyptian (0.550) and Emirati (0.626) samples. At the level of the whole sample, there were significant differences (p = 0.013, a <unk> 0.05) in favor of females with a low effect size (0.206). --- Differences in Anxiety about COVID-19 Infection by Social Status Differences in anxiety about COVID-19 infection by social status were explored by performing the ANOVA test with three categories: single, married, and divorced. These results are presented in Table 4. Table 4 shows that there were no significant differences (p = 0.364, a <unk> 0.05) in anxiety about COVID-19 infection by social status. --- Differences in Anxiety about COVID-19 Infection by Workplace Differences in anxiety about COVID-19 infection by workplace were explored by performing the ANOVA test with three categories: governmental job, private-sector job, and student. These results are presented in Table 5. Table 5 shows that there were no significant differences (p = 0.390, a <unk> 0.05) in anxiety about COVID-19 infection by workplace. --- Predicting Smartphone Addiction by Anxiety about COVID-19 Infection, Daily Smartphone Use Hours, and Age Pearson correlations among study variables were computed. A statistically significant (a = 0.01) negative relationship (r = -0.122) was found between age and smartphone addiction. A statistically significant (a = 0.05) negative relationship (r = -0.071) was found between age and anxiety about COVID-19 infection. A statistically significant negative relationship (r = -0.242) was found between age and daily smartphone use hours. Lastly, a statistically significant (a = 0.01) positive relationship (r = 0.427) was found between smartphone addiction and anxiety about COVID-19 infection, and between smartphone addiction and daily smartphone use hours (r = 0.357). To identify the predictive power of anxiety about COVID-19 infection, daily smartphone use hours and age in smartphone addiction, stepwise multiple regression was used. Table 6 shows these results. Collinearity was checked using the variance inflation factor (VIF), and the value was less than 10 (average VIF = 1), which indicated that the problem of multicollinearity was not present. Anxiety about COVID-19 infection was the best predictor of smartphone addiction, as it could explain 0.181 of the variance in smartphone addiction. The interaction of anxiety about COVID-19 infection and daily smartphone use hours explained 0.273 of the variance in anxiety about COVID-19 infection. Thus, the daily use hours variable could predict an additional amount of smartphone addiction of 0.090, which was significant at the 0.01 level. The prediction equation can be stated as follows: smartphone addiction = 31.160 + 0.168 <unk> anxiety about COVID-19 infection + 1.127 <unk> daily use hours. --- Discussion The results of the study revealed that the percentages of participants who had high, average, and low anxiety about COVID-19 infection were 10.3%, 37.3%, and 52.4%, respectively. This refers to an average level of anxiety at the level of the whole sample. Regarding the frequency of anxiety in the four target countries, all frequencies were at the average level, with Egypt being in first place with a mean of 2.655, followed by Saudi Arabia (M = 2.458), the United Arab Emirates (M = 2.4130), and Jordan (M = 2.336). This finding largely concurs with the findings of previous studies conducted in some Gulf states during the outbreak of the pandemic. Those studies reported average anxiety and stress resulting from the pandemic [13,14]. The percentages here were also close to their counterparts in the Chinese study [15], and slightly higher in high anxiety than the percentages in the Italian study [16]. The current percentages, showing average and high anxiety, exceeded their counterparts in the Australian study [25]. Data collection in the present study coincided with the application of strict health procedures in all countries globally, e.g., the prohibition of gatherings and curfews. Regarding differences in the frequency of anxiety about COVID-19 infection in the four Arab countries, the results revealed significant differences between Egypt and Jordan in favor of Egypt. This finding seems logical given that Egypt, in comparison with Jordan, was late in imposing health restrictions and giving the real numbers of infected cases. Unlike Egypt, Jordan took actions with the appearance of the first infected case. Jordan imposed a curfew and closed schools, governmental institutions, mosques, and airports. Such procedures largely reduced the number of infected cases. Accordingly, the number of infected cases in Jordan up to 7 July was 1167, with a recovery rate of 82% and a death rate of 0.08%. On the other hand, the number of infected cases in Egypt up to 7 July was 76,222, with a recovery rate of 28% and death rate of 4.5%. This may refer to a deficiency in health procedures and the provision of health support to critical cases that required special and costly treatment protocols. Egypt's population is also more than 100 million. The frequency of high anxiety (15.1%) in Egypt exceeded its counterparts in a number of Arab and Asian countries that were covered in previous studies [13][14][15][16]25]. The finding of insignificant differences in the level of anxiety about COVID-19 infection between Saudi Arabia and the United Arab Emirates is in line with the study conducted on Omani and Bahraini samples [14], in which no significant differences were found between the two countries in anxiety about COVID-19 infection. The Saudi environment is largely similar to the Omani and Bahraini environments. Analysis of the data collected from the whole sample revealed gender differences in anxiety about COVID-19 infection in favor of females. Gender differences were also found in three of the four countries. The differences were in favor of females in the Egyptian and Jordanian samples, and in favor of males in the Emirati samples. No gender differences were found in the Saudi sample. This general finding about females having higher anxiety about COVID-19 infection than males concurs with several previous studies [13,15,16,56]. This finding is also consistent with previous studies exploring gender differences in general psychological anxiety [19,20,[22][23][24]57]. The finding about gender differences in COVID-19 infection anxiety in favor of males in the Emirati sample can be explained by the fact that most respondents in the sample were non-Emirati, who represent about 89% of the total population in the United Arab Emirates. Those respondents live with their families and work in various sectors in the country. Male residents in the United Arab Emirates may have higher levels of anxiety than females do because of fears about their jobs with the economic damages resulting from the pandemic. Some sectors there made some employees redundant or reduced their salaries. For this reason, non-Emirati male employees may fear the loss of their jobs and becoming unable to sustain their families. Women, on the other hand, do not have these fears because women in Eastern societies are not required to work and sustain their families. Furthermore, women stay at home most of the time, which makes them less anxious about catching the infection. This finding is consistent with [14], in which residents had higher levels of anxiety because of the lack of occupational security and being in countries other than their own. This finding is also consistent with studies investigating general anxiety and anxiety about the future, in which males were reported to have higher levels of anxiety than females [21,58]. Males and females in the Saudi sample had comparable levels of anxiety about infection. A possible explanation for this finding is that they live in the same environment and face the same threats. This finding is in line with the Australian study, in which no significant difference in infection anxiety was found [25]. Regarding the effect of social status on anxiety about infection, no significant differences were found among single, married, and divorced participants. This means that anxiety about infection is not affected by one's social status, or being single, married, or divorced. This same finding was reached in [15,16]. It is, however, inconsistent with [25], in which the unmarried had a more significant level of anxiety. This finding also concurs with studies conducted before the coronavirus pandemic, in which the unmarried had higher levels of general anxiety [22][23][24]. As with social status, no gender differences were found in infection anxiety by workplace. Participants working for the government and the private sector and students had comparable levels of anxiety about infection. This finding is consistent with [16], and with studies that did not find differences in general anxiety by workplace [22][23][24]. However, it is inconsistent with [15], in which students outnumbered employees in terms of anxiety, and with [14], in which unemployed respondents outnumbered employees in terms of infection anxiety. Overall, social status and workplace need to be further studied with other variables such as educational level, income, and age because of the inconsistent results about the latter two variables in the few studies conducted so far. Regarding the predictive power of infection anxiety, daily smartphone use hours, and age in smartphone addiction, stepwise multiple regression analysis revealed that smartphone addiction can be predicted by infection anxiety and daily smartphone use hours. Age, on the other hand, did not contribute to the prediction of smartphone addiction. Infection anxiety was the strongest predictor of smartphone addiction, followed by daily use hours. This means that people who are more anxious about infection tend to excessively use their smartphone. The authors did not find studies exploring the relationship between infection anxiety and smartphone addiction. However, the current study's findings are in line with previous studies that reported a positive correlation between general anxiety, depression, stress, and loneliness on the one hand, and smartphone addiction on the other [9,[27][28][29][30][31][32][33][34]37,39]. This finding seems logical and concurs with the mainstream views from previous research. With the outbreak of the coronavirus, and restrictions such as social distancing and staying at home most of the time, the smartphone can be the only resort for people in order to vent, pass time, and search for information about the virus. The smartphone is also used for distant learning due to the closure of schools. People may therefore excessively use the smartphone to the degree that they cannot control the time spent in its use. This, in turn, can lead to compulsivity, sleep interference, and excessive attachment to the smartphone, which are all symptoms of addiction. This concurs with [35,36], reporting anxiety as a major symptom of smartphone addiction. It also concurs with the assertion of [59] that overdependence on smartphones and the use of social media to know about current events can result in the fear of missing events, known as "fear of missing out". The finding that daily use hours contribute to smartphone addiction is consistent with some studies [42][43][44][45], and is inconsistent with [39], in which a weak relationship was found between smartphone use hours and addiction. The finding that age did not contribute to the prediction of smartphone addiction despite the presence of a significant negative relationship between them indicates that age is not a factor contributing to smartphone addiction during the coronavirus pandemic. This is in line with most studies that have examined the relationship between age and smartphone addiction [39][40][41]. Lastly, Pearson's correlation revealed a significant, weak relationship between age and infection anxiety. This finding is partly in line with studies in which anxiety was found to be more frequent among young people [16,25,56]. It also concurs with the contention that young people are more prone to anxiety because of their quick access to information via social media [60]. This finding is inconsistent with [14], in which people aged over 40 years were found to be more anxious about infection, and with [15], in which age did not correlate with anxiety. --- Conclusions This study explored anxiety about COVID-19 infection and its relationship with some psychological and demographic variables. It revealed that this anxiety exists in some Middle East countries. Regardless of their social status, workplace, and age, participants in the study suffered average-to-high infection anxiety. Some sort of intervention is therefore required so this anxiety does not become morbid. The study also revealed that infection anxiety can lead to smartphone addiction, with all its negative psychological and physical effects, as well as the disorder known as nomophobia. Women were found to be more anxious about infection. Anxiety about infection and daily use hours were found to significantly contribute to smartphone addiction. It is therefore necessary to develop preventive programs to eliminate this phenomenon. Awareness must also be raised about the judicious use of smartphones. People should be advised on how to find alternative ways to fruitfully spend time, control their desire to use smartphones, and sterilize their phones, which can be a source of infection. It is also recommended that social media should be used to support people during the pandemic, and instruct them on how to keep safe and manage their anxiety. They should be told not to show fear and anxiety in front of their children, as this can leave negative effects on their development. People, especially mothers, should be advised not to spend too much time on social media, as this can make them anxious. This can adversely affect childcare, which might cause insecure attachment. During quarantine, people should telecommunicate with relatives to alleviate the impact of social isolation on children and adolescents. People can make an opportunity out of the crisis to practice activities and hobbies for which they previously had no time. Adults should distract children and adolescents from bad news by providing them with daily home activities and events. The use of smartphones and electronic games by children should be monitored so that they do not become addicted to them. It is a good idea to develop electronic programs to enhance people's psychological hardiness and to teach them how to face crises. There should also be programs of interest for old people to help them safely pass the time. It is also necessary to use social media to spread awareness about the virus and preventive healthcare. In this respect, medical sites do not make good use of social media. Study results show that further research is required to explore anxiety about infection on larger samples and different populations. Future research is expected to focus on the negative effects of infection anxiety. Research endeavors are also required to develop and test the effectiveness of counseling and preventive programs in eliminating pandemicrelated anxiety. Researchers can also examine the relationship between anxiety about infection and other variables-such as depression, burnout, anxiety about the future and death, psychological security, hardiness, optimism and pessimism, healthy behavior, selfefficacy, and achievement-and attitudes to the vaccination process. Even though the results of the study documented the relationship between smartphone addiction and gender, the application of the instruments to a limited sample from four Middle Eastern countries,whose ages ranged between 18 and 73, limits the generalizability of the results to age groups and populations in different contexts. Furthermore, the study was limited to an electronic questionnaire distributed via social media (WhatsApp and Twitter) during the period of restrictions on movement and social distancing. The authors used the available data in the four countries about the numbers of infected cases and deaths up to 7 July 2020. Cautious interpretation of results is important due to the use of a self-reported questionnaire. The results of self-reported questionnaires are prone to be affected by social desirability. Lastly, in this study we used the descriptive-comparative method. Further experimental and longitudinal studies using quantitative and qualitative data collection tools are required. --- Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. All the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all the patients for being included in the study. --- Data Availability Statement: Data of this research will be available on demand. --- Conflicts of Interest: The authors declare that they have no conflict of interest.

This study explores the level and frequency of anxiety about COVID-19 infection in some Middle Eastern countries, and differences in this anxiety by country, gender, workplace, and social status. Another aim was to identify the predictive power of anxiety about COVID-19 infection, daily smartphone use hours, and age in smartphone addiction. The participants were 651 males and females from Jordan, Saudi Arabia, the United Arab Emirates, and Egypt. The participants' ages ranged between 18 and 73 years (M 33.36, SD = 10.69). A questionnaire developed by the authors was used to examine anxiety about COVID-19 infection. Furthermore, the Italian Smartphone Addiction Inventory was used after being translated, adapted, and validated for the purposes of the present study. The results revealed that the percentages of participants with high, average, and low anxiety about COVID-19 infection were 10.3%, 37.3%, and 52.4%, respectively. The mean scores of anxiety about COVID-19 infection in the four countries were average: Egypt (M = 2.655), Saudi Arabia (M = 2.458), the United Arab Emirates (M = 2.413), and Jordan (M = 2.336). Significant differences in anxiety about COVID-19 infection were found between Egypt and Jordan, in favor of Egypt. Significant gender differences were found in favor of females in the Jordanian and Egyptian samples, and in favor of males in the Emirati sample. No significant differences were found regarding workplace and social status. The results also revealed a significant positive relationship between anxiety about COVID-19 infection, daily smartphone use hours, and age on the one hand, and smartphone addiction on the other. The strongest predictor of smartphone addiction was anxiety about COVID-19 infection, followed by daily use hours. Age did not significantly contribute to the prediction of smartphone addiction. The study findings shed light on the psychological health and cognitive aspects of anxiety about COVID-19 infection and its relation to smartphone addiction.

Introduction Religious counselors,civil and non-civil servants under the Ministry of Religion of the Indonesian Republic,have duties, responsibilities, and authority to conduct religious guidance and development counselling through religious language. All activities carried out by religious counselors related to spirituality to people who need spiritual assistance in their environment. 1 Religious counselors provide spiritual services in various counselling, such as worship guidance, marriage guidance, etc. One of the Religious Counselors whose role is most important in a Muslim-majority society is the Islamic Counselor 2. The increasingly advanced era of digitalization has made the spread of Islamic teachings more advanced. The growing development of the deployment also requires human resources to develop it. One profession that plays an essential role in spreading Islamic teachings is Islamic Religious Extension. In addition to carrying out his primary duties as a Religious Extension Officer, he also holds many positions in the scope of religious activities. 3 Based on the Decree of the Director General of Islamic Community Guidance Number 504 of 2022 concerning Guidelines for Islamic Religious Instructors, which is a reference in carrying out the duties of Islamic Religious Instructors l the 2020-2024 service period which was established on June 4, 2022, explains that the main task of Islamic Religious Instructors is to carry out Islamic guidance and counselling development through religious language to the target group according to the policies stipulated by the Director General of Islamic Community Guidance, Ministry of Religion. There are four functions of Islamic Religious Instructors: informative and educative, consultative, and advocative. 4 Islamic religious counselors are structural officers and have a valuable field function. They not only master the role structurally but rather the role and function. Concerning the function of Islamic religious instructors, the main tasks carried out by the two types of Islamic religious instructors remain the same, namely, carrying out Islamic guidance and counselling activities as well as community development and development in the language of religion towards an Islamic society. The problem currently being faced by religious instructors is the increasingly intense challenge of da'wah, both internal and external. 5 Challenges arise from various forms of modern society's activities, such as behavior that always wants entertainment and tourism in a broad sense which is now increasingly opening opportunities for the emergence of social problems. Such as the occurrence of vulnerability, gaps, unrest, and instability. Many people are easily provoked to commit deviant acts, such as acts against the law and violence, which are increasing daily. There are so many problems that exist in today's society, especially those that occur to Muslims themselves, so it requires qualified abilities from religious instructors, both the ability to master theories and methods, as well as mastery of communication media which are currently being used more and more. By the community so that the method of providing religious understanding to the community is not only focused on the pulpit media, but religious instructors can guide the form of direct counselling. Wara District is one of 9 Districts in Palopo with a high number of marriage events. There were 510 recorded marriages from 2019 to June 2022. Of the number of marriages, only 17 were underage marriages (Early marriage), a percentage of around 3.33%. This percentage is low. The details of the marriage events in Wara District are in tabular form. Marriage has an age limit. Regarding the age limit for marriage, so far, no rule has been found in fiqh discourse (Islamic jurisprudence) that limits it. The fuqaha only stated that the measure of the permissibility of underage women for intercourse is that they need to be ready to engage in sexual activity. ( <unk> <unk> <unk> <unk> ) with all the consequences, such as pregnancy, childbirth, and breastfeeding, marked by puberty's arrival. Following the words of Alqorori, "until the little girl reaches perfection and physical maturity."6 Early marriage is very vulnerable to family conflicts. Various problems, such as they do not have psychological, economic, and educational maturity, are problems that lead to divorce. The results of research reinforce this by Rahman and Nasrin that Marriage at a young age is low monthly income, stress, cases of high school dropouts, the occurrence of domestic violence, high chances of maternal death, low schooling, and low reproductive health rights. 7 The primary legal basis for marriage is the Koran. Many verses in the Qur'an talk about marital problems, one of which is found in the Qur'an Surah al-Nisa' 4; 3: "and if you are afraid that you will not be able to do justice to (the rights of) orphaned women (if you marry them), then marry (other) women you like: two, three or four. then if you are afraid that you will not be able to act fairly, then (marry) only one, or the slaves you have. that is closer to not doing wrong." (Q.s al-Nisa': 3). Marriage is generally done by adults regardless of profession, religion, ethnicity, poor or rich, living in a village or in a city. Nevertheless, only some people who already have physical and mental abilities will find a partner according to what they want. In human life, marriage is not temporary but for life. Unfortunately, not everyone can fully understand the essence and purpose of marriage, which is to achieve true happiness in the household. The age limit for getting married is essential. Marriage requires psychological maturity. The age of marriage that is too young can result in an increase in divorce cases due to a lack of awareness to be responsible in married life husband and wife. 8 The prevalence of early marriage practices in society makes the role and function of Islamic religious instructors interesting to discuss in this study. How is the performance of Islamic Religious Counselors in minimizing early Marriage in Wara District? What are the roles and functions of Islamic Religious Counselors in minimizing early Marriage in Wara District? What strategies are carried out by the Islamic Religion Counselor in reducing the number of early marriages in Wara District? So this research wants to know the performance, roles, and functions, as well as the strategies used by Islamic Religious Extension Workers in minimizing early Marriage in Wara District. The implications of this research are expected to enrich the body of knowledge regarding marital problems from the perspective of religion and Islamic law regarding efforts to reduce the number of early marriages. In addition, it is hoped that this can be input and consideration for Islamic Religion Counselors who work in the Office of Religious Affairs to reduce the number of early marriages related to their functional roles, namely informative function, consultative function, educative function, and advocative function. Research conducted by Abdul Basit explains that the challenges faced by Islamic religious educators in Indonesia are clearly mapped, the emergence of liberal and fundamental Islamic movements, where their presence clashes one community with another. Therefore, as an extension of the government through the Ministry of Religion, the Islamic Religious Counselor profession is expected to be an antidote to movements that divide society in particular and the Indonesian nation in general. 9 In addition, Hasan Dau's research, Rizal Darwis, shows that the existence of the Penghulu in North Gorontalo Regency has a huge role in minimizing the occurrence of divorce. This success is due to the existence of practical communication efforts by the Penghulu with troubled families and the desire of the troubled parties to solve their problems amicably. 10 From the research above, the presence of Islamic Religious Counselors is crucial. Their presence not only functions as a social institution but their function and role have a significant role in coaching amid society. The role is a dynamic aspect of position (status). If a person carries out his rights and obligations according to his position, he plays a role. The difference in roles and positions is for the sake of science. The two cannot be separated. Since there is no role without a role and a role without a position, they are interdependent. 11 Roles are the general expectations about the appropriate behaviors that people with a particular role should perform. 12 There are at least three functions of the Religious Extension Officers, which they must play in carrying out their duties, namely: (1) Informative and educative function, namely as a preacher who is obliged to preach his religious teachings, convey religious information and educate the public as well as possible following the teachings of his religion. (2) Consultative function; namely participating actively and participating in solving problems faced by the community, both personal, family, environmental, and community problems with guidance and solutions from religious teachings. (3) Advocative function, namely having a moral and social responsibility to carry out advocacy activities for the inmates against various threats, disturbances, obstacles, and challenges that are detrimental to society's faith, worship, and morals. 13 --- Method This research is qualitative research with an empirical approach to Islamic law. The steps and designs of empirical legal research follow the patterns of social science research, especially sociology. Therefore it is not 9 AbdulBasit,. "Tantangan Profesi Penyuluh Agama Islam dan Pemberdayaannya. Jurnal Dakwah, XV, No.1 (2014) h. 157. 10 Hasan Dau, Rizal Darwis, "Eksistensi Penghulu dalam Meminimalisir Perceraian di Kabupaten Gorontalo Utara. Jurnal Al-Mizan Vol. 15 No. 2, 201 ISSN 1907-0985 E ISSN 2442-8256. Hal. 268 11 Soerjono Soekanto, Sosiologi Suatu Pengantar, (Jakarta: Raja Grafindo Persada, 2012), h. 210 12 Sarlito Wirawan Sarwono, Teori-Teori Psikologi Sosial, (Jakarta: Raja Grafindo Persada, 1995), h. 99-100. 13 Dudung Abdul Rohaman dan Firman Nugraha, Menjadi Penyuluh Agama Profesional (Analisis Teoritis dan Praktis), (Bandung: LEKKAS, 2017), h. 9. wrong to say that this empirical legal research can also be called "socio-legal research." 14 The subjects in this study were two functional Islamic Religion instructors (PAIF), four Non-PNS Islamic Religion extensionists (PAI-Non PNS), and one BP4 mediator who served at KUA Wara District. In addition to the six research subjects above, the authors interviewed three beneficiary community members from activities carried out by religious extension workers and BP4 to serve as research informants. The object of this study is the role and function of religious instructors in carrying out professional functions for cases of early marriage in the Wara sub-district, Palopo. At the same time, the data collection techniques in this study used interviews, observation, and documentation. The data analyst used is an interactive analysis from Miles and Huberman, which includes data reduction, data presentation, and data verification or conclusion. Data analysis is carried out continuously and continuously until complete data is obtained. --- Result and Discussion --- The Performance of Islamic Religious Counselors in Minimizing Early Marriage in Wara District From 2019 to 2022, the Wara District Office of Religious Affairs handled 375 marriage events (the table is presented in the background), and 17 of them were cases of early marriage. Suppose the percentage is around 4.5%. This figure is small when compared to marriage events in other districts. Early marriage events in 2019, there were only 6 cases out of 168 marriage events that occurred in Wara District. From the findings in the field, the number of Marriage cases in the Wara District was small because religious instructors in the Wara District Office of Religious Affairs directly went into the community to socialize the dangers and impacts of early marriage. --- "Sebagai penyuluh agama Islam di wilayah Kecamatan Wara ini, selain melakukan pembinaan kepada orangtua melalui pengajian. Kami memang langsung membina anak-anak remaja. Melakukan penyuluhan tentang dampak dari pernikahan dini. Apalagi saat ini arus informasi dan digital kencang sekali. Sehingga kami sebagai penyuluh agama mencoba mengarahkan mereka untuk tidak terpengaruh melakukan hal-hal yang belum halal. Kami biasa melakukan workshop bahaya pernikahan dini meskipun tidak bisa dihindari bahwa ada saja muncul peristiwa pernikahan dini yang disebakan karena faktor pendidikan". 15 From 2020 to 2022 there were 8 early marriages at the Wara District Religious Affairs Office. A low level of education or not going to school anymore for a woman encourages her to get married quickly. People with low levels of education tend to marry off their children at a young age, in line with what was expressed by uztadsah NS, one of the Islamic religious instructors at the KUA Wara District. "Faktornya itu pendidikan, biasanya orangtua mendukung jika anak ingin berhenti sekolah, kalau sudah tidak sekolah terus kerja lalu mau kerja apa lagi kalau tidak menikah, jadi pilihannya yah menikah Rata-rata mereka itu pendidikannya di SMP atau SMA, kalau di jenjang perguruan tinggi masih jarang ditemukan kasus seperti itu". 16 The results of the author's interview with teenagers who were married at the age of 17, namely Youth I, are currently 19 years old. The teenager got married in November 2020; it has been two years since she was married, and she is now six months pregnant with her first child. He is the first child of two siblings; his younger sibling is currently studying at junior high school, and his parents work as farmers. The teenager I was last educated with was in high school; after graduating, he immediately worked in a shop. Not long after working, his parents introduced him to his husband because a teenager I and her husband, who are six years apart, have the same principle: they do not want to date and want to get married, so they decided to get married. "Tidak suka ka' pacaran Pak, sudah pernah kerja jadi lebih baik langsung menikah mi saja. Saya lulus waktu masa corona dan sudah kerja walaupun ijazah belum keluar. Sebelumnya juga sudah kenal sama suami cuma tidak pernah ketemu terus dikenalkan sama ibunya suami". 17 The reality in people's lives in Wara District is that there are still people who do not know about government policies regarding the prohibition of underage marriage, namely in the latest regulation, Marriage Law No. 16 of 2019, which requires that men and women be allowed to marry with a minimum age of 19 years, so below that prohibits prospective brides from marrying. This is as expressed by Uztad MIR, one of the Islamic religious instructors at KUA Wara District. "Masyarakat itu ada yang kurang tahu tentang larangan pemerintah terkait undang-undang yang melarang menikah di bawah umur 19, jadi pas datang ke KUA mau daftar menikah umurnya masih kurang". 18 The lack of public knowledge of the government's recommendations is a challenge for the Islamic Religion Counselors in Wara District, so their program and duty is to socialize it to the community. Furthermore, this is done by religious counselors through recitations in groups of taklim assemblies. Underage marriages are under government recommendations in the law on marriage no. 16 of 2019; it is stated that bridal couples may carry out marriages with a minimum age limit of 19 years. This marriage could be better compared to marriages that are old enough to increase child productivity and mother's safety; also, the possible impact is divorce. The marriage law was made to assure the public that marriage is not as easy as one might imagine; marriage is sacred and should not be treated as a toy. In addition, underage marriages have a negative impact. Moreover, a man, as a leader in the family, has a great responsibility to his wife, namely the responsibility of the world and the hereafter and vice versa. 19 "Menurut saya, selama menjadi anggota majelis pengajian yang dibimbing oleh penyuluh agama Islam yang bertugas di Kecamatan Wara ini, saya pribadi mendapatkan banyak pencerahan. Khususnya tentang pernikahan. Apalagi saya ini khan orangtua yang memiliki anak. Jadi kalau menurut saya kinerjanya penyuluh agama Islam di sini bagus, mereka langsung terjun kelapangan, terbuka sama warga". 20 Based on these interview excerpts, the Islamic religious instructors who work in Wara District have performed well in the eyes of the community because they have a straightforward program that directly reaches out to the community. This is in line with the opinion of the contents of the letter Attaubah verse 105 that in carrying out the assigned duties of employees, they should carry out work without any element of compulsion, but because the work given to them is their responsibility, because all actions carried out will be accounted for in the afterlife later and also affect the job done in this world related to the results of employment and wages received from that work. Also, Mangkunegara states that performance results from work in quality and quantity achieved by an employee in carrying out his duties following his responsibilities. 21 --- The Roles and Functions of Islamic Religious Counselors to Minimize Early Marriage in Wara District The main task of the Religious instructor by the provisions of the Decree of the Coordinating State Minister for State Supervision Number 54/KEP/MK.WASPAN/9/1999 is to carry out and develop Religious guidance or counselling and development activities through the language of religion. 22 Religious instructors as community leaders act as priests in religion and social issues as well as in matters of state by making government programs successful. 23 In addition to carrying out their duties, Islamic religious instructors are also required to carry out their functions in society so that they can be said to have a role in society. a) Informative and Educative Functions 19 Hasil wawancara dengan Bapak HNF selaku penyuluh agama Islam KUA Kecamatan. Wara. 20 Wawancara pribadi dengan Ibu Nirwana, Jama'ah majelis taklim binaan Penyuluh agama Islam Kecamatan Wara, 20 Oktober 2022. 21 A.A Anwar Prabu Mangkunegara, Evaluasi Kinerja Sumber Daya Manusia, (Jakarta: Rafika Aditama, 2017), h. 27 22 Kemenag RI, Petunjuk Teknis Pelaksanaan Jabatan Fungsional Penyuluh Agama, (Jakarta: Kemenag RI, 2012), h. 12. 23 Trisnayati, Strategi Komunikasi Penyuluh Agama Islam Fungsional Dalam Upaya Pencegahan Perceraian Di Kabupaten Tangerang, (Tesis: Jurusan Komunikasi Penyiaran Islam, Fakultas Ilmu Dakwah dan Ilmu Komunikasi UIN Jakarta, 2018), h. 71. KUA Wara Islamic Religion Counselors carry out coaching and guidance activities to congregations in taklim assemblies and assist KUA's duties in conveying information about the importance of participating in pre-marital guidance activities, which are the KUA Wara program. "Sekaitan dengan fungsi informatif, kami senantiasa memberikan informasiyang aktual, terbaru, terupdate sejak perkembangan yang ada. Baik semua aturan-aturan pernikahan terbaru, disosialisasikan kepada masyarakat. Perkembangan digital yang maju pesat kami manfaatkan untuk menjadi media untuk sosilisasi terkait aturan-turan terbaru tentang perkawinan". 24 The description of the explanation that the author found in the field is as follows: --- 1) Activities of Majelis Taklim Related to carrying out informative and educative functions for cases of early marriage, the KUA Wara Islamic Religion instructor provides information and teaching to the counselling target with material guidelines originating from the shekinah family movement development program designed by the Ministry of Religion. This particular material about the shekinah family is usually in the form of munakahat fiqh material, but because the Islamic Religious instructors are not devoted to conveying material only about the shekinah family, but deliver counselling material from all aspects of religion. The material usually inserted is in the form of age maturation in marriage, morals, and fostering household life. As revealed by Uztadzah KDJ. "Materi yang biasa disisipkan seperti materi kesiapan mental dalam menjalani rumah tangga. Kesiapan umur dalam menjalani pernikahan. Juga materi berakhlak yang baik sama pasangan, misalnya bersikap lemah lembut dan tidak berkata kasar sama pasangan misalnya, seorang istri harus mematuhi perintah suami dengan catatan kepada hal-hal yang dibenarkan sama Agama dan bukan mengikuti perintah yang dilarang Allah Swt. Selain itu juga materi tentang bagaimana memanage rumah tangga mulai dari pola asuh anak. Karna membangun keluarga sakinah bukan hanya hubungan antara suami dan istri saja tetapi seluruh yang berada dalam keluarga, baik anak, orangtua, bahkan dilingkungan masyarakat".25 --- 2) Pre-Marital Marriage Guidance Pre-marital marriage guidance for the bride and groom is a form of activity that aims to educate the prospective bride and groom before going through the process of married life. This marriage guidance activity is carried out once a week, on Thursday from 10.00-13.00 WIB, located in the KUA Wara marriage hall. To find out more clearly about the initial stages of marriage guidance activities for the bride and groom, the following is the expression of the Uztad BDJ. "Jika calon pengantin mendaftarkan diri, pihak KUA melihat kelengkapan persyaratan yang mereka serahkan. Kalau sudah terpenuhi persyaratannya, kemudian di Billing atau didaftarkan ke pusat. Nah, baru oleh kita diberikan surat panggilan untuk mengikuti BIMWIN itu. Biasanya bisa seminggu atau dua minggu sebelum mereka melangsungkan pernikahan. Kita kondisional, dan ada waktu-waktu tertentu yang memang diarahkan oleh Kantor Kementrian Agama Kabupaten itu untuk dilaksanakan secara serentak atau massal. Nah diluar itu, ketika misalnya tidak secara definitif ditentukan oleh Kementrian Agama Kabupaten Bogor, setiap orang yang daftar untuk pernikahan kita tetap melayani kegiatan BIMWIN itu meskipun hanya satu atau dua pasang". 26 This guidance is carried out after the prospective bride and groom who register have fulfilled all administrative requirements at the KUA. After all the requirements are met, the KUA will issue a summons to the prospective bride and groom containing a timetable for the activity to take place one to two weeks before the activity is carried out. Apart from that, there are certain times when marriage guidance activities are held simultaneously, but outside of these times, the KUA will continue to carry out BIMWIN activities even if only one or two pairs of prospective brides and grooms register. The material in BIMWIN's activities included the basic teachings of Islam, the law on marriage, domestic violence, family planning, and reproductive health. In addition, in the pre-marital marriage guidance activities that were held simultaneously, participants who participated in the activity received certificates and souvenirs in the form of a sakinah family foundation book, notes, and pens. Pre-marital marriage counselling activities are a preventive effort so the prospective bride and groom can know about marriage. From the explanation above regarding the informative and educative function of the KUA Wara Islamic Religious Instructor for cases of early marriage, the KUA Wara Islamic Religious Instructor has implemented it well. --- b) Consultative Function In carrying out the consultative function, the Islamic Religious Education instructor at KUA Wara provides himself to think about and solve problems faced by the community, both personally, as a family, and as members of the general public with guidance and solutions to religious teachings, especially regarding household problems experienced by the people of Wara District.. As for reports of household problems experienced by the community, such as infidelity, husbands not providing a living, differences of opinion, domestic violence, and polygamy. As expressed by Uztad TS. "Saya sering terima curhatan dari jama'ah tentang masalah rumah tangganya. Tapi ada juga masyarakat yang mau konsultasi dan datang langsung ke KUA.Biasanya masalah yang dialami mereka itu macam-macam seperti masalah perselingkuhan, istri mengeluh suami tidak memberikan nafkah, masalah perbedaan pendapat, KDRT, poligami. Nah kebanyakan yang datang konsultasi soal masalah KDRT adalah pasangan muda-muda. Mereka menikah di bawah umur. Based on the results of the interviews above, Islamic religious instructors are a place to ask questions and a place to complain to the community to help solve the problems they are facing. Unscheduled consultation activities such as activities at the taklim assembly. For this reason, extension workers must be ready to serve people who want to consult with them. This is because questions related to personal problems in public. So usually, people who want to consult ask for an extension time after the activities of the taklim assembly or come directly to the KUA. In consultation, the Islamic Religious Education instructor at KUA Wara cooperates with BP4 in helping to deal with household problems experienced by a client where BP4 is a professional organization that is socio-religious as a partner of the Ministry of Religion and related institutions, both government and non-government in realizing a sakinah ma waddah wa rohmah family. 27 The author also had the opportunity to interview a member of the community in Wara District who had household problems and to conduct consultations at the Wara District Office of Religious Affairs in 2020. Ms. Sabawiyah was a victim of domestic violence committed by her husband in 2019. Ms. Sabawiyah received a bruise on her head, but the problem was resolved so that Ibu Sabawiyah and her husband can reconcile. The household problems of Mrs. Sabawiyah re-emerged when Mrs. Sabawiyah decided to return to her original place, namely in Wara District, when she was pregnant with her second child. Ibu Sabawiyah's husband again showed an uncompromising attitude, such as always getting angry at things that were considered trivial. As expressed by Mrs. Sabawiyah. "Dua kali maka' bermasalah sama suami. Pertama waktu saya tinggal di daerah Sabbang, suami saya menuduh saya ambil iuangnya, saya tidak terima. Sebelumnya memang ada perselisihan juga, terus suamiku napukul kepalaku sampai memar. Saya bilanglah sama bapakku lewat telepon, dan bapaku kasi saran untuk visum dan lapor ke polsek supaya ada efek jera buat suamiku. Kalau dulu saya tidak cabut berkas, suamiku bisa dipenjara. Tapi alhamdulillah masalah yang itu sudah selesai. Nah yang kedua, waktu hamil ka' anak kedua ini, kebetulan saya disesar. Saya minta biaya untuk sesar, dia bilang ji "jangan-jangan itu bukan anakku" malah bilang begitu. Suami saya itu wataknya keras, masalah yang spele-spele saja dia suka banting-banting barang, kalau marah suka tidak jelas. Saya juga sudah bingung dan coba datang ke KUA untuk curhat, terus aku konsultasi sama penyuluh tentang masalah rumah tangga saya". 28 Based on the interviews and the author's findings in the field, the authors conclude that the Islamic Religion instructors who work with BP4 KUA Wara are very open and helpful to people who wish to conduct consultations regarding the household problems they are currently experiencing. --- c) Advocative Function In the advocative function, the KUA Wara Islamic Religion instructor has a moral and social responsibility to carry out activities to defend the people/society from various threats, disturbances, obstacles, and challenges that harm faith, disrupt worship, and damage morals. The way for the KUA Wara Islamic Religion extension staff to maximize their role in carrying out their advocative function is to provide advocacy in the form of assistance. Based on the author's observations in the field, the problems experienced by the community are already at a critical level, and both parties lack the effort to reconcile. For this reason, assistance is provided with techniques and strategies that can calm and provide solutions to couples in conflict. In addition, efforts to build communication with related institutions were also carried out. What has been done by the Islamic Religious instructors above can be related to the extension theory put forward by M. Arifin. In extension theory, it is said that counselling means illuminating, advising, or giving clarity to others so that they understand or understand what they are experiencing. 29 --- The Strategies of Islamic Religious Extension in Reducing Early Marriage Rates in Wara District The task of religious extension officers is to provide guidance, information, and direction to the community in the religious and social fields to increase public knowledge of religious teachings further and then encourage them to implement them as well as possible. Likewise, in social matters, they provide guidance and encouragement so that people know what to do and organize in everyday life for the sake of progress and prosperity. 30 Romauli's theory states that efforts to overcome early marriage include setting the early marriage age above 20 years, not forcing children, and providing counselling about the risks of early marriage. 31 In addition, Ketty Mangkey also believes that underage child marriage can be prevented through parents being proactive in supervising children, family education, religion, early sex education control from parents, frequent discussions with children/making children friends. 32 Likewise, regarding dealing with underage marriages, Islamic religious instructors at the KUA Wara District, Palopo, made various efforts and strategies to convey government policies and prevent underage marriages, especially in the District. Wara. The following strategy is carried out, namely: 1. Counselling on the Prevention of Underage Marriage An underage husband and wife carry out underage marriages according to Law no. 16 in 2019, i.e., under 19 years. Handling underage marriages requires proper counselling so that youth can consider the decisions made to avoid the possible impacts that may occur. Based on the results of research on the strategy of Islamic religious instructors in reducing the number of underage marriages by socializing the impact of underage marriages to adolescents in their working areas. Extension officers try to provide understanding for both adolescents and parents regarding marriage, readiness for marriage, readiness for reproductive organs, and marriage problems so that they can make the right decision if one day they are going to get married and are old enough. In carrying out counselling activities related to underage marriages, extension workers conduct outreach about the dangers of underage marriage to congregations of taklim majlis, when there are public recitations at village halls or mosques as well as at schools. Counselling is not only for extension workers who play a role, but there must also be cooperation from all government agencies at all levels of society. Likewise, KUA also conducts direct pre-marriage guidance at KUA, called kurscatin (bride-to-be courses), and provides marriage guidance books when couples register at KUA. 33 Intensifying the PUP (Marriage Age Maturity) program the aim is to provide understanding and awareness to adolescents so that in family planning, they can consider various aspects related to family life, physical, mental, emotional, educational, social, economic readiness and

This research aims to determine the strategies by Islamic Religious Counselors in reducing the number of early marriages in the Wara district. The author chooses qualitative research with an empirical approach to Islamic law to analyze social reality in depth. This approach was chosen because the authors wanted to explain an in-depth analysisof Islamic religious extension officers' role in carrying out informative, educative, consultative, and advocative functions in early marriage cases. The subjects in this study were two functional Islamic religious instructors, five non-civil servant Islamic religious instructors, and one BP4 mediator. The object of this study is the role of religious instructors in carrying out professional functions in cases of early marriage. The study results showed that the Islamic Extension Counselors in Wara District performed well because they carried out informative and educative roles and functions, consular and advocative functions as extension agents consistently by conducting direct counselling to the community. The strategies undertaken to reduce the number of early marriages arecounsellingto prevent underage marriages, rejecting underage brides, socializing the importance of formal education to adolescents, and approaching parents to maximize their role in educating children.

socializing the impact of underage marriages to adolescents in their working areas. Extension officers try to provide understanding for both adolescents and parents regarding marriage, readiness for marriage, readiness for reproductive organs, and marriage problems so that they can make the right decision if one day they are going to get married and are old enough. In carrying out counselling activities related to underage marriages, extension workers conduct outreach about the dangers of underage marriage to congregations of taklim majlis, when there are public recitations at village halls or mosques as well as at schools. Counselling is not only for extension workers who play a role, but there must also be cooperation from all government agencies at all levels of society. Likewise, KUA also conducts direct pre-marriage guidance at KUA, called kurscatin (bride-to-be courses), and provides marriage guidance books when couples register at KUA. 33 Intensifying the PUP (Marriage Age Maturity) program the aim is to provide understanding and awareness to adolescents so that in family planning, they can consider various aspects related to family life, physical, mental, emotional, educational, social, economic readiness and determine the number and spacing of births. 34 --- Rejection of Underage Brides A marriage dispensation case filing is made in the form of a request (volunteer), not a lawsuit. The Court's decision is in the form of a determination. A copy of this stipulation is made and given to the applicant to fulfill the requirements to enter into a marriage. If the applicant is unsatisfied with the Court's decision, he can appeal to the Supreme Court. 35 The results of the study resulted in the District KUA. Wara Kota Palopo refuses to submit a marriage proposal if it is known that the prospective bride and groom are not old enough to register their marriage according to the latest law, Marriage Law No. 16 of 2019 article 7, paragraph 1 with the condition of being pregnant, the KUA cannot prevent it so that the prospective bride and groom must submit an age dispensation to the Court to conduct a trial. If the Court's decision on the outcome of the trial is permitted, the KUA can continue the marriage process from the letter that has been attached. On the other hand, if the prospective bride and groom come to the KUA at an underage age under 19 years, but there is no compelling reason to get married, the KUA refuses to do so without a hearing. This is per Law no. 16 of 2019 concerning amendments to Law Number 1 of 1974 concerning marriage article 7 paragraph 2 that if there is a deviation from the age requirement, the parents of the man/woman can request a dispensation from the Court with very urgent reasons accompanied by sufficient supporting evidence. 36 Rejection of the prospective bride by the District Office of Religious Affairs. Wara to underage couples is expected to confirm that getting married is not as easy as imagined; it is necessary to have administrative files that follow the terms and rules referring to the marriage law, which has been passed as a state regulation to its citizens without being sub-district so that it must be carried out and paid attention to under applicable law. --- Socialization of the Importance of Formal Education to Teenagers There is a correlation between the level of education and age at marriage; the higher the child's age at marriage, the education the child is relatively higher and vice versa. According to a 2016 UNICEF study, marriage at an early age is associated with a low degree of education. Delaying the age of marriage is one way for children to receive higher education. 37 A low level of education or not a continuing school for a woman can encourage her to get married quickly. People with low levels of education will marry off their children at a young age. 38 This follows the results of research that children who stop going to school, do not continue their education, and decide to work will think about getting married even though they are still young because children do not have responsibilities that allow their time to be busy with valuable things. This is supported by Yunus' opinion, which states that the reason for early marriage is that those who do not go to school have an impact on their inability to make decisions and, on the other hand, do not have information related to reproductive health. Likewise, according to Yunita, education is essential in a person's life, and she has a good mindset in making decisions and choosing good or bad actions. The higher a person's education, the more information that is owned is broader and more readily accepted, especially about reproductive health, the ideal age for marriage, and the impact of marrying young. 39 Besides opening the horizons of thinking, education can also make idle time that has not been productive so far become more productive with various activities that add to children's discourse. Free time that is not filled with practical activities is perilous for young people to do various activities that are not particularly useful for themselves, such as dating or associating with many things that tend to be negative. This is in line with its function, extension as an educational function that participates in thinking about and solving problems faced by the community by providing an understanding of education for children with the aim that children do not drop out of school and can get a higher education. --- The role of parents In the concept of communication as a system, it is found that the integrity of communication built since childhood is significant. If one of the parents has not physically accompanied the child since they were small, communication function will not be optimal. Some parents are physically present but do not meet the child's communication needs. Parents tend to communicate less openly, do not have enough time together, and lack knowledge about the child's environment, girlfriends, hobbies, and school, so the function of family communication does not work. This causes adolescents to look for a forum for communication outside the family without knowing what possible consequences they will face later. One of the consequences is the early marriage which begins with pregnancy out of wedlock. 40 According to Handayani, the role of parents in controlling children's lives is closely related to early marriage; the role of parents who are not good is 5.78 times more likely to encourage children to marry at an early age. 41 This follows the results of interviews with respondent A, who at school needed more attention from his parents, especially in terms of communication. Parents are rarely at home, resulting in a tenuous relationship between parents and children and parents not following the child's growth and development. Therefore, children feel they are not being given affection, so they look for someone to give them the attention their parents do not get. According to Suprajitno, family is a marriage bond and blood relationship that lives together in one or the other with their respective roles and emotional ties. Kumalasari and Andhyantoro stated that to prevent early marriage, and the family has a significant role; namely, parents need to introduce marriage laws, guide teenagers and explain sex education to children. 42 The Office of Religious Affairs, as an institution at the forefront of implementing Islamic marriages in Indonesia, must follow up on age limit rules according to government policies on marriage. KUA Wara District has carried out efforts and programs optimally in this task. Not only the KUA but cooperation from all levels of society is needed so underage marriages can be handled correctly. 40 April 2023, Vol.8, No.1, hal.125-144 --- Conclusion The Islamic religious instructors at KUA Wara perform well because they go into the field to counsel the community about early marriage. In carrying out its informative and educative roles and functions, the instructor socializes the latest marriage laws through the Quranic study forum. In carrying out the consultative function, extension workers provide consulting services related to problems for couples in conflict. Meanwhile, in carrying out the advocative function, the extension worker acts as a companion and becomes a mediator regarding the community's household problems. The number of early marriages in the Wara sub-district has decreased in the last three years because extension workers have implemented an outreach strategy based on a direct approach to the community. They were socializing the law on marriage, providing knowledge of the dangers and impacts of early marriage. This research suggests to; (1) the Ministry of Religion; Make policies that are more in recruiting Islamic Religious Instructors by taking into account the educational background of the Instructors and the technical capabilities of Islamic Religious Instructors in approaching the community and in carrying out their duties. (2) Islamic religious instructors; improve performance to always uphold professionalism and responsibility to the community by adopting, diffusing, and innovating in conducting guidance and counselling to the community so that it can keep up with the times. (3) KUA Institutions; Monitor on an ongoing basis the activities carried out by Islamic Religious Extensionists and BP4 in conducting guidance and counselling to the community to further evaluate and improve the guidance and counselling. Cooperating and outreach to community leaders, traditional leaders, and religious leaders regarding the role of Islamic religious extension officers, the role of BP4, and the role of KUA institutions so that people can know who and where they can meet to help solve their problems.

This research aims to determine the strategies by Islamic Religious Counselors in reducing the number of early marriages in the Wara district. The author chooses qualitative research with an empirical approach to Islamic law to analyze social reality in depth. This approach was chosen because the authors wanted to explain an in-depth analysisof Islamic religious extension officers' role in carrying out informative, educative, consultative, and advocative functions in early marriage cases. The subjects in this study were two functional Islamic religious instructors, five non-civil servant Islamic religious instructors, and one BP4 mediator. The object of this study is the role of religious instructors in carrying out professional functions in cases of early marriage. The study results showed that the Islamic Extension Counselors in Wara District performed well because they carried out informative and educative roles and functions, consular and advocative functions as extension agents consistently by conducting direct counselling to the community. The strategies undertaken to reduce the number of early marriages arecounsellingto prevent underage marriages, rejecting underage brides, socializing the importance of formal education to adolescents, and approaching parents to maximize their role in educating children.

Introduction Talk of promoting'recovery' looms large in mental health policy discussions, especially in Englishspeaking countries, where there is much talk of a need to implement'recovery oriented' mental health systems and services (e.g. Brown and Kandirikirira 2008;Farkas et al. 2005;Sowers 2005). However, despite repeated attempts to formulate a universally acceptable 'working definition' (e.g. US Substance Abuse and Mental Health Services Administration 2011), the precise meaning of'recovery' in this context remains ill-defined and often contested (Bonney and Stickley 2008). Talk of recovery in the policy literature tends to focus on how mental health service users might be expected to experience recovery: most commonly, recovery is described as a personal 'journey' with no fixed end-point and no predefined route, in the course of which individuals are enabled to live meaningful and satisfying lives, whether or not they continue to experience symptoms of mental illness (e.g. Frese, Knight, and Saks 2009;Scottish Government 2010). As Ramon and colleagues note in their analysis of Australian and British literature on recovery, such definitions tend to emphasise the kinds of values -notably the provision of individualised, person-centred care and support -that recovery advocates believe should inform mental health care (Ramon, Healy, and Renouf 2007). However, it remains unclear how those values should be translated into mental health policy and practice, despite increasingly sophisticated efforts to specify just what'recovery-oriented' services should look like (Farkas 2007;Farkas et al. 2005). Some social scientists have sought to understand this lack of clarity in the meaning of'recovery' with reference to the divergent interests of the different actors laying claim to it or the different contexts in which it is articulated. In a study of UK policy debates, for instance, David Pilgrim (2008) points to the different concepts of recovery articulated by traditional biomedical psychiatrists, community-oriented social psychiatrists and dissenting service users. On the other side of the Atlantic, Nora Jacobson (2004) adds a historical dimension by showing how, in the United States, the idea of recovery acquired different meanings, first as psychiatric assumptions about the possibility of recovery were challenged by radical service users, and subsequently as it was incorporated into mental health policy and the wider politics of welfare provision. Such approaches undoubtedly help to explain the tensions and multiplicity of meanings associated with recovery. But they leave one wondering why such divergent groups should nonetheless have converged in their advocacy of something called'recovery'. Thus while Pilgrim (2008) characterises recovery as a "polyvalent concept" providing an "uneasy consensus point" around which different actors could combine to redefine the aims of mental health policy, he says nothing about how that consensus was established and how it is maintained. Jacobson, meanwhile, is primarily concerned with charting the incorporation of recovery into policy, and is more interested in following the shifts in meaning that accompanied that incorporation than in understanding the drivers or processes that made it possible. The present paper seeks to fill this gap by offering a new account of how and why recovery became so prominent in mental health policy. It does so through a case study of the development of recovery in Scotland. Here as elsewhere, talk of recovery has come to figure prominently in mental health policy debates over the past decade. In addition, Scotland has implemented a growing armamentarium of practices and techniques in the name of recovery (Bradstreet and McBrierty forthcoming; removed for blinding). Such developments are not uncontentious, however; while many hail them as placing Scotland at the forefront of developments in mental health reform, some recovery advocates object that standardised procedures are at odds with the individualised, personcentred values of recovery, which by definition should cannot be identified with particular practices (removed for blinding). Scotland thus provides an interesting site for investigating not just how the concept of recovery came to figure as a focus for policy debates, but also for analysing the social dynamics of alignment and contestation around specific practical instantiations of recovery. Our analysis draws heavily on theoretical perspectives from social movement theory. It is of course common for recovery advocates and commentators alike to talk about recovery, not just as a set of ideas or values, but as a'movement', either in its own right (e.g. McCranie 2010) or, more usually, as an expression of the mental health consumer/survivor movement (e.g. Frese and Davis 1997;Sowers 2005;Tomes 2006). Such usage registers a widely-held awareness that the growth of recovery as a policy aim owes at least as much to a groundswell of popular pressure as it does to leadership from the policy elite. However, it is rare for commentators to explicate just what they mean by a'movement'; and even rarely for them to make use of the analytical and explanatory resources afforded by social movement theory (cf. Brown et al. 2004). Even where they do make such use, moreover, it is almost exclusively in order to analyse the relationship between recovery and the specific aims and interests of the consumer/survivor movement. Thus Jacobson and Curtis (2000) draw on social movement theory when they observe that, as articulated by members of the consumer/survivor movement, the concept of recovery expresses a distinctive identity politics; and Adame and Knudsen (2007) further develop this perspective by exploring how the consumer/survivor movement adopted the language of recovery to articulate an alternative to biomedical discourses of illness and healing. No-one, to the best of our knowledge, has drawn on a rather different strand of social movement theory which focuses, not on the politics of identity, but on the processes whereby social movements expand beyond their original constituency by recruiting new members. The present paper shows that much can be gained by adopting this perspective. Thus, we are able to offer novel insights into how and why different actors in the mental health policy landscape came to align themselves around the promotion of recovery as a policy goal. We are also able to identify and explain emerging tensions within the recovery movement, and to case light on the possible futures of recovery, both as a policy aim and as a social movement. Perhaps most interestingly, we are able to suggest why the very vagueness with which recovery is defined might actually be more an asset than a hindrance to the success of recovery in Scotland. --- Social movement theory Ideas about what can legitimately be understood as a social movement -or, more precisely, about what kinds of social phenomena can appropriately be understood through the lens of social movement theory -have expanded significantly in recent years. Early commentators tended to suppose that social movements are essentially oppositional, extra-institutional, and organised from the grass roots. This view continues to colour much thinking on the topic; according to one recent review, for instance, "Social movements are conscious, concerted and sustained efforts by ordinary people to change some aspect of their society using extra-institutional means" (Goodwin and Jasper 2009:3; see also Tarrow 2011). But scholarly interest in social movements has also developed in other directions. Notably, many commentators are now less concerned to determine what social movements are than to understand the processes by which they come into being, develop and decline. And this focus on process rather than definition has in turn led to a much more expansive and inclusive view of a social movements. Thus it is now widely accepted that participation in social movements is not necessarily confined to 'ordinary people', if by that is meant people without access to prevailing power structures and institutional configurations. Health social movements, for instance, commonly involve alliances between lay people and professionals (Joffe et al. 2004;McCormick et al. 2003). They may also include actors embedded within state agencies, forming "state actor-social movement coalitions" which often prove particularly effective in securing positive policy outcomes (e.g. Stearns and Almeida 2004;Wolfson, 2001). Some social movement scholars go further, rejecting the assumption that social movements typically exist outside institutionalised politics, and seeing social movements within as well as without the political establishment (Goldstone 2003). Nick Crossley, in his groundbreaking study of the British mental health service user movement, has gone so far as to suggest that social movements might best be understood, not in terms of their membership or social location, but, following Bourdieu, as "fields of contention" (Crossley 2006) -a formulation that is notably inclusive, and that allows space for diversity and divergence within a larger shared orientation towards political action. One does not have to take on board Crossley's entire Bourdieusian framework to welcome this move towards understanding social movements, not in terms of the particular constituencies that they mobilise, but in terms of how they work to orient the politics of contention (e.g. McAdam et al. 2001). This shift in focus is evident also in a concern to understand how social mobilisation occurs, and in particular how and why individuals are persuaded to align themselves with -and lend their time, energy and resources to -the goal of securing a particular social change. Of particular interest to the present paper has been the adoption of the idea of 'framing'. Borrowing from Goffman's (1974) conception of frames as "schemata of interpretation", Benford and Snow, among others, have identified framing as key to social mobilisation (Snow et al. 1986;Snow and Benford 1988;Benford and Snow 2000;Benford and Snow 2005). As Benford and Snow (2000:614) state: "Frames help to render events or occurrences meaningful and thereby function to organize experience and guide action." A growing body of empirical research has shown how social movements frame social issues in such a way as to imply particular courses of action and particular policy responses (e.g. Cress and Snow 2000;Coe 2009;Moghadam and Gheydanchi 2010;Rose 2011). Meanwhile, Snow and Benford (1988;Benford and Snow 2000) have gone on to identify a number of 'core framing tasks' that they see as central to the way that social movements frame social issues for the purpose of mobilising supporters. First is 'diagnostic framing' -the identification and characterisation of a shared problem in need of action. Second is 'prognostic framing', or the articulation of a common understanding of how this problem should be addressed and solved. And third is'motivational framing', which involves identifying or suggesting a reason why the issue should be acted on; in effect, motivational frames "function as prods to action" (Snow and Benford 1988: 202). Individually and together, these different forms of framing all operate "by simplifying and condensing aspects of the 'world out there'... in ways that are 'intended to mobilize potential adherents and constituents, to garner bystander support, and to demobilize antagonists'" (Benford and Snow 2000:614). Mobilisation itself is achieved through through 'frame diffusion', as a particular action frame expands into new social and cultural settings. Benford and Snow see such diffusion occurring in two ways: either through a process of'strategic fitting', whereby social movement actors engage in "tailoring and fitting the objects or practices of diffusion to the host culture"; or through'strategic selection', which involves "intentional cross-cultural borrowing, with the adopter or importer... strategically selecting and adapting the borrowed item to the new host context or culture" (Benford and Snow 2000: 627). As we shall see, this strand of social movement theory provides a singularly effective toolkit with which to understand the growth of recovery in Scotland. In what follows, we will present a narrative of the development of recovery as an action frame that resonated with the aims and interests of a wide range of mental health activists, and that provided a way of guiding and aligning their actions into common channels. In this respect at least, recovery can be regarded as having emerged as a social movement in its own right, and we will speak of it as such throughout this paper. However, we are less interested in arguing over whether or not recovery really is a social movement, than with seeing what can be gained analytically be regarding it as such. As we shall see, those gains are significant. --- Methods This paper derives from a five-year research project looking at knowledge and policy in mental health in Scotland, undertaken as part of a much larger project, KnowandPol, whose aim was to investigate the role of knowledge in policy for health and education across twelve European research sites. The initial stages of our research on this project involved mapping the Scottish mental health policy landscape (removed for blinding), including a series of 42 interviews with individuals prominent in Scottish mental health policy. In the course of these interviews we also sought to identify topics of particular interest for investigating how knowledge creation or mobilisation was involved in or impacted on the development of mental health policy in Scotland. A number of our respondents from these initial interviews indicated that recovery was an area at the forefront of Scottish mental health policy and practice, and suggested that it would be a potentially fruitful topic for further research. We accordingly set out to supplement our data from this preliminary research with a more in-depth investigation of recovery in Scotland, based on detailed content analysis of key documents and a series of semi-structured interviews. Key texts were located through searches of the Scottish Government website, NHS websites and the Scottish Recovery Network website. We searched for any documents produced in the period between the establishment of the devolved Scottish government and the end of the KnowandPol project (1999 -2010). A number of additional texts, including some from before the period covered by our literature search, were identified by interview respondents and incorporated into our analysis. However earlier documents were also analysed through the inclusion of additional texts identified by respondents. The documents were mainly government documents including policy or service guidance, official and unofficial documents produced by NGOs and service user organisations, meeting summaries, minutes and policy consultation submissions. In the end, over thirty such texts were identified and incorporated into the analysis. Interviewees were selected on the basis of having being mentioned by respondents in the preliminary stages of our research as particularly important in the incorporation of recovery into Scottish mental health policy. On this basis we were able to identify a number of interviewees including government policy makers, practitioners (including those working in psychiatry and as service managers), advocacy workers, activists and service users, thus providing a good balance of the types of roles engaged in recovery policy and practice in Scotland (removed for blinding). The lead author went on to conduct semi-structured interviews of 30 to 75 minutes in length with nine of these individuals, in locations convenient to the respondents. Questions related to the history and implementation of recovery from the perspective of the respondent. Analysis of the results proceeded concurrently with the interviews. Once saturation was reached, in the sense that new interviews ceased to yield new data, no further interviews were conducted (Morse 2000;Onwuegbuzi and Leech 2007). We note that saturation was reached relatively quickly. We attribute this to three factors. First, the mental health community in Scotland is relatively small and closely interconnected, with the consequence that members tend to reproduce a relatively small range of well-rehearsed narratives and opinions. Secondly, the limited range of answers available to our respondents was further constrained by the fact that our research questions focused quite narrowly on the role of knowledge in mental health policy, specifically in relation to recovery. Thirdly, our research into recovery came relatively late in the overall KnowandPol research project, with the consequence that we already possessed extensive data and understanding of mental health policy in Scotland, some of which related specifically to recovery. This prior knowledge further informed and helped to focus the conduct of our interviews and the analysis of the resulting data. Where appropriate, some of these earlier findings have been incorporated into the present paper, and we have cited our previous papers where this has occurred (removed for blinding). Analysis of the data proceeded through documentary and discourse analysis of the key texts and interview transcripts. As the focus of the KnowandPol project was on understanding the role of knowledge in relation to policy, particular attention was paid to discovering what knowledge was deployed by our respondents and in the documents. This included factual and technical knowledge of mental health, of recovery, and of policy. But it also included knowledge of actors, relationships, and social processes in the development and implementation of recovery. We also paid attention to how that knowledge had developed over time, and the combination of interviews and documents enabled us to begin constructing a history of the growth of recovery in Scotland. The relevance of social movement theory to our analysis became apparent inductively, when we realised that the early years of recovery in Scotland were dominated by service users drawing on their own experiential knowledge, and that only more recently has recovery become incorporated into official policy and practice. We therefore refined our analysis to produce a history of the growth and progress of recovery as a social movement, drawing particularly on the insights that Benford and Snow provide into the role of framing in social mobilisation (Snow andBenford 1988, Benford andSnow 2000). --- Results and discussion --- Actors' histories of recovery: genealogy and framing Given the lack of consensus or clarity about just what kind of mental health practices'recovery' might refer to, it plainly makes little sense, from a sociological point of view, to ask just when and where such practices began. Actors in the recovery movement share no such qualms, however, and accounts of historical origins are frequently rehearsed in the literature on recovery. This is unsurprising. The construction of historical genealogies and the election of ancestors can serve a powerful legitimising purpose. By identifying venerable antecedents, recovery advocates not only seek to forge a common identity, but also to highlight the particular values and ideologies that inform their present-day activities. In this respect, recovery advocates' reconstruction of history can itself be seen as a way of framing mental health in line with contemporary aims and interests, as was apparent from the interviews we conducted with our Scottish respondents. When asked about the origins of'recovery', many of our respondents recited elements of a historical narrative that would be familiar to recovery activists around the world. Some sketched a history that went back long before the term acquired anything like the meaning or currency it now enjoys in relation to mental health, looking back as far as the'moral' treatment pioneered by the Quaker William Tuke at the York Retreat in the 1790s (Practitioner 2 1 ; NGO 1; cf. Davidson et al. 2010). But the majority identified more recent origins, pointing especially to the United States and to the peer support organisations such as Alcoholics Anonymous and Abraham Low's 'Recovery, Incorporated' that emerged there from the 1930s (NGO 2; Government 1), or to the psychiatric rehabilitation movement that developed from the 1960s (Community 2; NGO 1; Community 1; NGO 2; Government 1). What these origin stories have in common is an emphasis on the development of mental health practices that stood outside of, and in opposition to, the mainstream psychiatric practice of their time, and that involved a shift away from professional psychiatric care towards service user empowerment. Take for instance the connection that our interviewees drew with Recovery, Incorporated. Set up in the late 1930s by psychiatrist Abraham Low, Recovery, Inc. was initially intended to provide aftercare for patients discharged from psychiatric hospital. Rooted in Low's neuropsychiatric understanding of mental illness and its symptoms, Recovery, Inc. provides patients with training in behaviour modification techniques aimed at controlling symptoms and thereby facilitating life in the community. For present-day advocates of recovery, however, the technical content of the training programmes is less important than the fact that Recovery, Inc. quickly grew beyond Low's direct involvement to become a self-help organisation run by and for service users themselves. According to Wesley Sowers, an American recovery advocate, Recovery, Inc. now "offers a peer assisted healing program that focuses on changing thought processes, developing autonomy, and regaining productive and satisfying lives. Like the 12-step approach [of Alcoholics Anonymous], it attempts to empower people to take responsibility for managing their illness or disability" (Sowers 2005: 758; see also Buchanan-Barker and Barker 2008;White 2000). A similar emphasis on self-help and empowerment can be seen in our interviewees' invocation of the psychiatric rehabilitation movement. Developing chiefly in the US from the 1960s onwards, psychiatrist advocates of rehabilitation such as William Anthony initially defined it in functional terms: "...to ensure that the person with the psychiatric disability can perform those physical, emotional, and intellectual skills needed to live, learn, and work in his or her own particular community, given the least amount of intervention necessary from agents of the helping professions." - (Anthony et al.1986:249-250) Subsequently, however, in a widely cited article that he published in the early 1990s, Anthony moved beyond this vision of rehabilitation to speak of "recovery from mental illness". Recovery, according to Anthony, is a deeply personal process, rooted in validation of individual experience, empowerment and peer support, and ill served by a psychiatric system that he depicted as anonymous, ineffective and damaging to those it was designed to help (e.g. Anthony 1993: 527). More recent advocates of recovery underline this same transition from the functionally oriented focus of psychiatric rehabilitation to an idea of recovery based in service user groups and oriented towards personal and political 'empowerment' (e.g. Jacobson and Curtis 2000). In locating the origins of recovery in innovations such as Recovery, Inc. and psychiatric rehabilitation, present-day recovery advocates thus construct a genealogy that foregrounds the agency of mental health service users themselves, and stresses their increasing independence from conventional psychiatric services. Our Scottish informants invoked these American origins for much the same purpose. However, when they came to narrate the subsequent development of recovery, it is notable that our informants quickly departed from a US-centric account and instead pointed to other antecedents. Our interviewees placed particular stress on relating the growth of recovery to the consolidation, during the 1990s, of an increasingly powerful and effective mental health service user movement (NGO 1; NGO 2; Rogers and Pilgrim 1991, Crossley 2006). This movement found expression in a proliferation of meetings, conferences and other events, where service users were "increasingly sharing their experiences, sharing their stories, becoming the focal point of efforts to improve mental health and mental health outcomes both here [in Scotland] and abroad" (NGO 1). The language of recovery was quickly taken up in this setting, and discussed in a number of important international forums including the World Network of Users and Survivors of Psychiatry, MindFreedom International, the European Network of (ex-) Users and Survivors of Psychiatry and, more recently, the International Initiative for Mental Health Leadership. Strikingly, our Scottish informants made little mention of the contributions that American service users made to those discussions. Instead, they argued that a number of key service user groups and individual service users from the UK, New Zealand and Canada were pivotal in linking the term'recovery' with aims and ideals that resonated with those of the Scottish service user movement (Community 1; Community 2; Government 1). In particular, four of our respondents identified developments in New Zealand as crucial for the development of the idea of recovery, and for its diffusion into Scottish mental health policy (Government 1; Practitioner 1; NGO 1; Community 2). This privileging of precursors from New Zealand rather than the US tells us much about the values that our Scottish informants wished to identify with recovery. In 1997, the Mental Health Commission for New Zealand published a Blueprint for Mental Health Services in New Zealand: How Things Need to Be (O'Hagan 2004;Mental Health Commission 2007). This was the first time that recovery was specified as a guiding priority for the provision of national mental health services. The involvement of service user activists in policy development was key to this achievement. The first Chair of the Mental Health Commission, Barbara Disley, consulted widely with service users, who ensured that recovery become a key theme of the Blueprint (O'Hagan 2004; Government 1; Community 2). One of those service users, Mary O'Hagan, later reflected on what was intended by this. O'Hagan took the view that, as used in the United States, the term'recovery' remained too closely associated with the work of psychiatric rehabilitation and "did not place a great deal of emphasis on challenging the veracity of or the dominance of the biomedical model in mental health services." Service users in New Zealand therefore adopted the term, not to denote the kind of psychiatry-led services that they associated with the US, but rather as a useful "container" which could be employed to express their own preferred concepts and values, including a "spotlight on human rights, advocacy and on service user partnerships with professionals at all levels and phases of service planning, delivery and evaluation" (O'Hagan 2004). It was these values that the service users sought to have written into the Blueprint, which declared that "The focus of this Blueprint is on a recovery approach in service delivery... services must empower consumers, assure their rights, get the best outcomes, increase their control over their mental health and well-being, and enable them to fully participate in society... The recovery approach requires mental health services to work towards righting the discrimination against people with mental illness which occurs within services and in the wider community." - (Mental Health Commission 1998: vii.) Scottish recovery advocates' identification of New Zealand rather than the United States as the principal source for their own conception of recovery reflects a similar concern to 'own' recovery, and in particular to emphasise the independence of user-led knowledge and practice from earlier psychiatry-led models of service provision. This is apparent, for instance, in the Scottish recovery narrative project (for more detail see removed for blinding). According to our informants, this project was explicitly intended to "Scottishise" recovery by collecting personal narratives of recovery from service users across Scotland (NGO1; NGO2, Community 2). Significantly, the recovery narrative project was modelled on a similar project -"Kia Mauri Tau!" narratives of recovery from disabling mental health problems -that had taken place in New Zealand in 2002 (Lapsley et al, 2002). According to our respondents, an important motive for emulating the New Zealand example by adopting a narrative project in Scotland was to distinguish Scottish recovery from the American version, which was seen as "more mono-cultural", less "community centred" and less flexible with regard to personal situations and needs than what was being developed in New Zealand (NGO1 and NGO2). Whether or not this negative portrayal of how recovery had developed in the United States is accurate is not the point here. Rather, what is important is the way that service users both in New Zealand and in Scotland projected a particular image of America as a means of exemplifying values and practices that they did not wish to see enacted in their own countries. Seen through the lens of Benford and Snow's (2000) account of how social movements frame problems as a means of social mobilisation, we can understand this 'othering' of American recovery as in effect a rhetorical move in a more general reframing of the problem of mental health along lines that accorded with the aims and values of mental health service user movements in New Zealand and Scotland. Previously, mental health policy and practice had been understood within a predominantly psychiatric frame, which diagnosed mental illness as the problem and identified the exercise of psychiatric authority as the preferred solution. The idea of'recovery', as exemplified in the New Zealand Blueprint and the "Kia Mauri Tau!"narrative project, involved a very different framing: excess psychiatric power was now framed diagnostically as part of the problem, while service users' individuality, autonomy and personal experience became part of the prognostic framing, as key values around which mental health services needed to be reoriented. The idea, first articulated by Mary O'Hagan in New Zealand and subsequently echoed by our Scottish informants, that this involved appropriating the very term'recovery' from an excessively psychiatry-led American rehabilitation movement, gave additional rhetorical bite to this reframing. The contrast with America, whether or not it was based in reality, served to further emphasise the agency of service users and problematize existing mental health services. In so doing, it provided a useful shorthand to express the values and expectations of the service user movement -a striking instance of what Benford and Snow (2000: 627) call'strategic selection' of an idea from one frame and its adaptive incorporation into another. The fact that our Scottish informants looked to developments in New Zealand rather than the US when identifying immediate antecedents to their own activities thus tells us much about the radical and emancipatory that the Scottish mental health service user movement associated with the concept of recovery. Our Scottish informants can be seen as constructing a historical narrative or genealogy that served to legitimise their own activities, aims and values, and that helped to frame the problems of mental health in line with the interests of the service user movement. This is borne out if we now look at how the language of recovery actually came to be incorporated into Scottish mental health discourse. --- Recovery comes to Scotland While the 1990s saw the growth of a service user movement in the UK with many of the same aims and values as its New Zealand counterpart (Community 1), the term'recovery' does not appear to have been widely used in Scotland during that period. Rather, service user groups such as the Hearing Voices Network and the Highland Users Group (HUG) discussed and advocated approaches to mental health that a number of our respondents would retrospectively identify with a recovery orientation (NGO 1; Community 2; NGO 2; Community 1). For instance, a 1998 report by HUG highlighted what kinds of service its members would expect from a satisfactory mental health service: -"be able to secure their rights to benefits, good housing etc. -have the presence of a caring person in their lives -get well -have enabled individuals to influence their care and treatment -be recognised and treated as a person -be treated better by others -be able to maintain their chosen lifestyle -be able to accept their illness and cope better with it -have a choice of services -feel better about themselves -be more informed about their illness and what to expect from services and treatments -be given care in both the short and long term -get help quickly when in crisis -to be more in control -have access to people who care" -(Highland Users Group 1998) It was not until 1999 that such aims and values began to be explicitly identified in Scotland with the word'recovery'. That year saw the publication of Recovery: An Alien Concept by Ron Coleman, a Scottish service user prominent in the service user movement. Coleman was concerned that existing mental health services were so pervaded with an idea of mental illness as intractable that most people diagnosed with mental illness health did not think that recovery was possible (Community 1); recovery had become totally 'alien' to the mental health system (Coleman 1999). Coleman's book, which advocated a very similar user-led approach to service provision to what was being promoted in New Zealand, was crucial both in domesticating the language of recovery in Scotland and in associating it with the aims and values already being articulated by the service user movement. Coleman proved to be a very effective proselytiser for recovery, not just in Scotland but abroad. As one respondent commented: "Ron Coleman has been a kind of lynchpin of recovery in the world" (NGO 2). Thereafter, talk of recovery quickly gathered momentum in Scotland. Several of our respondents (Community 2; Community 1; cf. Scottish Development Centre for Mental Health 2002) spoke of the importance of a discussion at the Visions and Voices conference held in Dundee in 2001, which culminated in a decision to establish a Scottish Recovery Forum. This initiative was spearheaded by a small group of representatives of service user organisations, mental health charities and research organisations (Community 1). The aim of the Forum was to establish a network "to help create and promote further opportunities for sharing experiences, learning and understanding the recovery process in Scotland" (Scottish Government 2002), and it proved highly effective in placing recovery firmly on the mental health agenda in Scotland (Scottish Development Centre for Mental Health 2002). It also marked something of a transition in the status of recovery. Until that point, recovery had served in effect as a useful term with which to rebrand many of the aims and values that the service user movement had already been promoting under other names. Increasingly, however, recovery was now coming to be seen as an movement in its own right, that attracted adherents from beyond the confines of the service user movement. A key event in this respect was a 2002 workshop and national dialogue event on recovery which set out to consider "the many different ways of thinking about recovery" and to discuss what kinds of services were needed in order to help to promote recovery (Bradstreet and McBrierty 2012). The event generated considerable interest across Scotland, attracting an audience of over 100 participants. Importantly, the participants were drawn, not just from the service user movement, but also from various governmental and non-governmental service providers, and the audience was more or less equally divided between statutory agencies, voluntary organisations and people who attended as individuals (Scottish Development Centre for Mental Health 2002: 3). The report of the workshop, published later that year, tells us much about how the event was organised, and for what purpose. Although the report was published under the title Would Recovery Work in Scotland? it gives no indication that the organisers had any doubts that it would work. The formal presentations that opened the workshop do not appear to have raised any critical questions about the effectiveness of recovery, nor to have provided any empirical evidence to counter such questions. Rather, as one of the main organisers announced at the start, the workshop was "about supporting existing work on recovery and starting new work to build good practice" (Scottish Development Centre for Mental Health 2002: 3). Far from being an evaluation of the possibilities of recovery, it was an opportunity to build support and spread the word. In this regard, it is striking how closely the organisation and content of the workshop conformed to Snow and Benford's (1988) account of how social movements seek to mobilise adherents by projecting a particular framing of a social problem and its proposed solution. The workshop opened with a series of short presentations that each addressed the question "What is recovery?" and that each offered a similar framing of recovery as the preferred solution to the difficulties experienced by those who experienced mental health problems. Diagnostically, the problem was presented, not as one of mental illness, but rather as a lack of "hope" and "control" (Scottish Development Centre for Mental Health 2002: 3) that tended to be compounded rather than relieved by "the effects of the mental health system" (Scottish Development Centre for Mental Health 2002: 4); as Ron Coleman put it in his presentation, "People need to recover from the system, not their mental health problem" (Scottish Development Centre for Mental Health 2002: 5). The corresponding prognostic framing accordingly cast recovery as the means of addressing this problem by "enabling individuals to take charge of their own lives with the support which they require... empowering people to make real

Recovery' has become a key element in Scottish mental health policy and practice, despite continuing uncertainty over just what is meant by 'recovery'. This paper draws on social movement theory to explore the processes underlying the growth of recovery in Scotland. Based on documentary analysis and semi-structured interviews with key actors, it looks at the emergence of a 'recovery movement' in Scotland, and in particular at how that movement articulated a 'recovery frame' that subsequently came to inform policy and practice. It then reflects on the dilemmas posed by this success, as the recovery movement expanded to intersect with state agencies, and the recovery frame was adapted to accommodate the needs of government policy. It concludes that the future of the recovery movement in Scotland will depend on its ability to maintain a sufficiently broad and inclusive framing of recovery even as it becomes associated with specific policies and practice.

the workshop conformed to Snow and Benford's (1988) account of how social movements seek to mobilise adherents by projecting a particular framing of a social problem and its proposed solution. The workshop opened with a series of short presentations that each addressed the question "What is recovery?" and that each offered a similar framing of recovery as the preferred solution to the difficulties experienced by those who experienced mental health problems. Diagnostically, the problem was presented, not as one of mental illness, but rather as a lack of "hope" and "control" (Scottish Development Centre for Mental Health 2002: 3) that tended to be compounded rather than relieved by "the effects of the mental health system" (Scottish Development Centre for Mental Health 2002: 4); as Ron Coleman put it in his presentation, "People need to recover from the system, not their mental health problem" (Scottish Development Centre for Mental Health 2002: 5). The corresponding prognostic framing accordingly cast recovery as the means of addressing this problem by "enabling individuals to take charge of their own lives with the support which they require... empowering people to make real choices for themselves" (Scottish Development Centre for Mental Health 2002: 3). In consequence, the organisers argued, the mental health services needed to be thoroughly reoriented around recovery, in such a way as to: -"support the development of services and interventions that are recovery focused -nurture the development of recovery focused workers -nurture the process of recovery for people with experience of mental health problems" -(Scottish Development Centre for Mental Health 2002:4) Strikingly, the meeting and report also offered what Snow and Benford call "motivational framing", in the form of the personal story of an individual whose difficulties had been exacerbated by the treatment she received from the mainstream mental health services, but whose life had been turned around when she found more recovery-oriented support: "Audrey described her experiences of being diagnosed and treated and the effects that her medication had on her ability to work and to study. She came to feel that she no longer wanted to live under the shadow of medication. She felt she had been 'written off' and was depressed -'who wouldn't be?' Being part of self-help groups and the Hearing Voices Network was a liberating experience and the start of a journey towards recovery." -(Scottish Development Centre for Mental Health 2002:5) Following these presentations, the participants broke up into discussion groups to consider, first, the question "what does recovery have to do with me?", and secondly to address issues raised by participants themselves. Again, the workshop report does not record any critical examination of the framing of recovery as the solution to the problems of mental health, and it would appear that the discussions were conducted squarely within that frame. The report ended by outlining "ways ahead", not just for "people already committed to recovery", but also "for others who have yet to 'get the message' of recovery" (Scottish Development Centre for Mental Health 2002:12). The succeeding years have seen a continuing stream of conferences, meetings and other 'talking events' where service providers, researchers, NGOs and service users can meet to talk about recovery and to spread the recovery message to others (Community 1; NGO 1; Community 2; NGO 2). Such events have been crucial to the continuing diffusion of the recovery frame in Scotland, and they appear to have been effective in mobilising a growing number of recovery advocates and activists. One respondent, for instance, spoke about his first exposure to the concept of recovery at a conference jointly hosted by SAMH and service user groups in Glasgow in 2004: "People from the Hearing Voices Network started talking about their experience of using services, how everything about their life had become symptomatic and diagnosis was reflected -they only lived through diagnosis and in some way people interact with them through diagnosis... The conference instigated a lot of self-reflection for service providers." -(NGO 2) A number of our respondents, meanwhile, suggested that they had found the idea of recovery attractive because it resonated with and succinctly expressed ideals that they were already seeking to put into practice in their own work: "...the voluntary sector were very much involved as well who saw recovery as a very positive way of articulating what they had been saying for a very long time about the way they approach mental health issues." -(NGO 1) "... [recovery] connects with what we think is wrong with mental health services, what we want to be doing with them... When I do recovery training...it's not as though people are learning anything new, they are kind of unlearning what it is they have been doing." -(NGO 2) In consequence, an increasingly wide range of actors came to agree with the view that mental health provision should be reoriented around the values of recovery, while recovery became an accepted language for representing the values that many wished to see expressed in the mental health services. The recovery frame was diffused well beyond its origins in the mental health service user movement, and was now being deployed by a growing range of service providers -both statutory and nongovernmental -and, increasingly, by policy makers. In effect, recovery had gone beyond being just one among a number of ways of expressing the values of the service user movement, and had become a social movement in its own right. --- Recovery in policy and practice It is an indication of the success of that movement that recovery was quickly incorporated into official Scottish government mental health policy. In 2001 the Scottish Executive (established in 1999 following the creation of the Scottish Parliament, and renamed the Scottish Government in 2007) introduced the nation's first population mental health strategy under the title of the National Programme for Improving Mental Health and Wellbeing (hereafter the National Programme). Gregor Henderson, a mental health researcher and campaigner who had been closely involved in the creation of the Scottish Recovery Forum and subsequent meetings (Community 1; Community 2), was appointed Director of the National Programme. According to a number of our informants, Henderson's appointment was crucial to the adoption of recovery as an official policy priority by the Scottish Executive (Community 1; NGO 1; Community 2; Bradstreet and McBrierty 2012). Recovery certainly loomed large in the National Programme, which published its first action plan in 2003. "Promoting and supporting recovery" was listed as one of four "key aims" for action over the next three years (Scottish Executive 2003:2); and the action plan also announced that the National Programme would support and fund "the development of a National Recovery Network for Scotland" (Scottish Executive 2003:6). According to the action plan: "The proposed aims of the Network are to collect and disseminate people's experiences of recovery and to provide information and advice to a range of local and national agencies to promote and support recovery. The proposed Network will also collect and disseminate relevant national and international evidence and material on recovery." -(Scottish Executive 2003:6) The Scottish Recovery Network (SRN) was duly launched in December 2004 under the direction of Simon Bradstreet, another community activist who had been closely involved in promoting recovery in Scotland. In effect, the SRN took over the work previously undertaken by the Scottish Recovery Forum of promoting the development and diffusion of the recovery frame within Scotland. One of our respondents explicitly equated this with building a'movement' for recovery: "[SRN is] a network in that we are a pretty loose association of organisations and individuals so a lot of people link in and work with us one way or another by coming to events and being involved in training to create a sort of a movement for a recovery approach. But also a network in terms of getting information out there as quickly as possible. About sharing information." -(NGO 1, emphasis added) Government support also enabled the SRN to explore additional ways of developing and diffusing the recovery frame. As we have seen, the National Programme action plan proposed that, among its other activities, the SRN would "collect and disseminate relevant national and international evidence and material on recovery" (Scottish Executive 2003:6). Accordingly, one of the first initiatives undertaken by the SRN was the preparation and publication of a series of discussion papers on topics that included "Researching recovery from mental health problems" (Berzins 2004), "Elements of recovery: international learning and the Scottish context" (Bradstreet 2004), and "Recovery and community connections" (Connor 2004). The creation of a documentary evidence base helped not only to reinforce the recovery frame but also to recast it in a format that was more acceptable within the Scottish policy environment. From its initial inclusion in the National Programme, recovery thus became increasingly firmly embedded in mental health policy in Scotland, being adopted as a central element in a succession of policy documents including the review of mental health nursing Rights, Relationships and Recovery (2006), the planning document Delivering for Mental Health (2006), and the new population mental health strategy Towards a Mentally Flourishing Scotland (2009). The adoption of recovery as a policy aim also helped to pave the way for the development and implementation of what we have elsewhere described as'recovery technologies' (removed for blinding). These are specific practices that recovery advocates see as instantiating the aims and values of recovery within mental health services. Our respondents identified four such recovery technologies as particularly important in rolling out recovery in Scotland. These were: the collection and dissemination of'recovery narratives' (discussed above); the development of the Scottish Recovery Indicator (SRI); the adoption of the Wellness Recovery Action Planning (WRAP); and the formalisation of peer support. Each of these technologies served to diffuse recovery into the mental health system in different ways. The personal recovery narratives collected by SRN through the recovery narrative project resulted in publications that helped to spread the recovery message throughout the mental health sector. They not only provided a further means of exemplifying and disseminating the recovery frameparticularly the'motivational framing' of recovery as effective relief from the distress of mental illness -but also helped to build an evidence base that could be used to justify the adoption of recovery as a policy goal in Scotland. Other mental health organisations have since followed SRN in collecting and publishing recovery narratives (removed for blinding). Meanwhile, the other three recovery technologies impacted more directly on how services are organised and delivered. WRAP, developed by US-based service user Mary Ellen Copeland, is used in the context of in-patient and community mental health services and self-help groups to help service users to assess their own needs and strengths and to plan their own route to recovery (Cook et al. 2009). 'Peer support' involves the employment of service users within mental health services in order to'model' recovery, demonstrate to both service users and staff that recovery is possible, and help steer the reorientation of services towards recovery. And the SRI is a self-assessment tool, adapted from an American model (Mancini and Finnerty 2005), for staff working in mental health service delivery to assess the extent to which their particular services embody a recovery orientation. The fact that all three of these technologies were partly modelled on or inspired by practices in the United States is at first sight rather surprising, given our respondents' claims that the development of recovery in Scotland was modelled on initiatives pioneered by the New Zealand service user movement as an antidote to excessively psychiatry-led American models of recovery. However, as we document in more detail elsewhere, considerable efforts were made, under the auspices of the SRN, to 'Scottishise' each of these technologies by making them more service user-centred, less bureaucratic, and more oriented towards the realisation of recovery values than towards the delivery of specific kinds of services (removed for blinding). In Benford and Snow's terms, we can see this as another instance of'strategic selection' and'strategic fitting' of tools from one action frame to another. The adoption of recovery into official Scottish Government mental health policy, and in particular the activities of the Scottish Recovery Network, have thus been highly effective in achieving further diffusion of the recovery frame from the mental health service user movement to a much wider constituency of actors. A key step in this diffusion has been the adoption and promotion by government and the SRN of a number of new'recovery technologies', which not only serve to instantiate and exemplify the values of recovery in practice, but have also been effective in extending the recruiting mental health practitioners and service providers into the recovery frame. This is striking evidence of the success with which the Scottish recovery movement was pursuing its goals. At the same time, however, our interviews indicated a degree of ambivalence and sometimes even hostility among our respondents regarding the direction in which recovery was developing, both as a set of ideas and practices and as a social movement. --- Emerging tensions At issue was who should own recovery. The financial links between SRN and the Scottish Government were a matter of particular concern in this respect. Officially, the SRN is a nongovernmental organisation, hosted and run by the mental health charity Penumbra. As one of our respondents emphasised, this arms-length relationship with government has been crucial in enabling the SRN to operate as an inclusive network that brings together voluntary bodies and individuals who would have been less enthusiastic about dealing with an official government body (NGO 1). As another observed, official endorsement of recovery had done much to further the dissemination of the recovery frame: "To be fair. The one thing that having that policy, that having that arm of a strategy on recovery coming from the government has meant [is] that everybody has been able to hear that message and I think that was really important." -(Community 1) But the same respondents also expressed a concern -echoed by other interviewees -that the recovery agenda in Scotland had become too close to government, and was losing its connection to the service user movement that had initially championed it (NGO 1; Community 1; NGO 2; Community 2). Where recovery had started as a "grassroots movement", we were told, the agenda was increasingly being "driven by the centre rather than local groups" (Community 1). Recovery activists' concerns about the ownership of recovery were not merely proprietary. Importantly, they came down to an anxiety that, as a result of the incorporation of recovery into official policy and practice, it was coming to serve rather different aims and interests from those originally intended by the service user movement. Thus, as one respondent put it: "I think unfortunately along with [the adoption of recovery as a policy goal] comes this desire, because policy makers are always looking for models, and because recovery has never been a model for us it has always been a process, I think this desire to find a model I think some of us became quite antagonistic towards, you know that there was a model that you could fit everybody and that would do recovery and that's never been the experience of recovery from a consumer perspective, but it's what systems like. Systems like models because you can measure them and work with them in a much easier way." -(Community 1) For this respondent, the worry was that the institutionalisation of recovery led to a standardisation of practice that was at odds with the idea that recovery should be tailored to the needs of each individual service user. In particular, this respondent feared that recovery technologies such as the SRI would lead not just to standardisation but to bureaucratisation of recovery (Community 1). Under the wrong circumstances, another service user opined, the SRI might be turned into an audit tool for regulating and standardising services in a way that would hinder rather than promote the kind of open-ended patient-centred support originally associated with the recovery framework (Community 2). Our Scottish Government respondents seem to have shared such fears, one of them insisting that the SRI "should be a system for people to improve and change services rather than scoring and condemning them" (Government 2). Some of our respondents went so far as to express a concern that, while the terminology of recovery was being adopted by policy makers and service providers, what was actually being implemented was not really recovery at all, at least as it had initially been understood by members of the service user movement (Practitioner 2; Community 1; NGO 1; cf. Bonney and Stickly 2008;Tilley and Cowan 2011). Official usage of the term'recovery', one respondent argued, was no more than an empty rhetorical gesture: "They use it to rename wards. But I say to them,'recovery is a verb, not a noun'" (Practitioner 2). Others even hinted that there might be more cynical motives behind policy makers' appropriation of the language of recovery, which they feared could be used to justify cuts in services by shifting responsibility for mental health back onto service users (Community 2; Community 1). The same respondents also worried that government policies encouraged professional take-over of recovery, in a way that tended rather to disempower than to empower service users: "People do their recovery and people had been recovering before all this came on board so who owns it? Is it grounded in users' experiences, in people's experiences of recovery or is it something that comes down as a policy and mediated through professions." -(Community 2) "One of the big tensions, I think in some ways, is that this has been professionalised, that recovery has been professionalised and the professionals have taken responsibility for it and rolled it out." -(Practitioner 1) Here too, the adoption of certain recovery technologies was seen as especially problematic. WRAP, for instance, had initially been developed by Copeland with the expectation that service users would facilitate the work of drawing up their own personal action plans. Increasingly, however, that role was being taken on by mental health service staff, in a move that one service user saw as "further evidence of the colonisation of a process" that had originally been user-led (Community 1). For this recovery advocate, WRAP was something of a Trojan horse; despite the inclusion of'recovery' in the name, it actually reproduced the values of the system that recovery was intended to replace. Just as bureaucratisation was seen as threatening to undermine the original meaning and aims of recovery, then, so too was professional colonisation. For recovery to work, our respondents argued, service users needed to be free to shape it around their own individual lives and needs; but professional control, like bureaucratisation, diminished their ability to do so (NGO 2; Community 2). All of these factors have meant that the adoption of recovery into government policy and mental health practice has led to a growing tension within the Scottish recovery movement. In a sense, the movement has been a victim of its own success. Recovery activists have been very effective in diffusing the recovery frame outwards from its original base in the service user movement to mobilise support among a growing constituency that now includes service providers and policy makers as well as service users. Increasingly, the movement has come to be centred on the government-sponsored Scottish Recovery Network, in what we can see as an instance of the 'interpenetration' of social movements and state organisations (cf. Epstein, 2007: 506). At the same time, however, the recovery frame has itself developed and changed, notably with the inclusion of new technologies such as SRI and WRAP among the armamentarium of'recovery oriented' solutions it now offers for the problems of mental health. In effect, as the recovery movement has penetrated the world of official policy and practice, so the recovery frame has been partially realigned, through processes of'strategic fitting' and the'strategic selection' of new techniques, with the requirements and expectations of that world. This has in turn led to growing ambivalence on the part of many within the recovery movement. Unsurprisingly, that ambivalence focuses in part on the adoption of new recovery technologies from the USA, which, despite efforts to 'Scottishise' them with a greater emphasis on patient-centred support rather than psychiatric control, are seen by some recover advocates as introducing elements that are more in keeping with the psychiatry-led and bureaucratic approach to mental health services that recovery was supposed to replace. Opposition to the adoption of these recovery technologies has been particularly vehement among those members of the mental health service user movement most opposed to psychiatric and other institutional responses to mental ill health and most insistent that any acceptable solution can come only from service users themselves-a group that some of our respondents referred to as an "angry edge" of activists (NGO 2; Community 1; NGO 1; Government 3). It remains unclear how the "angry edge" of the recovery movement will react to the continuing official adoption of recovery. While some respondents feared that they would foment wider resistance towards what they saw as the hi-jacking of recovery by an agenda that they did not approve of (NGO 2), others suggested that they were more likely simply to withdraw from the recovery movement in order to develop a more radical vision of mental health that was more closely aligned with the values of the service user movement (NGO 1; Community 1; Government 3). As one respondent put it: "So... the reality is that we are now beginning to think beyond recovery and you'll start to see conferences begin to happen now that are called 'beyond recovery' and things like that and a lot of that is a consumer response to what we see as the start of the next turn off on the journey." -(Community 1) Just as the recovery movement emerged from and expanded beyond its origins in the service user movement, it would appear that a new movement is beginning to form as some recovery movement members look for a new way of reframing mental health that will once again prioritise the role of service users themselves in determining how their own mental health needs are to be met (see also Edgley et al. 2012). What form such a frame will take, and whether it will enjoy anything like the success of the recovery frame, remains to be seen. In the meantime, despite the ambivalence of some members and the withdrawal of others, it would appear that the existing recovery frame still resonates strongly with service users as well as service providers and policy makers. As such, it seems likely that the recovery movement, strongly interpenetrated as it is with the Scottish Government, will remain a potent force within Scottish policy on mental health for some time to come. --- Conclusions: recovery as a social movement In this paper we have used the lens of social movement theory to view and recount the growth of recovery in Scotland, from its beginnings in the mental health service user movement to its present position as a key element in Scottish mental health policy. Thus we have shown how the idea of recovery was first adopted in Scotland as a way reframing the problem of mental health to reflect the aims and values of service users. But as we have seen, the recovery frame was not only of interest to service users; it also diffused into new social spaces, attracting a growing constituency of reformist mental health professionals and policy makers, who shared many of the values of the service user movement, and who saw recovery as a way of advancing those values. At the same time, these new actors also began to implement new techniques and new forms of mental health care in the name of recovery, thereby refitting elements of the recovery frame in ways that better suited the needs of mental health service providers, but which alienated at least some of the users of those services. In many respects, this narrative reinforces the views of Pilgrim (2008) and Jacobson (2004) that'recovery' does not denote any single, determinate set of mental health practices, theories or values; rather, the precise meaning of recovery depends to a considerable extent on who is talking about it, and the context in which it is being discussed. However, our use of social movement theory, and specifically of that strand of social movement theory that looks at the mobilising role of framing, enables us to go beyond this deconstruction of recovery, and to consider how and why different actors and constituencies should have aligned themselves with the recovery movement. If we are to understand the rise of recovery, then, there is little to be gained by asking what recovery actually is, in the sense of what kind of mental health practices it implies. But much may be gained by asking how recovery works as an action frame that serves to align and mobilise activists and mental health reformers from a broad range of constituencies. Our use of social movement theory also enables us to throw light on a particularly puzzling aspect of the rise of recovery, namely the fact that it has been widely endorsed, adopted and incorporated into policy, even while what is meant by recovery remains unclear and contestable. As we have seen,'recovery' has never been defined with any great degree of clarity or specificity; rather, its use in mental health discourse serves chiefly to denote a set of rather general values, including the empowerment of service users and scepticism regarding the role of organised mental health services. Seen as a way of framing the problem of mental health, recovery -it least in its earlier stages -was at best only loosely articulated, and included little in the way of specific recommendations for mental health policy or practice. Consequently, it could readily be adapted to accommodate not only the aims and values of service users but also those of service providers and policy makers: in the language of Benford and Snow (2000), it could be'strategically fitted' to a range of contexts and practices beyond those with which it was originally associated. It would appear that the lack of clarity with which recovery has generally been defined, far from being a handicap, may actually have been an asset, at least in terms of building a recovery movement. In this respect, our findings mirror the observation of Ilana Löwy (1992) that 'loose concepts' may sometimes provide a more effective basis for building interdisciplinary alliances in the sciences than tighter ones, since they can be interpreted to suit the particular interests of different actors. By the same token, it would seem that loose framings may sometimes be more effective in building social movements than tighter ones (see also McCormick et al. 2003). Of course, that does not mean that all loose concepts or 'loose framings' are equally capable of sustaining a successful social movement. Looseness is only a virtue within certain limits. Any framing, if it is to be effective as a means of social mobilisation, must also offer a sufficiently clear diagnosis of the issues to be addressed and a sufficiently compelling account of the aims and values to be pursued. The recovery frame seems on the whole to have struck a fortuitous balance: it is unequivocal in identifying excessive psychiatric power as part of the problem of mental health, and in advocating service-user-led services as the preferred solution to that problem; but it is generally vague enough, in specifying just what such services should look like, to appeal to actors from a wide range of backgrounds. The continuing vigour of the recovery movement will almost certainly depend upon whether it can maintain this balance as implementation comes to focus more tightly on the promotion of specific policies, practices and'recovery technologies'. There are clear indications that some actors, at least, see this as a betrayal of the aims and values that they originally associated with recovery, and are increasingly inclined to abandon both the concept and the movement. What this means for recovery remains to be seen. Some social movement theorists have identified official co-optation of movement aims, methods or activists as one of the reasons why social movements may decline, as those elements of the movement with a more oppositional motivation become disillusioned and disengaged (e.g. Miller 1999); while Archibald and Freeman (2008) suggest that this is a particularly common problem for movements that originate as'self-help or mutual aid' organisations. Certainly, something of the sort appears to be occurring in the case of the Scottish recovery movement. This does not necessarily mean the end of the recovery movement, however. It may be that, despite the increasingly close association of the recovery frame with particular mainstream practices and technologies, it will remain sufficiently aspirational in its values as to mobilise continuing calls for reform of services -in which case the recovery movement will survive the secession of some of its more radical activists to become increasingly firmly embedded as a still effective alliance of activists, professionals and state actors. Alternatively, it may be that as recovery loses some of the definitional looseness that up till now has served it well, it will also lose its potency as a diagnostic and motivational frame -in which case, there are already suggestions that it could be replaced by a new 'post-recovery' frame and movement. Clearly, social movement theory does not enable us to predict the future of recovery. But it does enable us to envisage some of the different futures that may be in store, and to understand what kinds of factors may determine which of those futures comes to pass.

Recovery' has become a key element in Scottish mental health policy and practice, despite continuing uncertainty over just what is meant by 'recovery'. This paper draws on social movement theory to explore the processes underlying the growth of recovery in Scotland. Based on documentary analysis and semi-structured interviews with key actors, it looks at the emergence of a 'recovery movement' in Scotland, and in particular at how that movement articulated a 'recovery frame' that subsequently came to inform policy and practice. It then reflects on the dilemmas posed by this success, as the recovery movement expanded to intersect with state agencies, and the recovery frame was adapted to accommodate the needs of government policy. It concludes that the future of the recovery movement in Scotland will depend on its ability to maintain a sufficiently broad and inclusive framing of recovery even as it becomes associated with specific policies and practice.

AIDS epidemic. The increased detection of syphilis appears to be a global phenomenon, with reports from Europe (5,6), other developed countries (7,8), and Latin America (9) noting similar trends. Among 44 U.S. states reporting information on the sex of intimate partners for more than 70% of male cases, the overall rate of P&S syphilis among all men (aged <unk>18 years) in the United States in 2015 was 309.0 per 100,000 among MSM compared to 2.9 among men who reported sex with women only (MSW) (2). The disparity in syphilis rates between MSM and MSW reflects multiple factors, including the increased number of sexual partners among some MSM compared to most MSW, assortative mixing among MSM (i.e. only having MSM partners, concentrating the spread of infection within the subpopulation) and biological susceptibility (see below), The syphilis epidemic in American MSM is characterized by marked racial disparities. Among 11,359 cases of P&S syphilis among MSM with known race/ethnicity in 2014, 40.3% were among white MSM and 32.2% were among black MSM (4). Although more cases were diagnosed among white MSM, the national rates of P&S syphilis diagnoses were 168.4 per 100,000 for white MSM and 583.9 per 100,000 for black MSM. Regional rates suggested syphilis was most prevalent in the South at 602 per 100,000 for Black MSM, with rates were consistently higher among black MSM in each region compared to white MSM (3,4). However, even in jurisdictions with relatively fewer Black MSM, syphilis incidence among MSM, particularly HIV-infected MSM, have reached unprecedented levels, e.g. between 2.5 and 4% annual incidence in Seattle (10). The reasons for the current increases in syphilis among American MSM are diverse and include social, behavioral, biological, and epidemiological factors, not of all them are unique to the U.S. epidemic. However, some issues are specific to the American context, particularly the disproportionate syphilis burden among Black MSM. The multifactorial etiology of increasing syphilis rates among MSM means that ultimate control will require diverse approaches that address key drivers of this persistent epidemic. Some of the most salient features will be reviewed below. --- Socio-behavioral issues Historically, MSM have tended to have more partners than heterosexual men, and have been more likely to engage in concurrent relationships (11). In recent decades there has been a tendency towards decreased condom use (12), which may reflect the relaxing of safer sex norms in an era when HIV is no longer perceived to be a fatal disease, and other STDs have been increasingly perceived to be as treatable, preventable, or inconsequential. However, the explanation for MSM having multiple condomless sexual partners may have longer-standing antecedents. Throughout human history, until recently, MSM have generally grown up in non-affirming societies, and as they have matured they have had to contend with the knowledge that their sexual preferences were not societally acceptable (13)(14)(15). This has led to high rates of internalized stigma, resulting in elevated rates of depression, general anxiety disorder, and other behavioral health challenges for which MSM tend to have much higher prevalence than do demographically matched heterosexual males (16)(17)(18)(19)(20). Perhaps to mitigate the psychological trauma that they may feel, the use of recreational drugs among MSM has been common, with higher rates of specific substance use, e.g. poppers, marijuana, alcohol, and stimulants, than among heterosexual males (21,22). The phenomenon of "chem-sex" has been associated with high rates of syphilis acquisition and transmission as well as HIV and other sexually transmitted infections (23)(24)(25). Early childhood violence/victimization may potentiate the likelihood of ongoing sexual risk taking, substance abuse, and increased STD/HIV risk (25,26). The frequent co-occurrence of these behavioral adversities in MSM create a syndemic (27,28), requiring preventive interventions that address co-prevalent factors. --- Bio-behavioral Issues Although insertive and receptive anal intercourse are the most efficient ways to transmit HIV, and syphilis (29)(30)(31), receptive or insertive oral sex (fellatio) may also transmit syphilis while not transmitting HIV (32). The practice of oral sex has been more prevalent among MSM before and during the HIV/AIDS era, but the rates of oral sex compared to anal sex have increased in many settings as a safer sex practice in order to decrease the risk posed by anal intercourse (30,33). In addition to the efficiency of oral sex in transmitting syphilis, HIV itself may be a driver of the efficiency of syphilis transmission (34). Individuals who are HIV-infected and acquire syphilis are more likely to transmit syphilis to their partners. Moreover, the practice of serosorting (preferentially choosing partners of the same HIV serostatus) may have helped to concentrate the syphilis epidemic among HIV-infected men who have sex with men (35)(36)(37)(38). The hyper-concentration of syphilis among HIV-infected individuals could abate as the rationale for serosorting becomes less necessary, given that HIV infected individuals may feel that they won't transmit HIV to their partners if they are virologically suppressed on antiretroviral therapy when engaging in condomless sex (39), and high risk HIV-uninfected individuals can avail themselves of pre-exposure prophylaxis (PrEP) (40)(41)(42). Thus, HIV-uninfected individuals, who previously had a lower prevalence of syphilis, may now be in more frequent contact with HIV-infected individuals with a higher prevalence of syphilis (43).. More recently, the growth of sexualized internet-based social media has been a facilitator of syphilis transmission, given the newfound ease in meeting sex partners on line (43)(44)(45)(46). --- Systemic and structural issues Many of the phenomena that have led to the growth of syphilis among American MSM are not unique to the United States, and the ease of travel, in addition to the use of the Internet to meet partners, has helped to further globalize the syphilis epidemic in MSM. However, one of the distinguishing characteristics of the U.S. syphilis epidemic is the disproportionate disease burden among black MSM (2,3). Multiple studies have indicated that black MSM do not have more sexual partners than MSM of other races or ethnicities, but are more likely to be HIV positive and more likely to engage in assortative mixing (47). That is to say, they are more likely to choose partners within their own racial community, thereby hyper concentrating the HIV epidemic. Moreover, black MSM like other African Americans may often be economically disenfranchised and therefore less likely to access health services in a timely manner (48). Black MSM may have also experienced racism and other microaggressions and be less likely to access healthcare in settings they do not feel are culturally sensitive (49,50). Thus, the U.S. syphilis epidemic is potentiated by health disparities that are unique to the U.S., and which require more intensive social attention if the goal of "syphilis elimination" is to be achieved. --- Syphilis in the ART for prevention era The recognition that effective antiretroviral treatment renders HIV-infected individuals functionally non-infectious and the more recent demonstration of the efficacy of PrEP has been associated with increased condomless sex in MSM (40)(41)(42)(51)(52)(53). Thus, individuals can be protected from retroviral transmission or acquisition, while being highly susceptible to acquiring and transmitting syphilis. Individuals who use antiretrovirals for prevention may be more likely to play part of a syphilis transmission chain, since their choice to use HIV preventive medication may signal a desire not to use condoms. Although the rise of syphilis has antedated the demonstration of the efficacy of PrEP (1-3), several recent studies have shown that individuals who are using PrEP have a high likelihood of acquiring syphilis (40-42, 51, 53). Although it has been speculated that antiretrovirals could increase susceptibility to syphilis through a biological mechanism, an analysis of incident syphilis cases in the iPrEX MSM PrEP study found that the rates of syphilis acquisition were comparable in the placebo group as among those who were receiving the active medication (54). Thus the interaction of PrEP and syphilis reflects behavioral and epidemiologic realities, rather than a direct biological effect. While concerns have been raised about the role of PrEP in decreasing condom use, and potentiating risk compensation because of decreased worries about HIV acquisition (50), HIV-uninfected individuals who are not using PrEP who are not using PrEP are of even greater concern, since incident syphilis is a harbinger of increased likelihood of acquiring HIV (55). Thus, rather than focusing on syphilis as a negative consequence of PrEP, incident syphilis among HIV-uninfected, high-risk MSM is an indication for those individuals who may most benefit from PrEP, and a reason for frequent syphilis screening for those using PrEP. Quarterly STD testing of PrEP users may allow for earlier identification and treatment of incident syphilis cases, allowing for prompter partner notification and fewer onward transmissions.. --- Syphilis, MSM and the healthcare system The dramatic increases in syphilis among MSM are a cause for concern among clinicians and public health officials. The rise syphilis among MSM could possibly be associated with increasing rates of congenital syphilis in the progeny of female partners (1). For MSM themselves and their partners, there are increasing reports of neurological and physiological complications of syphilis in both HIV-infected and HIV-uninfected individuals (56,57). Thus, it is particularly important for clinicians to be attentive to identifying syphilis in order to provide optimal health services for patients who may be at greatest risk. Part of the challenge to controlling the MSM syphilis epidemic is that sexual and gender minority patients may not feel comfortable disclosing their same-sex attraction behavior to their primary providers (57)(58)(59)(60), underscoring the need for healthcare providers to be trained to provide culturally competent care for their sexual and gender minority patients. Some MSM, particularly those from racial and ethnic minority communities, may not be comfortable working with partner notification services, because of concerns about stigma and cultural insensitivity. The common recurrence of syphilis among some MSM underscores the need for effective partner notification services (61). Fortunately, over the past decade, more attention has been focused on sexual and gender minority health (62), and an increasing array of tools have been developed to assist providers in the provision of culturally-informed care (e.g. www.lgbthealtheducation.org) (63). As clinicians become more capable to provide culturally competent care for MSM patients, they will be able to screen and counsel individuals whom they might not otherwise have thought to be at risk for syphilis. It is very unlikely in the current era of HIV treatment as prevention and pre-exposure prophylaxis that the rise in syphilis and other sexually transmitted diseases will result in increasing use of condoms by all MSM, though increased community education may motivate some to use condoms for STD prevention. Thus, the utilization of traditional clinical and public health tools, i.e. patient education, frequent routine screening of at-risk individuals (61), prompt initiation of treatment, and partner notification services will be the mainstays efforts to curtail the further spread of syphilis among MSM for the near future. --- Summary The reasons for the increase in syphilis in MSM are multi-factorial and complex, involving individual behavioral, socio-cultural, structural and biological factors, which will be reviewed in this paper.

Since the turn of the current century, syphilis incidence and prevalence have been increasing more rapidly among men who have sex with men (MSM) than any other U.S. subpopulation, exceeding their previously high rates in the 1970's and 1980's, prior to the AIDS epidemic. The reasons for these trends are multi-factorial and complex, involving individual behavioral, socio-cultural, structural and biological factors, which will be reviewed in this paper. MSM tend to have more sexual partners than heterosexuals, and engage in practices (e.g. anal sex) that are highly efficient for syphilis transmission, and non-detection of primary chancres. In the era of highly active antiretroviral therapy rendering adherent patients non-infectious and the use of pre-exposure prophylaxis, there is substantially less concern about HIV transmission and acquisition among MSM, resulting in higher levels of condomless sex. The increased concentration of syphilis among Black MSM is partially related to assortative mixing, i.e. Black MSM being more likely to have other Black sex partners, as well as decreased access to preventive services and treatment due to economic marginalization, Societal rejection and discrimination may also potentiate factors that may increase sexual risks resulting in syphilis, e.g. depression and substance use. The anticipation of experiencing homophobic discrimination in health care settings may lead many sexually active MSM to delay needed screening and treatment, thus being infectious to partners for longer periods of time than other populations. To effectively control the syphilis epidemic among MSM, scaling up a combination of programs, ranging from enhanced community education to training clinicians and health care systems to provide culturally competent care, will be necessary.The number of Primary and Secondary syphilis (P&S) cases reported to the Centers for Disease Control & Prevention (CDC) have increased dramatically since the beginning of the new century, with MSM accounting for 58% of primary and secondary syphilis cases in the United States in 2016 (1,2). These rates reflect a dramatic increase in the prevalence of syphilis in American MSM over the past decade (3,4), which exceeded the the previously record high rates seen in the 1970's and 1980

Introduction Substance dependence recovery is a process often requiring multiple courses of treatment, with relapses a common occurrence (Koob & Simon, 2009;Miller, Westerberg, Harris, & Tonigan, 1996;Volkow & Fowler, 2000). For some individuals with substance use disorder (SUD), a stable living environment is known to be effective in maintaining abstinence (Jason, Davis, Ferrari, & Anderson, 2007;Jason, Olson, Ferrari, & Lo Sasso, 2006). An example is Oxford Houses (OH), which are democratically run, community based recovery residences, in which house members self-organize under basic principles of sobriety and peer support. OHs are known to decrease the likelihood of relapse when residents stay for a sufficiently long period, currently thought to be about six months (Jason, Olson, et al., 2007). Jason, Stevens, Ferrari, Thompson, and Legler (2012) found that OH residents who are friends with at least one other resident are less likely to leave their residence early. Additionally, Brereton et al. (2014) found that the presence of recovery home members in personal social networks predicted retention in the recovery home. These findings point to resident social relationships in the house system as a major factor in preventing early dropout and facilitating a sustained recovery (Jason et al., 2012). The purpose of this study was to further explore the relationships occurring in OH among residents. These relationships, developed in a process of social integration involving such mechanisms as becoming acquainted with other residents, learning and following house rules and norms, and supporting one's own and others' sobriety, constitute a novel and abstinence-supportive social environment for the recovering individual. The social environment monitors residents for potential recovery-threatening behavior, recognizes positive behavior being modeled, and rewards residents for positive changes (Jason, Davis, et al., 2007;Jason, Olson, et al., 2007;Polcin, Mericle, Howell, Sheridan, & Christensen, 2014;Stevens, Jason, Ram, & Light, 2015). Heilig, Epstein, Nader and Shaham (2016) discuss the role of social integration in addiction in a broader context. To date, however, few studies have attempted to model the social integration process itself. In a recovery home context, this means addressing how characteristics of residents and the existing residential network structure affect ongoing relationship maintenance, formation, and change. One example is a small study of 5 OHs with 31 total residents. The results indicated that involvement in recovery-related activities (e.g. attending AA meetings) were positively associated with trust in other house members and the likelihood of having a "confidant" within the house (Jason, Light, Stevens, & Beers, 2014). Further development of this research may help to confirm or adjust theory underlying the recovery-supportive role of Oxford House-which clearly depends on social relationships (Brereton et al., 2014;Jason et al., 2012)-in the recovery process. This article focuses on the role that residents' perceived quality of life (QOL) plays in relationship dynamics. Previous studies suggest that recovery house stays are helpful in part by providing social support for recovery (Kaskutas, Bond, & Humphreys, 2002). In general, if a new resident is able to develop and maintain strong relationships with other residents, these relationships can become "social capital" (Coleman, 1988) that help him or her through the inevitable rough patches of recovery: negative emotional states, behavioral lapses, and the fear associated with change and uncertainty, for instance (Koob & Simon, 2009). More specifically, relationships with other residents who score higher on a dimension associated with recovery, such as QOL (Jason & Stevens, 2017), may be particularly beneficial. A review by Reif and colleagues (2014) finds that interventions in which people who are relatively confident and stable in their recovery-those one might expect to report a relatively high QOL-are paired with people less stable in their recovery-those one might expect to report a relatively low QOL-tend to be effective at improving the recovery process and outcomes. Recovery homes are likely to include residents with varying perceptions of their own QOL, for recovery-related and probably other reasons. So the question naturally arises as to whether the patterning of relationships in OH with respect to QOL appears to mimic recovery-supporting mentorship relationships found in previous research. Our study explores how relationship formation and change are dynamically affected by self-reported QOL. --- QOL as a predictor of relationships Recently, Stevens, Guerrero, Green, and Jason (2018) found that both hope and sense of community were predictors of QOL for individuals living in OHs. These findings suggest one of the important functions of a recovery residence is in the creation of a sense of community, but more granular investigations of mechanisms and relations need to be pursued. Studies of relationship formation typically find that homophily-a preference for others who are similar to one's self in many respects-is an important basis for friendships (Lazarsfeld & Merton, 1954). Theoretical arguments explaining this phenomenon have centered on the tendency of shared activities and perspectives to facilitate interpersonal understanding, acceptance, and feelings of support (Feld, 1981;McPherson, Smith-Lovin, & Cook, 2001). Homophily-based friendship choice can be further reinforced by network closure effects such as transitivity-the tendency for friends of friends to also become friends-in that friendship brings similar individuals who are not yet friends into closer and more regular contact by virtue of mutually shared activities and interests (Kossinets & Watts, 2012). Homophily is also known to predict friendship for demographics such as social class, gender, and ethnicity (Marsden, 1988) even among young children (Martin, Fabes, Hanish, & Hollenstein, 2005), as well as characteristics such as tastes in music (Steglich, Snijders, & West, 2010) and social popularity (Dijkstra, Berger, & Lindenberg, 2011). QOL, as conceptualized and measured in health related research, represents an individual's perceived well-being (e.g. Saxena, Carlson, Billington, & Orley, 2001). Higher QOL should normally be a preferred state for relationship partners as well as for one's self, as higher-QOL alters will tend to be happier, more satisfied, calmer, less stressed, and a better resource. Relationships can sort according to similarity on a desirable characteristic such as QOL when the relationship is exclusive (e.g. marriage), or has costs associated with it that limit the optimal number of such relationships. Friendships are normally of this nature; empirical studies invariably find that people limit the number of others whom they consider a friend (Snijders, 2005), consistent with friendship as a selective relationship. Selective relationships promote clustering on desirable traits through assortativity: highly desirable individuals represent a mutually best dyadic choice. Less desirable individuals end up together not because of preference, but because the desirable relationships are already taken or otherwise inaccessible. Assortative processes are commonly observed in, for instance, adolescent peer group dynamics (Dishion, Patterson, & Griesler, 1994) and marital relationships (Schwartz, 2013). In light of these considerations, we might normally expect relationships to tend to cluster based on similar QOL, all else equal. However, in the context of OHs, where social support is a major and fundamental component of residency and where, moreover, residents depend on one another to keep the house afloat financially and otherwise, the dependency of friendship dynamics on QOL could differ from traditional expectations of relationship homophily. Instead, residents with relatively high QOL could be inclined to befriend residents with lower QOL, motivated by the mutual beneficence of whole-house survival associated with the success of everyone living in the OH residence and the particular vulnerability of individuals who are less secure in their recovery. Thus, examination of the effect of QOL on friendship should allow for these differing dynamics to be detected. Light, Jason, Stevens, Callahan, and Stone (2016) proposed a general framework for studying recovery as a socially-embedded, dynamic process (see also Wölfer, Faber, & Hewstone, 2015). That approach was influenced by recent advances in dynamic social network modeling, particularly the Stochastic Actor Oriented Modeling (SAOM) framework developed by Snijders and colleagues (e.g., Snijders, van de Bunt, & Steglich, 2010). The recovery residence social system is a process of relationship formation and change, which may in addition be causally linked to recovery-related characteristics of individuals. This modeling framework has several characteristics including being dynamic (a model of change), endogenous (it can include feedback), stochastic (it assumes that outcomes are inherently probabilistic) and data-based (parameters can be estimated from data, using wellestablished statistical principles). These features align well with current conceptions of the recovery process and the objectives of the present study. --- Recovery and social networks We could summarize the framework as a type of complex system model (e.g., Hu, Boker, Neale, & Klump, 2014;Strogatz, 1994). SAOMs were developed specifically to model changes in social networks. Thus, if we identify a recovery home resident's social environment with the social network of relationships in that home, SAOM provides a natural, dynamic system framework for answering questions about how resident characteristics bear on the evolving structure of the house friendship network (Light et al., 2016). In this study, given our primary interest in the role of QOL in recovery home social integration, we employed a simplified version of the SAOM framework that included only predictors of friendship relationships. We tested whether dyads with similar QOL were more likely to create or maintain friendships with each other. Because of the special nature of OH governance and the resulting social processes, we also ensured our examination could reveal whether friendship patterns with respect to QOL differ from those expected in other populations. Specifically, we modeled friendship networks as a function of QOL with two different SAOM specifications that, together, allow for a variety of relational patterns to be revealed. We then discuss the results in the context of the OH and substance use recovery literatures. --- Method --- The OH model OHs are a network of over 2000 self-governed, rented, gender-specific single-family recovery homes for 6 to 12 individuals. OHs are the largest network of recovery homes in the United States (Jason, Olson, & Foli, 2008). Residents can remain in these OHs for as long as they want, provided they pay about $100 a week in rent, abstain from using drugs or alcohol, and comply with democratically agreed-upon house rules. The OH model includes procedures and practices designed to encourage a supportive environment across houses. This OH network is the only substance abuse recovery home model that had been endorsed by SAMSHA (SAMSHA's National Registry of Evidence-Based Programs and Practices, 2011), and has been found an effective resource for substance abuse recovery in many empirical studies (Jason et al., 2006;Jason, Olson, & Harvey, 2015). --- Participants Data were collected from a total of 396 residents (88% of all eligible) of 42 Oxford Houses (n=6.14 per house, 5.45 of whom participated, on average) at three time points, about four months apart during a one-year period (see Table 1 for details). Response rates by wave were 87%, 79%, and 88% for waves 1-3, respectively. Additionally, of the total 122 house level observations across three waves, 80% had <unk> 20% missingness within a house, and only two (1.5%) had>50% missingness. Some individuals included at baseline (n=123) left the houses before the second or third wave of data collection, and some residents (n=83 at wave 2, n=132 at wave 3) entered the houses after the first wave of data collection (further detail of missingness, new enrollment, and attrition are presented in the results). The final analysis sample included the 396 residents who completed at least one assessment and who were not the only survey participant in their house for any wave. --- Procedures Data were collected from Oxford Houses located in North Carolina, Texas, and Oregon; these states were selected because OH had well-established, stable statewide organizations that could assist in locating and approaching specific houses as potential participants, and because taken together, they provided some level of geographical diversity. Field research staff assembled lists of houses in each state with the help of the statewide OH organization. Inclusion criteria for houses included only that the house must have been operating for at least one year, and that it was within one of the specified states. All house residents were recruited and could opt out at will. Staff approached these houses in approximately the order that their contact location information became available, and requested that the memberelected house presidents introduce the study to other members by reading a description from a project-provided script. If the president and all (or all but at most one) other members agreed, the house was accepted into the study. We accepted the first 13 consenting houses from each state, with an additional three houses because of temporal overlap in the consent process, for a total of 42. Although the absence of complete, centralized data on all roughly 2000 US OH's made full probability sampling impractical, project leaders, who have decades of experience conducting research among these houses, judged the final sample as reasonably representative of the national population. However, the same lack of comprehensive national data prevented any formal test of representativeness. Once houses were recruited, staff recruited participants via face-to-face meetings. Individuals were informed about the purpose, objectives, and methodology of the study and were advised of the voluntary nature of the study before signing and returning a consent form. Interviews were scheduled and conducted that included self-report measures of QOL, social network, and other demographic information. Participants were compensated $20 for completing each assessment. Permission to do this study was granted by the DePaul University Institutional Review Board. --- Measures 2.4.1. QOL-An item from the World Health Organization Quality of Life Assessment Brief Version (WHOQOL Group, 1998) was used to assess QOL. The WHOQOL index measures domains involving physical, psychosocial, social relationships, and environment. We used one item in this index that measures an overall impression of one's QOL: "How would you rate your quality of life?" Response options ranged from 1=very poor to 5=very good. We chose to use a single item rather than an aggregation of all items because the WHOQOL constitutes an index, not a scale, implying the items are not necessarily intended to represent a single underlying construct. Moreover, while the index's use has been fairly well established in large scale population level studies, this is not the case for clinical studies. As such, the single overall item represents the most practical measure for our research purposes. --- Social network instrument- The Social Network instrument measures relationships known to be important to how OH residents relate to each other within the house. This instrument measures several different types of relationships: friendship, mentoring, and trust (Jason & Stevens, 2017). Because this study is concerned with social acceptance, we focused on friendship, which was assessed by asking, "How friendly are you with this person?" Response options included: close friend; friend; acquaintance; stranger; adversary. The friendship rating was coded present (1) if the respondent identified a peer as a close friend or friend, and not present (0) otherwise (i.e., acquaintance, stranger, or adversary). Such measures have been found to be reasonably reliable in network studies (e.g. Hlebec & Ferligoj, 2002), and this particular measure has been successfully applied in other related studies (e.g. Light et al., 2016). --- Analysis After examining descriptive aspects of measures (Table 1), we examined three SAOMs (Table 4). The models included one null model, exclusive of any QOL related terms, that acts as a baseline for comparison with two more complex models that include QOL in multiple ways. The latter two models have similar complexity, and represent two different specifications allowing for different patterns of ego-alter friendship mixing with respect to QOL. Effects (predictors) included in at least one of our models are defined and explained in Table 2; the RSiena manual (Ripley, Snijders, Boda, Voros, & Preciado, 2018) expands on these explanations. The null model contains only network structural effects unrelated to QOL, namely outdegree, reciprocity, transitivity, indegree-popularity, and outdegree-activity effects (effects 1-6 in Table 3). These effects are like predictors in a regression model, but based on calculations from the time-evolving modeled network. Model 1 adds to the effects in the null model QOL-ego, QOL-alter and QOL-similarity effects, which address, respectively, the effect of QOL on the number of out-choices made by ego, the number of in-choices received by ego, and the effect of ego-alter similarity on ego's preference for that alter. The similarity effect is symmetric with regard to QOL, in the sense that its contribution to the probability of a tie to alter is the same regardless of whether ego's QOL is higher or lower than alter's, so long as the absolute value of the difference is the same. If the associated coefficient is positive, then ego's preference to be tied to an alter is proportional to the degree of QOL similarity between ego and alter. A negative coefficient simply reverses this relationship such that more distance in QOL between ego and alter increases the probability of a tie. This specification represents a standard approach to modeling relational mixing with respect to a covariate (QOL in our case). Because of this specification's assumption of symmetry in QOL similarity, it cannot capture patterns in which a resident always prefers a peer with a higher QOL, but not a peer with a lower QOL, or vice versa. Because of the limitations to the Model 1 specification, and given structural components of OH that might bear on relationship patterns, we specified a second model to capture potential patterns that the first specification cannot. For example, residents depend on one another to keep the house operating smoothly. OH residents rotate through leadership positions (e.g., treasurer, comptroller) that entail certain responsibilities upon which the stability of the household rests. If one resident starts to slip, the well-being of others could be affected. This dependency could incentivize residents who are more secure and stable in their recovery (high QOL) to support those less so (low QOL) to ultimately support the stability of the house. Such a pattern would be counter to the concept of homophily. Model 1 can capture anti-homophily (heterophily), which would include such a pattern, but would also impose the reverse relationship-low QOL residents are more likely to nominate high QOL alters than their similar QOL peers and would assume both occur with the same strength. We wanted to consider a model that does not enforce this in the case that the effect of relative QOL varies depending on the direction of the difference. Like Model 1, the specification of Model 2 includes QOL-ego, but replaces QOL-alter with a higher-QOL effect, i.e., higher QOL egos preferring lower QOL alters (notice, too, that the amount of difference does not matter, so this measure is essentially dichotomous). Additionally, QOL similarity is replaced by an interaction between ego's QOL and the higher-QOL effect. The interaction term can diminish, enhance, or even completely reverse the effect of higher QOL depending on the QOL of ego. We investigate this model because, as noted previously, the nature of OH could counteract typical social preferences in a way that breaks the symmetry assumption of the similarity effect in Model 1. A limitation of the Model 2 specification is that it is not expected to be able to capture a pattern of homophily very well. Thus, the two models are complementary, and facilitate a more comprehensive examination of the effect of QOL on friendship patterns in OH. The results of a goodness-of-fit assessment of both models can further guide our interpretation of the data by revealing which has a better capacity to explain the data. We assessed model fit in multiple ways to compare the relative credibility of the models. We followed the goodness-of-fit testing approach proposed by Schweinberger (2012) and discussed in the RSiena software manual (Ripley et al., 2018). Our approach measures statistical agreement of 3000 model-simulated networks with the observed network according to user-defined multivariate network statistics; the difference was measured using Mahalanobis distance (MHD). 1 The statistics included the network indegree and outdegree distributions, the triad census (counts of each of 16 types of possible directed triads), and a 3<unk>3 mixing matrix for the number of ties observed between every possible pairing of egoalter QOL values. We reported the MHD for each statistic for each model, along with probabilities of a test statistic (MHD) equal to or larger than that observed under the assumption of no difference. A larger MHD and smaller p-value implied worse fit. We additionally calculated an entropy-based measure for explained-variation designed specifically for SAOMs (Snijders, 2004), and reported it as a pseudo-R 2 for each of the three models. A larger value of the pseudo-R 2 implies a better fit. Models were compared based on MHDs and the pseudo-R 2 values. We conducted the analyses using the RSiena software package (Ripley et al., 2018) for the R statistical computing environment (R Core Team, 2017). We report "statistical significance" where 95% confidence intervals did not include zero. RSiena utilizes all available data, but only during the approximate time an individual is part of the network for a particular house. In general, parameter estimates are pooled across houses and waves, and missing data are in effect treated as MAR (Little & Rubin, 1987). Further details are available in the RSiena manual (Ripley et al., 2018). --- Results --- Description of the data Statistics describing the analytic sample are presented in Table 1. In summary, 2 across waves, the average resident was about 38.4 years old and had a QOL of 1.3 (min=0, max=2). The majority (81.6%) of the sample participants were White (non-Hispanic), 8.7% were Black (non-Hispanic), 7.6% were Hispanic, and 2.2% reported some other race/ ethnicity classification. Just over half (54.3%) of the sample participants were male. The mean across houses of the house-level mean outdegree was 3.1 friendship ties. The mean density indicates that, in the average house, 59% of ties that could be present were present, and the average number of directed friendship ties within a house was 17.1. The minimum withinhouse response rate at waves one, two, and three were 43%, 40%, and 57%, respectively. 3 The proportion of houses with a response rate of at least 80% at each wave was 81%, 75%, and 85%. Like any statistical model, missingness can create inferential issues for SAOMs. We therefore assessed the sensitivity of our findings to these lower-retention houses by fitting a model that excluded any houses that had a response rate lower than 80% at any wave (an exclusion of 140 participants in total). The results of the sensitivity analysis substantively mirrored those of the analysis reported in the Results section, which included all houses regardless of response rate. Specifically, the statistical significance and sign of coefficients was the same in both analyses, and the magnitude of the coefficients was approximately the same. Some characteristics of the friendship network among the entire sample is described in Table 2. The numbers of possible ties (and tie density), excluding cross-house ties at waves one, two, and three were 1369 (0.60), 884 (0.62), and 1208 (0.60), respectively. Table 2 also describes a moderate number of tie transitions from wave one to two and from two to three resulting in Jaccard coefficients of 0.69 (wave one to two) and 0.77 (wave two to three) indicative of a fairly stable friendship network. Participant stability is also described in Table 2. During the transition from wave one to two, 63 new participants joined the study and 116 left. During the transition from wave two to three, 115 new participants joined the study and 87 left. While not reported in Table 2, resident QOL also changed over time. Specifically, of residents present at both waves one and two, 37 residents increased their QOL and 45 decreased it. Among those present at both waves two and three, 20 increased their QOL while 44 decreased it. Notably, wave three QOL data are not used in our analysis because the observation at wave three is precisely the time point at which the model of the network transitions stops (Ripley et al., 2018). --- Stochastic actor-oriented model results --- Null model- The coefficients and fit statistics for the null model are reported in Table 4. Parameter estimates are parenthetically reported in-text along with their 95% CIs (b=estimate, [95%CI lower, upper]). Outdegree (b=2.70, [-0.48, 5.87]), reciprocity (b=0.72, [0.02, 1.41]), and transitive triplets (b=0.32, [-0.03, 0.67]) effects were all positive; only reciprocity was statistically significant. The outdegree effect is usually negative in other SAOM studies (e.g. Light, Greenan, Rusby, Nies, & Snijders, 2013;Steglich et al., 2010), but for this data set, a positive coefficient suggested that, controlling for other effects in the model, residents typically nominated more than half of other house residents as friends. Recall that in this study, a "friend" is defined as something more than a mere "acquaintance" (specifically, a friend or close friend). Probably the typical house size (on the order of 5-8 individuals) played a role in this implied familiarity as well. The positive reciprocity effect shows that residents tended to reciprocate friendship nominations. Indegree popularity (b= -0.33, [-0.84, 0.17]) and outdegree activity (b=-0.21, [-0.53, 0.10]) effects were both negative and not statistically significant. The model fit metrics for the null model provided a baseline for quantifying improvements in fit for the other two models. The indegree MHD was 7.16 (p=0.56), the outdegree MHD was 8.65 (p=0.67), the triad census MHD was 46.14 (p=0.05), and the QOL mixing matrix MHD was 29.20 (p=0.27). All MHDs suggested the fit of the baseline model was reasonably consistent with the data from the standpoint of null hypothesis significance testing (all p<unk>0.05). However, the statistcal power of a test of the null hypothesis is not clear. As such, we rely on the quantitative values of MHD and p to compare fit across models rather than statistical significance. Finally, the pseudo-R 2 value for the null model, and the baseline against which model 1 and model 2 were compared, is 0.12, and we were interested in how much the QOL-related model terms added to Model 1 and Model 2 improved this value and the MHDs. 4, the signs, approximate magnitudes, and statistical significance of all but one of their common effects were similar to the null model. The transitive triplets coefficient, while similar in magnitude, became statistically significant in this model (b=0.38, [0.11, 0.66]). The indegree popularity and outdegree activity effects remained non-significant, though the parameter signs were the same, and the magnitudes were similar. --- Model 1-As shown in Table The QOL-related effects added to Model 1 included QOL ego, QOL alter, and QOL similarity. Of these, only the QOL ego effect was statistically significant (b=0.73 [0.01, 1.46]), with the positive coefficient implying that higher-QOL individuals chose more friends than lower-QOL individuals. In this model, alter's QOL had no significant effect on the likelihood of receiving a friendship nomination (b=-0.10, [-0.63, 0.44]), and QOL similarity was found to be negative, but not statistically significant (b=-0.82, [-1.77, 0.12]). The negative sign is suggestive of heterophily-a tendency for high QOL egos to choose lower QOL alters, and vice versa-albeit not statistically significant. Model 1 fit metrics suggested a moderate improvement over the null model. The indegree distribution MHD was 7.90 (p=0.45), the outdegree distribution MHD was 10.55 (p=0.40), the triad census MHD was 42.66 (p=0.08), and the QOL mixing matrix MHD was 21.97 (p=0.20). Thus, the triad census and QOL mixing statistics suggested a somewhat better fit. The pseudo-R 2 value was 0.14, a 15% improvement compared with the null model. 4, the sign, approximate magnitude, and statistical significance of common model effects were similar to the null model, but again the transitive triplets coefficient is statistically significant in this model (b=0.43, [0.02, 0.83]). --- Model 2-For this model, again consulting Table Turning to the QOL effects in Model 2, QOL ego became non-significant, and directionally negative (b=-1.24, [-3.25, 0.78]). The higher QOL effect was also not statistically significant (b=0.53, [-1.02, 2.08]). However, the ego QOL x higher QOL interaction was found to be positive and statistically significant (b=3.29, [0.29, 6.30]) suggesting ego's preference for having a higher QOL than a selected alter depends on ego's QOL. We further discuss this finding in a later section of the results. The model fit metrics for model 2 suggested an overall improvement over both the null model and Model 1. The indegree (9.17, p=0.37) and outdegree (10.89, p=0.28) MHDs indicated a subtly worse but still adequate fit vs. the null model or model 1, but the triad census MHD suggested a substantial improvement over the preceding models (33.31, p=0.24), as did the MHD of the QOL mixing matrix (10.31, p=0.77). The latter fit statistic is particularly important, as it suggests that Model 2 represents the role of QOL in friendship choice better than either of the other two models. Finally, the pseudo-R 2 value for Model 2 was 0.17, about a 41.6% improvement compared with the null model, and a 21.4% improvement over Model 1. The middle visual for Model 1 in Fig. 1 shows a pattern consistent with the negative QOL similarity coefficient, or heterophily. It is clear from this figure that the high QOL-ego to low (or medium) QOL-alter squares have the highest probabilities of friendship. However, the Model 1 figure also suggests a relatively low probability for friendships to high-QOL alters that are initiated by low-QOL egos (the upper-left square). --- Model implications-Because Comparing the visual for Model 2 to that of Model 1, it is evident that Model 2 is more fully consistent with heterophily. The lower-right (high ego, low or medium alter) squares again show the highest friendship probability, but now the upper left (low ego, hi or medium alter) show the next-highest probabilities. Given the somewhat better fit of Model 2 to the dataaccording to the QOL mixing fit statistics and the pseudo-R 2 values-we are led to put more confidence in the results represented in the coefficients and model predictions from Model 2. --- Discussion The structure and behavioral norms associated with OH residences are designed and theorized to encourage mutual help and support of peers. However, no previous work has examined whether this occurs in practice, or whether such support tends to be extended from those more stable in their recovery to those less stable. Alternatively, does social interaction in OH mirror what might be expected in a more typical social environment in which those with higher status prefer one another, leaving the lower status individuals to themselves? The evidence presented in this study suggests OH defies the conventional expectation, somehow encouraging those with a higher quality-of-life (QOL) to engage with lower QOL peers in friendship, and vice-versa (heterophily with respect to QOL). There are several reasons why such an unusual pattern of friendship relationships might be found in the OH social context. One possible path to understanding comes from the research literature on AA sponsorship (Stevens & Jason, 2015a). Sponsors within the AA paradigm provide information, act as an empathetic friend, and introduce the sponsee to others in recovery. Sponsees see the role of the sponsor as more than just an advice giver (Stevens & Jason, 2015a). Sponsorship represents an important aspect of AA affiliation and involvement (Majer, Jason, Ferrari, & Miller, 2011) and it reduces the likelihood of an individual dropping out (Kelly & Moos, 2003). Effective sponsors engage in 12-step activities themselves, are trustworthy, and make themselves available (Stevens & Jason, 2015b). Given that sponsorship is a good predictor of reductions in substance use behavior for the sponsee (Stevens & Jason, 2015a,b) and, moreover, given the central role of AA-related practices in OH residences, expectations for sponsorship relationships are likely to carry over to OH friendships generally. Sponsorship usually involves a "more recovered" individual helping a "less recovered" one, and Witkiewitz et al. (2018) provide evidence that this perspective is comparable to a higher-QOL resident helping one with lower QOL. It is entirely plausible that when individuals have achieved a certain degree of recovery success in their personal lives, they appreciate and value the opportunity to help others who are less sturdy or secure in their recovery. This is similar to Riessman's (1965) helper therapy principle which suggests the person providing help or assistance to another also obtains benefits, and helping others can increase a person's sense of well-being, as well as provide a sense of purpose and satisfaction (Dreher, 1995;Harris & Thoresen, 2005). Future studies should examine these hypotheses in more detail. In addition, all OH residences-even those where average member QOL is quite highbenefit from the growth and success of all residents, particularly those at high risk for dropout. A useful example derives from the requirement that all residents pay a fair share of expenses. If resident turnover is high or if vacancies persist, then the remaining residents might have to utilize reserve funds that they will later have to collectively rebuild, or alternatively they might have to immediately assume higher living costs. From this financial perspective, it is clear that the collective success depends on everyone, and everyone, particularly those most suited to help, should rationally direct their support to the house members that are most vulnerable. Hypothetically, the dynamics driven by a collective responsibility could be fundamental to a unique contribution OH makes among the variety of extant sober living environments. On the one hand, residences that involve higher levels of formal structure driving the day-to-day activities may put less of the collective responsibility on each house member.

Improved access to housing and recovery support is a low-cost, high-potential opportunity to help people recovering from alcohol and substance use sustain their recoveries. Oxford House (OH) recovery homes represent a recovery-favorable social environment for at least some people, but it is still unclear which resident characteristics and relational dynamics affect the social integration of residents. In the current study, OH residents in three geographic locations completed a social network instrument and self-rated their quality of life (QOL). The instruments were administered to the current (per wave) residents of 42 OHs at three time points over a period of a year. Findings indicated that those with a higher QOL were more likely to form friendships with those with a lower QOL than with their similar QOL peers, and vice versa. This finding would not have been predicted based on relationship mechanisms typical of broader social contexts, where homophily (similarity-based assortativity) is common. The self-governance model that characterizes OH residences, in which success among residents is necessarily viewed as mutually dependent and therefore mutually beneficial, seems a likely explanation for our result. Specifically, and aligned with current knowledge about what works in peer oriented recovery, our results suggest the governance mechanisms of OH favor relationships between those more stable in their recovery and those who are at a higher risk of dropout or relapse. This study reveals a potential research avenue examining an important ingredient for the effectiveness of OH.

, as well as provide a sense of purpose and satisfaction (Dreher, 1995;Harris & Thoresen, 2005). Future studies should examine these hypotheses in more detail. In addition, all OH residences-even those where average member QOL is quite highbenefit from the growth and success of all residents, particularly those at high risk for dropout. A useful example derives from the requirement that all residents pay a fair share of expenses. If resident turnover is high or if vacancies persist, then the remaining residents might have to utilize reserve funds that they will later have to collectively rebuild, or alternatively they might have to immediately assume higher living costs. From this financial perspective, it is clear that the collective success depends on everyone, and everyone, particularly those most suited to help, should rationally direct their support to the house members that are most vulnerable. Hypothetically, the dynamics driven by a collective responsibility could be fundamental to a unique contribution OH makes among the variety of extant sober living environments. On the one hand, residences that involve higher levels of formal structure driving the day-to-day activities may put less of the collective responsibility on each house member. In its own right, this reduced responsibility could be a key to success for those in recovery who are not ready for such responsibility. These recovery environments typically do utilize the value of more stable members to support less stable members. But they may do so in a more contrived and exogenously driven way, as in the designed interventions studied by Reif and colleagues (2014). On the other hand, we would argue that the collective responsibility inherent in OH residences is fundamental to encouragement of a much more organic constellation of support. That is, rather than following an exogenous directive to try to help a peer, the collective dependency for survival could be endogenously driving house members to do whatever is necessary to support their peers towards success, and therefore support themselves. Our analysis included only OH residences, and also did not address what might be the underlying force driving high QOL individuals and low QOL individuals to connect with each other. However, future research could explore ways to test for these distinctive mechanisms, and in which scenarios each of the identified mechanisms are optimal. Moreover, our speculation about the importance of mutual dependency could be measured and analyzed more directly with a measure of collective responsibility or ownership and its relationship to recovery outcomes. The term "social integration" is used to describe the multiple types of social linkages among residents-friendships, mentoring, helping, etc.-which influence current life satisfaction and a concomitant willingness to remain in the home. Friendship is an indicator of the supportive social relationships that can protect people in recovery from relapse and improve overall alcohol and substance use recovery rates (Groh, Jason, Davis, Olson, & Ferrari, 2007). A highly integrated individual has strong friendship, trust, and role model relationships with other house residents, who provide resources and support recovery. For example, having at least one other resident as a friend does seem to increase length of stay to six or more months (Brereton et al., 2014;Jason et al., 2012). Conversely, an individual isolated from the residential social network perceives few recovery resources and may be prone to drop out. Indeed, only approximately 50% of OH residents remain in these houses for six months or more (Jason, Olson, et al., 2007). The current study clarifies the social integration mechanism further by suggesting that low-QOL individuals-who are more likely to be new residents or variously otherwise struggling with their recovery-are particularly likely to be "adopted" by higher QOL individuals, and this may be a major reason why such friendships are so crucial for newer residents. That Oxford Houses comprise a system where this socially atypical (but in the recovery home context, highly desirable) relationship process can take place in practice also speaks to the value of the OH model as an effective pathway to sustained recovery. Of the two non-null models we fit and examined in our analysis, the point estimates of both were suggestive of a heterophilic pattern. However, our second specification (Model 2) appeared to fit the data better than our first (Model 1) according to goodness-of-fit statistics. Based on our understanding of the models and the predicted mixing patterns shown in Fig. 1, we would have expected Model 1 to be able to identify a pattern similar to that shown for Model 2 (Fig. 1), but it did not. One possible explanation is that while the similarity effect of Model 1 compares the QOL of ego and alter such that more distance implies a stronger effect, the "higher" effect of Model 2 ignores how much higher the QOL of ego is than alter. It might be that this is simply a better fit with the data. Substantively, this might suggest that high QOL residents recognize a level of relapse risk in their peers that does not disappear simply because a peer begins to perceive a somewhat higher QOL. As all studies are, this one is limited in several respects. First, the importance of our findings is premised on the assumption that friendship ties between individuals with high QOL and those with low QOL are beneficial to recovery. We did not test this assumption in our data, but the peer-oriented recovery literature indeed suggests such relationships are likely to benefit recovery (e.g., see the review by Reif et al., 2014). Second, we examined only OH recovery homes. Therefore, our findings may not generalize to more traditional staff-run sober living environments. In fact, we would hypothesize that the observed relationship patterns would be less likely to emerge in traditional recovery homes primarily because they do not encourage a collective ownership of the group's recovery success in the distinctive way OH does. That said, the literature clearly recognizes the value of such ties, and so they may be encouraged in ways other than through a collective ownership mechanism in non-OH residences. Moreover, even the sample of participating OHs cannot be considered formally representative of the entire population. Due to the lack of basic demographic data on all approximately 2000 such homes, along with their geographical dispersal and practical budget constraints, probability sampling would not have been feasible. This is, of course, a typical problem for behavioral studies, which rarely rely on probability sampling. Nevertheless, it would be informative for future studies to compare social integration mechanisms such as QOL-based selection across a wider variety of recovery homes, and this goal would be easier to achieve if OH and similar organizations were to obtain comprehensive data on key aspects of the populations they serve. Third, our approach to pooling the data from all houses (known in the RSiena manual as the approach using structural zeros to constrain the model to disallow cross-house ties) assumes house-specific rate parameters are all equal. The rate parameters, among others in the model, could realistically vary across houses, which would imply our model is misspecified. But because only three waves of data were available at the time of this study, the model degrees of freedom were limited allowing only simple model specifications. Fourth, while friendship is likely to be a multidimensional relationship, our measure of friendship is a single item measure that is likely to miss some nuance regarding the studied relationships. This is a general problem in the social network literature as the respondent burden for even a single item is rather high, and grows quickly with the size of the network and the instrument as more potential alters must be considered and as each one requires more data input. Finally, additional questions remain. Although QOL differentiated friendship relationships, it is still unclear how QOL is dynamically related to other indicators of recovery, as well as what both high and low-QOL individuals gain from these relationships-though we have offered some plausible hypotheses. Future studies should relate these and other network mechanisms to both short and longer term recovery outcomes, in order to identify predictors of what occurs when residents leave recovery housing and re-integrate back into their communities. Such studies will need to follow participants for longer periods of time. In conclusion, while our findings should be replicated first, they could have real-world policy implications for sober living best practices as well as patient-centered decision making and future research. Specifically regarding the current study, we presented evidence suggesting that, contrary to the usual findings that friendships tend to sort according to similarity in status and personal resource characteristics of individuals, OH residents are instead more likely to select alters whose QOL is different from their own. Thus, the OH model somehow encourages friendship ties that are known to constitute effective recovery supports (Reif et al., 2014). Our findings therefore point to a potential recovery-beneficial mechanism underlying OH. Similar studies need to be completed to determine whether similar patterns emerge in other types of sober living residences, and the mechanisms by which various contexts produce the patterns. This avenue of research could support improvement in our collective understanding of the interaction between the characteristics of people in recovery and those of specific recovery contexts, which may facilitate the development of policies that lead to enhancements in patient-centered decision making for those in recovery from substance use disorders. Expected friendship probabilities predicted by the null model, model 1, and model 2. Brighter boxes imply a greater relative probability of friendship between an ego and alter with the respective QOL levels. Person-level and house-level characteristics of the analytic sample (1 or more surveys) at each wave. x i j v j Effect of alter's QOL on tendency to be chosen by any ego. 9. QOL similarity simX j x i j sim i j v -sim v,Where sim i j v = <unk> -vi-vj <unk>,sim v is average sim ij v, <unk> = max ij vi -vj Similarity between i and j on QOL 10. Higher QOL higher j x i j g d where d =v i -v j and g (d) = 0 for d <unk> 0, 0.5 for d = 0, 1for d > 0 Indicator variable; 1 if QOL ego > QOL alter. 11. QOL ego<unk>Higher QOL Multiplicative interaction of effects 7 and 10. Allows the 'higher' effect to depend on ego's absolute QOL. a RSiena "short name" (identifies effect type; Ripley et al., 2018). b Formula Notation: i is ego (chooser), j is alter (chosen), x ij is a relationship between i and j (1 if i chose j, 0 otherwise), v i is the value of covariate QOL for individual i, "+" for an index indicates marginal sum. --- Author Manuscript b The count of tie transitions of type characterized by the row label occurring between the specified wave and the prior wave. --- Author Manuscript Doogan et al. --- Author Manuscript --- Doogan et al. Page 22 Table 4 Coefficients, confidence intervals, and fit metrics of the three stochastic actor-oriented models of network dynamics.

Improved access to housing and recovery support is a low-cost, high-potential opportunity to help people recovering from alcohol and substance use sustain their recoveries. Oxford House (OH) recovery homes represent a recovery-favorable social environment for at least some people, but it is still unclear which resident characteristics and relational dynamics affect the social integration of residents. In the current study, OH residents in three geographic locations completed a social network instrument and self-rated their quality of life (QOL). The instruments were administered to the current (per wave) residents of 42 OHs at three time points over a period of a year. Findings indicated that those with a higher QOL were more likely to form friendships with those with a lower QOL than with their similar QOL peers, and vice versa. This finding would not have been predicted based on relationship mechanisms typical of broader social contexts, where homophily (similarity-based assortativity) is common. The self-governance model that characterizes OH residences, in which success among residents is necessarily viewed as mutually dependent and therefore mutually beneficial, seems a likely explanation for our result. Specifically, and aligned with current knowledge about what works in peer oriented recovery, our results suggest the governance mechanisms of OH favor relationships between those more stable in their recovery and those who are at a higher risk of dropout or relapse. This study reveals a potential research avenue examining an important ingredient for the effectiveness of OH.

Introduction Forests provide numerous ecosystem services (ESs) to society. According to the ES concept presented in [1], the benefits people obtain from ecosystems, both material and intangible, result from the provisioning, regulating, supporting, and cultural services that ecosystems provide. Since the last decade of the 20th century, the ES concept has become vital in the debate on sustainable development and quality of life [2,3]. The concept of 2 of 14 ecosystem services is an increasingly important tool in environmental decision making [4]. According to Marchetti et al. [5], creating the right conditions for the development of European society requires an understanding of forest ecosystem functions and how to integrate the various dimensions of sustainability (i.e., economic, environmental, social, and cultural) into decision-making processes while paying greater attention to the public's views on forest ecosystems [5]. There is a growing pressure to incorporate public preferences into ecosystem service assessments. It is necessary to understand how the public uses different ecosystems and thus how people value and perceive ecosystem services [6,7]. Such studies have been conducted among forest owners and managers [8] and also among the general public [9] and local communities [10]. According to Ranacher et al. [9], while business organizations and public policy makers widely address concepts and issues associated with forest ecosystem services (FES), there is still a lack of comprehensive information on how members of the general public perceive different types of FESs or what their views are on the responsibility of the forest sector towards FESs. According to Orenstein and Groner [11], it is impossible to assess the benefits of ESs without understanding who the beneficiaries are and how they respond to the provision of ecosystem services. The importance of ESs depends not only on the biophysical and economic aspects of the environment but also on the assessment of the preferences of different sociocultural groups. It is therefore crucial to understand the perception of FESs by local people, who are the main stakeholders, de facto managers, and victims of the degradation of ecosystem services. Analyses of the sociocultural dimension of ecosystem services should play a special role in this respect by determining which ecosystem services are highly valued and preferred [12]. At the same time, it should be remembered that the results of research on social preferences and views on ecosystem services vary significantly depending on the region [13]. However, noneconomic, social approaches to ES assessment could significantly enhance the overall value of assessments, complementing traditional economic and ecological approaches. Differences in the perceptions of ecosystem services by different end-users may set the stage for conflicts related to natural resource management. The FES perspective offers a promising avenue for diagnosing and reconciling contrasting interests in the use of ecosystem benefits [14]. In order to harmonize the interconnectedness between people and nature and establish sustainable landscape management, it is important to understand the different perceptions of local residents under different socioeconomic conditions. He et al. [15] believe that it is important to incorporate local people's ES awareness and perceptions into ES evaluation for the planning of protected areas. In addition, the ES framework is a powerful tool for understanding the relationship between nature and society [16]. The objectives of this article are as follows: (1) to assess the importance of the various forest ecosystem services; (2) to determine how perceptions of these services have changed over the past decade; (3) to explain whether and how sociodemographic characteristics of beneficiaries influence perceptions of forest ecosystem services. The results of this research can be a reference point in designing effective information and educational campaigns about FESs and can also help integrate FESs with local policies and formulate assumptions for the future forest policy in Poland. --- Materials and Methods --- The Questionnaire The research material consists of the results of a questionnaire survey carried out in Poland in 2020. Due to the ongoing pandemic, we decided to conduct an online survey. A link to the survey, created on the Webankieta platform, was made available on social networks such as Facebook, Instagram, Twitter, and other websites. The survey questionnaire included questions about gender (female, male), age (18-30 years, 31-40 years, 41-50 years, and above 50 years), level of education (primary, secondary, higher), place of residence (rural area, small town with up to 15,000 inhabitants, medium town with 15,000-100,000 inhabitants, large town with more than 100,000 inhabitants), and satisfaction with their standard of living. It also included nineteen other questions relating to various issues related to the ecosystem functions of the forest. Most of them were questions with a Likert scale of five degrees of appreciation (very important, important, moderately important, not very important, irrelevant) through which we could obtain knowledge about the degree of acceptance of the analyzed phenomena, views, processes, features of the forest, etc. This article draws on respondents' views on the following issues: What is the importance to you of the following forest ecosystem services: (1) provisioning of timber; (2) provisioning of animal products, i.e., meat, hides, etc.; (3) water protection; (4) soil protection; (5) flood protection; (6) provisioning of mushrooms, berries, forest herbs, etc.; (7) oxygen production and carbon dioxide sequestration; (8) provisioning of recreation and leisure; (9) air quality regulation; (10) noise reduction; (11) biodiversity protection; and (12) cultural heritage protection. Respondents were asked to assign to each type of benefit one of five selectable responses ordered on a Likert scale The survey results are presented in Appendix A. Respondents were also asked how they thought perceptions of individual forest ecosystem services had changed over the past decade. --- Participants A total of 1402 respondents took part in the survey, including 655 women (46.72%) and 747 men (53.28%). Respondents aged 31-40 years (31.1%) comprised the most numerous group. Respondents aged 18-30 accounted for 27.82% of respondents, followed by those aged 41-50 (23.97%) and those above 51 years (17.12%). Rural residents comprised the most numerous group (42.44%). The survey included 807 urban residents (57.56%), of whom 18.54% of respondents were from small cities (up to 15,000 residents), 23.18% from mediumsized cities (15-100,000 residents), and 15.83% from large cities (over 100,000 residents). The vast majority of respondents had a higher education (64.55%). Secondary education was held by 32.03% of respondents and primary education by only 3.42%. The majority of respondents (63.86%) found their material standard of living satisfactory, 21.81% found it not very satisfactory, 9.69% found it fully satisfactory, and 4.63% found it unsatisfactory. --- Prioritizing Ecosystem Services In order to evaluate the prioritization of individual ESs, we used the Likert values and calculated the cumulative frequency of the very important and important assessments. The priority of individual services was determined according to the following formula: P s = <unk> n i=1 L s /N(1) where P s is the priority of ecosystem services s; L s is the assessment by respondent i to function (L s = 1 for respondents' assessment as important or very important; L s = 0 for assessment as irrelevant, not very important, or moderately important); N is the total number of respondents. Priority index P s takes values from 0 to 1; the higher the P s value, the higher the priority of the function being evaluated. The significance of differences between the importance of individual ecosystem services was, firstly, tested using analysis of variance. It was determined that the conditions necessary for the use of ANOVA were not met. Levene's test showed that the condition of homogeneity of variance in the analyzed groups was not satisfied. In the next step, the nonparametric Kruskal-Wallis ANOVA rank test was used. --- Assumption of a Logistic Regression Model A logistic regression (LR) model, in which the variables take dichotomous (qualitative) values, was used to profile respondents in terms of differences in perceptions of particular ecosystem services. LR determines the probability that the dependent variable (here, the full acceptance of the ES) takes the value 1, provided that the explanatory variables (x 1, x 2,..., x i ) adopt certain values [17]. A logistic model with one explanatory variable is given by the following formula: P(x) = exp(<unk> 0 + <unk> 1 x 1 ) 1 + exp(<unk> 0 + <unk> 1 x 1 )(2) If Equation (2) undergoes a logit transformation, we obtain the logit form of the model, which, generalized to multiple variables, is represented by the following equation: logitP = <unk> 0 + k <unk> i=1 <unk> i x i(3) The logit form of the model given by Equation ( 3) is commonly used in research due to the intuitive, simple interpretation of the right-hand side of the equation as a linear function. The sociodemographic characteristics of respondents were adopted as potential explanatory variables. All variables were binary, taking the value 1 if the attribute applied to the respondent and 0 if the respondent did not have the attribute. The feature "gender" was described by two variables: "female" (F) and "male" (M). If the respondent was female, the variable F = 1, otherwise F = 0. The variable M was coded in the same way. For variables consisting of several categories, dummy variables were introduced. For example, the age variable included four age ranges coded with the following variables: respondents aged 18 to 30 years-A; those aged 31-40 years-B; those aged 41-50 years-C; and those aged >50 years-D. We additionally used the categories BCD (>30 years) and CD (>40 years). Correlations among tentative independent variables were tested, but finally, no such significant relationships (p-value <unk> 0.05) were found between the proposed explanatory variables. A step-wise (progressive regression) approach was applied to build a multivariate model. In the first step, a model with one independent variable was drawn up and checked if it differed significantly from the model containing only the constant term. In the next steps, further variables were added and their significance was evaluated; if the variables turned out to be insignificant, they were removed from the model. The quasi-Newton method was used to parameterize the model. The significance of the model parameters was assessed using the Wald test. The goodness of fit of the model to the empirical data was evaluated using the Hosmer-Lemeshow test [18]. The modelled probability P(x) that the respondent would indicate the evaluated ES as important was determined by substituting into Formula (2) the corresponding values of the explanatory variables (1 or 0) describing the respondent's sociocultural characteristics. In a logistic regression model, in addition to the regression coefficients and their statistical significance, another important parameter is the odds ratio (OR). The OR is the ratio of the chance S(A) of an event occurring in group A (e.g., women identify ESi as important) to the chance S(B) of that event occurring in group B (men identify ESi as important). OR AxB = S(A) S(B)(4) OR = 1 means that the chance of considering ESi to be important (ESi = 1) is the same in the group of women as in the group of men; OR > 1 means that in the first group (women), the recognition of ESi as being important is significantly higher than in the second group (men). Conversely, OR <unk> 1 indicates that in the first group (women), the recognition of the ES as being important is less than in the second group (men). In the case of the logit form of the model with multiple variables, we used the following formula to determine the odds ratio: OR AxB = e <unk> k j=1 (X Aj -X Bj )<unk> j (5) Sustainability 2023, 15, 14154 5 of 14 --- Results --- Prioritizing Ecosystem Services The priority of individual ecosystem services ranked in descending order of importance is illustrated in Figure 1. Respondents primarily appreciated regulating functions (priority index 0.87-0.94), followed by the cultural (0.79-0.86) and provisioning functions (0.31-0.75). Figure 1). The highest priority group consists of all regulating functions and providing space for recreation from the cultural function category. The second group consists of the cultural heritage protection function and two provisioning functions: timber production and supply of nonwood products. Supplying animal products is significantly different from other provisioning functions, being the least important of all ecosystem services. Changes in the perceived importance of individual ESs over the past decade are shown in Table 1. The only function which decreased in importance is the provisioning of animal products. According to 34% of respondents, the importance of this function decreased, and only 12% thought it increased. In the case of the other ESs, the majority of respondents believed that they became more important, with the increase being much greater for regulating (from 46 to 61%) than provisioning (from 23 to 39%) functions. Results of the ANOVA Kruskal-Wallis test (H = 2911.029; p <unk> 0.0001) indicate that some ESs are not significantly different from each other in terms of respondent preferences, which allowed us to combine ESs with similar priorities (see group numbers in Figure 1). The highest priority group consists of all regulating functions and providing space for recreation from the cultural function category. The second group consists of the cultural heritage protection function and two provisioning functions: timber production and supply of nonwood products. Supplying animal products is significantly different from other provisioning functions, being the least important of all ecosystem services. Changes in the perceived importance of individual ESs over the past decade are shown in Table 1. The only function which decreased in importance is the provisioning of animal products. According to 34% of respondents, the importance of this function decreased, and only 12% thought it increased. In the case of the other ESs, the majority of respondents believed that they became more important, with the increase being much greater for regulating (from 46 to 61%) than provisioning (from 23 to 39%) functions. --- Modeling Perceptions of Ecosystem Services The impact of the selected sociodemographic characteristics of respondents on their perceptions of individual ecosystem services is described by logistic regression models (Table 2). Results of the Hosmer-Lemeshow test indicated that all developed models are well fitted to the empirical data (see Appendix B). The following rows of the table show separate models developed for each ES. In the air quality model, the most significant explanatory variable is "education". A positive parameter of this variable (<unk>U = 0.454) means that university education has a stimulating effect on the appreciation of air quality regulation. The significance level of p <unk> 0.001 and the high value of the Wald statistic (13.22) confirm the high statistical significance of this feature-the highest among all the variables included in the model (the higher the value of this statistic is above 1, the more accurately the trait describes the perceptions of a given ES). An OR value of 1.57 indicates that people with higher education were on average 57% more likely to indicate air quality regulation as a very important forest function. Another important characteristic is gender. Women were almost one and a half times more likely than men (OR = 1.47) to consider air quality regulation as a very important function. Respondents' age had a slightly smaller but significant effect (p <unk> 0.05, Wald = 4.20) on perceptions of air quality regulation. People over 40 years of age were on average 30% more likely than those under 40 to indicate that this function is very important. In contrast, characteristics such as "place of residence" and "financial status" proved statistically insignificant in characterizing perceptions of this function. Also, for the other ESs in the regulating group (with the exception of noise reduction), the educational attainment variable proved to be the most important trait in differentiating perceptions of regulating functions. In the "biodiversity" model, the odds ratio for the "university education" variable is 2.02, which means that people with this level of education are more than twice as likely to prioritize this service. The high statistical significance of this feature is also confirmed by the value of the Wald statistic = 34.21 and p <unk> 0.001. The profile of people who appreciate cultural ESs is not as homogeneous as in the case of regulating functions. For the recreational function, financial status is the most important feature (p <unk> 0.001, Wald = 14.33), while those who rated their financial status as "satisfying" were more than twice as likely (OR = 2.02) to consider this service very important. In contrast, age is the crucial variable for the appreciation of "protection of cultural heritage". People over 40 years of age were on average 38% more likely to indicate this feature as very important. The feature that primarily differentiates perceptions of provisioning functions is one's place of residence. Timber production and animal product provisioning were 2.40 and 2.37 times more often indicated as a very important service by rural residents than urban residents, respectively. For "mushrooms and berries", living in a rural area is also a significant stimulant (p <unk> 0.01 OR = 1.38), but the more important characteristic is gender-women were 41% more likely to perceive this feature as very important compared to men. The LR models built for individual ESs allowed us to identify the following profiles of individuals with different perceptions of forest ESs. Regulating functions are seen as very important primarily by those with higher education, by individuals satisfied with their financial status, and by women. Cultural functions are most appreciated by people satisfied with their material status, and people over 40 years old. Provisioning functions are perceived as very important primarily by rural residents, often with low material status (this characteristic does not apply to timber production), with the provisioning of animal products being more preferred by men and the provisioning of mushrooms and berries by women. --- Discussion The main goal of our research was to elucidate the social assessment of the importance of various forest ecosystem services. Correctly understanding the coordinated development between the social economy and the ecological environment is the key to achieving the sustainable development of land [19]. The application of a sociocultural approach to the identification and management of ecosystem services is crucial to avoid errors arising from ignorance of social expectations and to effectively link ecosystem services to human well-being [12,20,21]. According to Cuni-Sanchez et al. [22], sociocultural evaluation of ESs using research methods derived from the social sciences (e.g., surveys, interviews) enables the placement of stakeholders at the core of the research process [11,23]. Findings from our research unequivocally demonstrate that the regulating and cultural functions of forests are held in the highest regard, while the provisioning functions rank the lowest. Similar conclusions were reached by Mart<unk>n-López et al. [12] and Nastran et al. [24]. In recent years, political and scientific discourse around the world, Poland included, has focused on slowing down climate change. Climate change threatens the stability of forest ecosystems, and forests are perceived as a natural bulwark against climate change [25][26][27][28]. Forests are of great importance in sequestering carbon dioxide. A significant amount of it, as the study by Yang et al. [29] shows, is stored in above-ground biomass but also in soil (0-20 cm) and in below-ground biomass. Most people in Poland are aware of climate change and accept that it is an ongoing process that has a huge impact on the biological environment [30]. Widespread media coverage may be the reason why people attach great importance to regulating services such as "climate regulation" and "carbon sequestration". Given the current significance of and widespread concern surrounding climate change and its interconnectedness with forests, it comes as no surprise that in our survey, regulating forest functions featured prominently. Furthermore, for a long time in many countries, increasing attention has been paid to the use of forest environments not only as a source of measurable benefits such as wood, food, fiber, etc., but also as a space for recreation and health promotion [31]. In many countries, forests traditionally used for timber production are experiencing a shift towards recreational purposes, and their social importance continues to grow [32,33]. A similar trend has also been observed in Poland [34]. This fact is also indirectly reflected in the results of our research, as respondents highly valued cultural forest functions. This observation is consistent with the results of He et al. [15], who showed that regulating and cultural services, and especially local culture and ecotourism, were valued more highly than provisioning services. On the other hand, many studies (e.g., Garrido et al. [20]) found the following order of ES preferences: provisioning followed by traditional knowledge, recreation and ecotourism (cultural ESs), and species richness/diversity (supporting ESs). Also, the results of Mensah et al. [21] and Hochmalová et al. [35] provide a picture of the perceived importance of ecosystem services that diverges from our study. Healthy soil was the only supporting ES considered in the study of Mensah et al. [21], and still it was rated the most important, followed by provisioning and regulating ESs. The least important category was cultural ESs. In turn, Hochmalová et al. [35] reported that provisioning and regulation services are seen as more important than cultural services. Interestingly, Garrido et al. [20] found that respondents from the private and public sectors valued provisioning services more, while those in the civic sector mentioned supporting and regulating services more often. Similarly, in the study of Agbenyega et al. [36], forest owners attached more importance (10-20%) to forest production services than local residents and conservation groups (7-9%). Hence, it is important and interesting to monitor perceptions of the importance of ecosystem services, as they may vary across the globe, mainly due to socioeconomic and cultural factors, including ethnic origin and such issues as food consumption status, which may seem distant for the inhabitants of highly developed countries [37]. According to He et al. [15], identifying ways to balance provisioning and cultural services can actually help reduce the overexploitation or neglect of individual components of biodiversity, which is possible when communities appreciate its long-term importance. The sociocultural assessment of ESs enables the identification of differences in perceptions among stakeholder groups (e.g., Iniesta-Arandia et al. [38]). They can be caused by exogenous factors (e.g., cultural and social background) as well as endogenous ones (gender, age, place of residence, education). Many previous studies on ecosystem services [12,13,21,39] indicated that gender is an important predictor of activities broadly related to environmental issues. Women and men often have differential access to and derive different benefits from ecosystem services; therefore, their perceptions and knowledge of ecosystem services also differ [40]. This is also the case in our research. Mart<unk>n-López et al. [12] found that males mostly prioritized provisioning services, in contrast to females, who emphasized regulating services. Mensah et al. [21] reported that gender and age influenced the perceptions of supporting and provisioning ES. Men showed less enthusiasm about healthy soils (supporting ES), while women valued this function more highly. Women were more sensitive to ecological issues and had more favorable environmental attitudes than men [41][42][43]. They also displayed more pro-environmental behavior than men [44,45]. Women are more interested in health and living in a safe environment, while men tend to view the environment as a resource to be exploited. On the other hand, research by Mensah et al. [21] from Africa indicates that women's appreciation of the importance of provisioning and supporting ESs likely results from their sense of responsibility in the household [21] and how aware they are of direct environmental benefits and resources [39]. Gender differences in awareness of ecosystem services can be explained by gender differences in agroecological work, knowledge, and experience [12,39,46]. Also, the place of residence is a predictor for the appreciation of the importance of specific forest functions. Mart<unk>n-López et al. [12] as well as Lindemann-Matthies et al. [47] found that the inhabitants of rural areas mostly valued provisioning services, while urban residents emphasized regulating services. The perception of the importance of forest functions is correlated with the place of residence and probably indirectly also with the sense of place, attachment to a given place, and the memories and experiences related to it. This is indicated by Xi's et al. [48] research, which clearly shows that the sense of place has a direct impact on landscape preferences. The study by Muhamad et al. [49] demonstrated that rural residents were highly aware of ecosystem services, although they focused more on provisioning services as compared to other forest functions. Additionally, individuals living closer to forests exhibited greater appreciation of intermediate services, such as regulatory, cultural, and supporting services. One's place of origin and residence, the area of one's farmland and/or agroforestry land, and the number of livestock owned were the most salient socioeconomic factors determining the number of ecosystem services perceived by individual respondents. Hochmalová et al. [35] also drew attention to the cultural context of one's place of residence. Comparing perceptions of forest ecosystem services among Chinese and Czech citizens, they found that differences between the countries were conspicuous for cultural and provisioning services: the Chinese expected more relaxation and meditation activities (cultural services), while the Czechs prioritized mushroom picking (provisioning services). Our research also clearly indicates the role of education and educational attainment in the perception of the importance of individual forest functions, which is also confirmed by the research of Mart<unk>n-López et al. [12]. You et al. [50] and He et al. [15] found that as the level of educational attainment increased, residents tended to prioritize regulating and cultural services over provisioning services. In the study by Mart<unk>n-López et al. [12], it was found that people with a lower level of formal education attributed greater value to provisioning services, while those with a higher level of education paid more attention to protection status [50]. The type of knowledge possessed by the stakeholders (i.e., experiential or experimental) is also important [51,52]. Allendorf and Yang [39] found that people with a university education were almost 2.5 times more likely to appreciate the benefits of ecosystem services than those without such education. --- Limitation In our study, we used a survey questionnaire. It is a very popular research tool that can be applied to examine the expectations and preferences of tourists and visitors to naturally valuable areas [53,54]. However, we are aware that the results we obtained when using another tool may not always give similar results, even though the questionnaire we constructed was created in consultation with a sociologist. This is because, as shown by the research of Tahvanainen et al. [55], there are significant differences in the opinions of respondents depending on the survey technique adopted (descriptive questions-pictures). This study covered a very wide group of respondents in order to make the results as reliable as possible. We opted for an online survey, which has some undeniable advantages, particularly when targeting a large respondent pool. However, it also has drawbacks, notably in reaching older individuals who are typically less inclined to use technology and the internet. The low participation of older people may be attributed to the use of an online survey. According to a CBOS poll [23], internet use in Poland is widespread among the youngest respondents and those aged 25-34. The vast majority of respondents aged 35 to 44 are also online. Nearly half of Poles aged 55-64 and three-quarters of the oldest (aged 65 and over) remain offline. We are also aware that it is difficult to capture the "spirit of the place" (genius loci) in an online survey. As Li et al. [48] rightly point out, the relationships between landscape features, preferences, and site-related factors are very complex. The Public Participation Geographic Information System (PPGIS) tool could be of great help in this regard. Nevertheless, our goal was to recognize the general perception of forest ecosystem services in general, and in this aspect the survey is an appropriate research tool. In the future, we would like to conduct this type of research using volunteered geographic information (VGI) data. Another limitation is the fact that the research was conducted during the pandemic. The COVID-19 pandemic led to unprecedented changes in the lifestyles of most people around the world. The need for social distance, lockdown, home isolation, and the consequent restriction of outdoor leisure activities left a strong mark on the lives of millions of people [56,57]. The COVID-19 pandemic in 2020-2021 changed the lifestyle of local communities and entire societies [58]. Coronavirus disease 2019 (COVID-19) brought about a significant and far-reaching impact on the world's business environment, corporations, and individuals [59]. It was only under the influence of these new experiences that many people understood how many services and benefits forests and other green areas provide. This understanding likely had resonance in our respondents' views on the importance of ecosystem services. We were somewhat able to pick this up by asking about noticeable changes over the last 10 years. Further research should pay more attention to how these changes are shaped as a result of the pandemic. --- Conclusions In the process of planning for the sustainable development of forests and ecosystem, services of crucial importance is the identification of links between the condition of forest ecosystems and their functions which are useful for society. Of the categories of services considered, the most highly valued by respondents in this study were those primarily related to the regulation of climate, air quality, and water balance. Cultural services, namely, those affecting the perception of the forest landscape and those important for recreation, were less frequently prioritized. Provisioning services, such as timber production, were the least important to respondents. The survey also showed that the perceptions of forest ecosystem services should be considered with a specific socioeconomic group in mind, taking into account the demographic profile and economic status. This means that the evaluation of ecosystem services in forest areas was affected by such characteristics of respondents as gender, age, education, and financial status. Despite the fact that monitoring the importance of ecosystem services for the general population is important for institutional activities related to local development planning, it is rarely used in practice. In particular, the greater appreciation of the importance of regulating and cultural functions (compared to provisioning ES) suggests that local development planning should emphasize them much more strongly. In turn, identifying and estimating the demand for ecosystem services from the perspective of socioeconomic and demographic stakeholder profiles can provide a valuable insight during planning for sustainable forest and ecosystem services. Such information should be used not only to secure ecosystem services from different stakeholder groups but also to provide the basis for developing their potential through, e.g., planning compensation for the impact of activities and investments affecting the forest environment. --- Data Availability Statement: Data is unavailable due to privacy restrictions. --- Author Contributions: Conceptualization, E.J. and J.B.; methodology, E.J., J.B. and S.Z.; validation, M.W. and K.U.B.; investigation, K.J. and S.Z.; writing-original draft preparation, E.J., J.B. and J.F.; writing-review and editing, K.U.B., J.F. and M.W.; supervision, J.F. and K.J. All authors have read and agreed to the published version of the manuscript. --- Conflicts of Interest: The authors declare no conflict of interest. --- Appendix A

This paper assesses the priority of forest ecosystem services (FESs) and defines the sociodemographic profile of people who consider particular services to be an essential function of forests. The research material consists of the results of a questionnaire survey conducted on 1402 Polish respondents. Twelve different types of FESs were evaluated, to which respondents assigned relative priority (Ps) on a five-point Likert scale. The significance of differences in the importance of individual FESs was assessed using the Kruskal-Wallis ANOVA rank test, while a logistic regression model was used to profile respondents in terms of differences in perceptions of a particular FES. Regulating functions were considered the most important (Ps 0.87-0.94), followed by cultural functions (0.79-0.86), while provisioning functions (0.31-0.75) were deemed the least important. During the last decade, the trend in societal demand for FESs was upward. The greatest increase occurred for regulating functions and the lowest for provisioning (in the case of the supply of animal products, demand has actually decreased). Regulating functions are seen as very important by people with higher education, people who are satisfied with their financial status, and women; noise reduction is in particular valued by urban residents. Cultural functions are most valued by those satisfied with their financial status and people over 40. Provisioning functions are perceived as very important primarily by rural residents, often of low financial status, with the provision of animal products being more appreciated by men and the supply of mushrooms and berries by women. The greater appreciation of the importance of regulating and cultural functions (compared to provisioning ESs) suggests that local development planning should emphasize them much more strongly. In turn, identifying and estimating the demand for ecosystem services from the perspective of socioeconomic and demographic stakeholder profiles can provide valuable insight during planning for sustainable forest and ecosystem services.

Introduction Intentional behaviours to harm others through the Internet or through mobile devices have recently received much attention. Various terms have been used to refer to such behaviours, for example cyberbullying (Tokunaga, 2010), online bullying (Microsoft Corporation, 2012), electronic bullying (Raskauskas and Stoltz, 2007), internet harassment (Ybarra, Diener-West and Leaf, 2007) or online harassment (Wolak, Mitchell, and Finkelhor, 2007). Various definitions exist for some of these terms, some of which draw on offline bullying theory and exclude behaviours that are not repeated or acted out in within a power relationship (Tokunaga 2010). To avoid implying these more restrictive criteria, we use the term online harassment (Wolak, Mitchell and Finkelhor 2007) as an umbrella term to refer to all types of intentional behaviours to harm others through the Internet or mobile devices. The negative consequences of online harassment can include fear for personal safety, distracting headaches, sleep problems and suicidal ideation (Hinduja and Patchin, 2010;Sourander et al., 2010). Online harassment is also associated with offline bullying (Sourander et al., 2010;Beran and Li, 2007). Large-scale research programmes (e.g., Livingstone, Haddon, Görzig and <unk>lafsson, 2011;Microsoft Corporation, 2012) andinterventions (e.g., National Crime Prevention Council, 2012) have been launched to map and contain the risks of online harassment. Most of this research has been conducted in North America and Europe. Yet, a 2012 survey of 25 countries (Microsoft Corporation) demonstrates that online harassment is also a problem in developing countries. In Southeast Asia, online harassment is understudied. However, a recent 25-country survey found that Singapore had the second highest self-reported prevalence of online victimisation in the world (58% in the past year); China had the highest (70%) (Microsoft Corporation, 2012). Thailand was not surveyed. However, a 2010 regional youth media survey indicated that Thai young people were among the region's most avid mobile media users. They spoke on the phone twice the regional average and had more social network contacts than other young people in the region (personal communication, Ipsos, July 10, 2012). This intense media use may be a risk factor for online harassment perpetrated through mobile devices. One published article (Songsiri and Musikaphan, 2011) and other research literature (e.g., Rungsakorn, 2011) demonstrate the presence of online harassment among Thai young people. According to Songsiri and Musikaphan,52.4 per cent of 1,200 Bangkok high school and vocational school students had experienced online harassment in the past year. Offline youth violence has been studied more in Thailand than online harassment. Among a national sample of 1105 Thai youth, the self-reported 1-year prevalence of offline victimisation ranged from 4.3 per cent to 18.6 per cent depending on the type of violence (Pradubmook-Sherer et al., 2008). A comparison between these findings and published Thai research on online harassment (Songsiri and Musikaphan, 2011) suggests that a higher proportion of Thai youth might be victimised online than through offline violence. Studying young people involves specific challenges that may account for the scarcity of previous research on online harassment. Young people have diverse subcultures; representing them accurately may be difficult. Rigorously sampling out-of-school youth is another challenge. Institutional review boards may be reluctant to permit studies that ask minors about sexuality or substance use. Previous research in Thailand has only examined online harassment among school and college students, not among out-of-school youth. There is qualitative evidence that among heterosexual young people, online harassment may be motivated by intimate relationship conflicts and jealousy (Surat, 2010), but no quantitative data are available on the connections between online harassment and sexuality. Furthermore, while forced sex has been studied among young men who have sex with men and young transgender women (Guadamuz et al., 2011), the impact of online harassment on lesbian, gay, bisexual and transgender (LGBT) youth in Thailand has not been previously investigated. This is worrisome as homophobic and sexist themes are common in online harassment (Shariff, 2008). Furthermore, no previous research has investigated the linkages between online harassment and offline violence among young people in Thailand. To address these gaps, we conducted a mixed qualitative/quantitative study covering online harassment and offline violence, as well as selected demographics, gender, sexuality and online or mobile media use, among 15-24 year-old Thai students and out-of-school youth. The novel contributions of the study are (1) inclusion of out-of-school youth; (2) detailed coverage of online and mobile media use; (3) inclusion of both offline violence and online harassment; and (4) inclusion of gender and sexuality items, which permit investigating connections between these issues. The purpose of this article is to describe the data collection methods we used, how we identified participants and gained access to them, the key challenges we faced, and to critically discuss the methodological lessons we learned to inform future research. Empirical findings from the research project are reported separately (e.g., Boonmongkon et al., 2013). --- Methods --- Definitions Offline violence and online harassment-The World Health Organization (WHO, 1996) defines violence as the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation. This definition is in our view appropriate for offline violence. In online harassment, physical force is not used, and the people involved do not always have clearly defined unequal power (Shariff, 2008;Hinduja and Patchin, 2007). Nevertheless, online harassment (Wolak, Mitchell and Finkelhor, 2007) shares the characteristics of violence (as defined above) that it is intentionally harmful and has a high likelihood of resulting in psychological harm; it may even lead to suicide (Hinduja and Patchin, 2010). Only its means differ from offline violence. Youth-In this study, we used the United Nations definition of youth as implying the age period of 15-24 years (WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health, 1999). --- Design and approach We aimed at building a contextualised understanding of online harassment, to investigate how it links with offline violence, media use, gender and sexuality among Thai young people. We chose a mixed methods approach to first qualitatively contextualise the phenomena involved and then to quantitatively establish their prevalence and correlates. --- Research team The research team was diverse, representing various academic disciplines (medical anthropology, psychology, epidemiology, and economics); ages (from early 20s to late 50s); genders and sexual orientations. This diversity facilitated access to youth and institutional gatekeepers, particularly when approaching LGBT youth. All researchers in the team except for one were Thai, and all spoke the Thai language. --- Study site The study site was a district bordering Bangkok in Central Thailand, with three subdistricts in suburban and rural areas. --- Populations We tried to include all major groups of 15-24 year-old youth in the district: (1) university students, (2) upper secondary school students (general and vocational, formal and nonformal) and (3) out-of-school youth. With respect to inclusion criteria, participants had to be 15-24 years old; live, work, or study in the study district, and able to participate using Thai language. We did not recruit young people from juvenile detention centres or young people ordained as monks due to the restrictions on their lifestyles, especially on mobile phone and Internet use. Likewise, we did not recruit deaf or blind young people as their media use is likely to be very different to other young people. --- Ethical considerations The study was reviewed and approved by an institutional review board at Mahidol University. After briefing all participants and answering any questions or concerns, we obtained written informed consent from participants who were over 18 years old, and parental consent and assent from participants who were 15-17 years old. Participant information sheets containing information of the study, the research institutions involved and contact information of the principal investigator were given to all participants. Participants received cash incentives: 50 baht (1.66 USD) for completing the survey and 150 baht (5 USD) for participating in focus group discussions (FGD) or in-depth interviews (IDI). Participation in the study was voluntary; participants were informed that they could withdraw from the study at any point without adverse consequences, and that their data would be kept confidential. To protect confidentiality of our participants, participating academic institutions or the study site district will not be reported. --- Experiences and findings --- Preparation Community mapping-Mapping educational institutions to recruit students was relatively straightforward. Recruiting out-of-school youth in a way that would represent their diversity required more intensive mapping. We first identified areas with concentrated populations using satellite images from Google Maps. We then visited possible data collection sites at various times and days of the week to determine if there were enough outof-school young people to justify data collection in that particular context, if data collection was logistically feasible there, and if gatekeepers needed to be contacted. The final study sites included small vendor stalls/shops, Internet cafés, snooker halls, factories, food courts, local markets, housing developments, private homes, sport venues, district council election sites, a temple fair, and a golf course. Population estimation-We estimated the total student population in the study site by summing the number of students obtained from each relevant educational institution in the district. With respect to out of school youth, the number of all 15-24 year-olds residing in the district according to the Department of Provincial Administration (Population Data Service System) was roughly one tenth of the number of students in the district (1,902 out of 18,000). We considered this figure an underestimate, and extrapolated the total number of out-of-school youth in the district using the total number of students and national enrolment ratios for each level of education. Sample size and recruitment-We aimed at a large enough sample to draw population inferences separately for university students, secondary students and out-of-school youth at the precision level 0.05, and used a simplified Yamane (1967) formula for calculating these sample sizes. The secondary student sample was a stratified probability sample. The university and out-of-school samples were essentially convenience samples, although we did attempt to represent the diversity of both populations in our sampling. We aimed to recruit one focus group of male and another focus group of female students from each educational institution (from various grade levels), to capture the diversity of the student population. We aimed to recruit one additional focus group of gay and lesbian students each at one large educational institution. We also sampled male and female out-ofschool young people for FGDs and IDIs. We recruited participants from each FGD for an additional IDI whenever the FGD had participants who seemed to have more information than they could provide in the FGD, and were willing to participate in an IDI. We recruited up to two participants for IDIs from each FGD. --- Data collection: Measures, instruments and field guides Computerised survey-Informed by our qualitative findings, we developed a youth friendly computerised survey 1 to collect quantitative data on (1) demographic characteristics, (2) experiences of online harassment and offline violence, (3) online and 1 Details of this are available at (add URL) mobile media use and (4) sexual life and partnerships. We included several items to quantitatively test phenomena described by young people in the FGDs and IDIs. We adapted some items on offline violence from Pradubmook-Sherer et al. (2008) and others on online harassment from Rungsakorn (2011). We retained previously used item wordings when appropriate to increase the comparability of the findings, and edited wordings when necessary. Given the broad scope of the survey, the initial paper-and-pencil version took at least 25 minutes to complete. To minimise the risk that participants would find the survey too timeconsuming or boring to complete, we computerised the survey. We included colourful animations portraying young people in situations reflecting the study's topic areas, which further helped to make the survey more engaging. Computerising the survey also reduced the time burden on participants through skip patterns and minimised missing or unreliable data through programme checks. We reviewed multiple versions of the computerised survey and animations. The editing, programming and testing of the computerised survey took roughly two months. Based on pilot testing with students and out-of-school youth, we changed the order of the questions and reworded or deleted some items to shorten the survey. We moved questions on sexual behaviour toward the end of the survey because many pilot testers considered these questions sensitive, but also entertaining and relevant to youth lifestyles. We added a progress bar to give survey takers an idea of how much more was left. We asked our pilot testers if they would respond honestly to substance use questions; none said they would, so we did not include such items. We operated the final version of the survey programme offline. After the programme stored individual participants' responses on each computer's hard drive, the data were exported onto an online password-protected server for storage, and finally uploaded onto a central password-protected computer to collate all responses and to build, manage and prepare the database for analysis. Computers-We used netbook computers; they were affordable, lightweight, and had a long battery life, so we could use them for sustained amount of time, even outdoors. We considered netbooks more affordable, easier to use, more compatible with the web browser based survey programme, and more suitable for other uses after the completion of the survey, than tablets and other mobile devices. Field guide for FGDs and IDIs-We devised a semi-structured field guide to aid data collection during IDIs and FGDs. The field guide comprises 30 open-ended questions covering the following issues: (1) online and mobile media use, (2) patterns of online and mobile media use, (3) social, cultural and economic factors affecting mobile and online media use, (4) effects of mobile and online media use on gender and sexuality, and (5) offline violence and online harassment. Questions on individual behaviours were prepared for IDIs, whereas group norm questions were prepared for FGDs. --- Gaining access to school-based and out-of-school youth and engagement with community leaders School-based young people-We first telephoned all relevant universities and upper secondary schools in the study area to ask for their participation, sent them a formal letter, and made a follow-up visit if necessary to speak to the school's gatekeepers. Only one secondary school chose not to participate, first stating that the school had no violence, but later explaining it was not convenient for the school to participate. Teachers and administrative staff in participating institutions helped to recruit the requested number of students. These staff briefed the identified students about the study and gave them the informed consent form to decide whether to participate. In secondary schools, where most students were under 18 years of age, only students contacted in advance participated, since informed parental consent was required from their guardians, as per IRB regulations. At universities, we sometimes recruited participants directly from common areas within various academic faculties, since university students could give informed consent themselves. Out-of-school youth-To recruit out-of-school youth, we contacted community leaders (four village headmen and one community health worker) after obtaining their telephone numbers from the district office, but they only played a minor role in recruitment. A community health worker knew the parents of youth in the community and helped to recommend venues where young people congregated. The village headmen, on the other hand, had more limited involvement with young people and therefore not helpful to the study. Overall, we found most participants through observation in community locales where young people congregated, like snooker halls, small food stalls, or community stores. However, we noticed that in these places there were many men, but relatively few women. We therefore had to find other ways of accessing women. One way was to recruit women from a local golf course where many women worked as caddies, as well as in nearby factories where most of the workers were women. When recruiting participants in private enterprises, gatekeepers needed to be contacted. In smaller enterprises, we usually reached an informal agreement to collect data straight away from customers and staff inside or just outside their premises. In larger enterprises (the golf course and one factory) we had to send a formal request letter in advance and make follow-up telephone calls to gain permission. Some enterprises stated they did not have staff in our age bracket of interest. Our community observation reminded us that out-of-school young people often work during the day. Thus, they are only accessible to researchers after working hours. This prompted us to shift most of our out-of-school recruitment efforts to evenings. Snowball sampling technique, whereby participants helped to recruit their friends as participants, also worked well. Other community members met during fieldwork also volunteered to help recruit participants, even if they themselves could not participate due to the participant inclusion/exclusion criteria, for example if they were over 24 years old. --- Data collection Data collection was sequential in that FGDs and IDIs were first conducted in order to obtain qualitative data. Then, informed by the qualitative findings, the survey instrument was developed and pilot tested with young people and later used in the quantitative phase that was conducted three to eight months later in each site. The study took about two years to complete, spanning 2011 and 2012. Qualitative data-We recruited out-of-school participants for FGDs and IDIs directly by ourselves or through existing community contacts; participants in educational institutions were mostly recruited by teachers. We convened 22 FGDs (out of 26 targeted; 18 with students, 4 with out-of-school youth) with overall 110 participants (52 female, 58 male). We arranged all student FGDs inside educational institutions. Teachers typically had recruited a group of students and introduced them to us, then departed. FGDs with out-of-school youth were conducted in community locations where they spent their free time. In most cases, at least two research team members facilitated each FGD, with one facilitating the FGD and the other taking notes, observing non-verbal communications, drawing a figure of the seating arrangement and digitally audio recording the discussion. In the beginning of each FGD, the facilitator briefly explained the aims and process of the study, obtained informed consent, and provided snacks to the participants. The facilitator (and sometimes, the note taker) then asked prompt questions loosely based on the IDI/FGD field guide. At the end of each discussion, participants were asked if they had anything to add, or to ask the facilitator or note-taker. If not, we thanked them for their time and gave them their incentives. We conducted 26 IDIs (out of targeted 52). Similar to the FGDs, IDIs took place in the premises of participating educational institutions, or in public spaces like coffee shops, based on each participant's preference. Since most participants had already been in FGDs, they already knew the aims of the study. To start the conversation, the interviewer reminded the participant what had been discussed in the participant's FGD, then asked open-ended probing questions. IDIs were digitally recorded by the interviewer with the participant's permission. Quantitative data-We collected quantitative data between September 2011 and March 2012. In secondary schools, the informed consent process had been conducted in advance by teachers using the forms we had provided. In universities and among out-of-school youth, we usually obtained informed consent immediately before data collection. We also verbally briefed our participants about the aims of the study. Research team members remained seated nearby while participants took the survey, in case participants requested assistance. Participants in educational institutions usually spent 15-30 minutes to complete the survey, whereas out-of-school participants typically spent 30-60 minutes. This reflected differences in their literacy and computer skills. In secondary schools, we collected quantitative data in classrooms and other spaces set aside by the institution. In universities, we collected quantitative data in classrooms, study areas or open communal spaces. In out-of-school settings, we had to collect quantitative data wherever we found participants and had space for the participant and the netbook to take the survey. These spaces included the back of the research team's pick-up truck, motorcycle seats, local shops or cafés, market stalls, participants' homes, benches next to canals, pool/ snooker halls and so on. Thus, in educational institutions, privacy was better than in community locations, where lack of space sometimes meant participants sat very close to each other, or that other youth in the community looked over their responses to the computerised survey. Altogether 1234 participants completed the computerised survey -by self-identification, they comprised 595 men (48.2%), 554 women (44.9%), and 84 participants who identified with homosexual, bisexual or transgender identity categories (e.g., gay, kathoei, tom or dee; 6.9% of the total sample). Thai ethnicity was stated by 1165 (94.4%); 29 (2.4%) indicated Chinese and 32 (2.6%) stated mixed ethnicity. Most (1193, 96.7%) stated they were Buddhist, while 15 (1.2%) stated they were Muslim and 19 (1.5%) that they were Christian. --- Data preparation Qualitative data-Digital recordings of all IDIs and FGDs were transcribed by a research team member or an outsourced transcriber. The accuracy of transcription was checked by at least one research team member who had been present at data collection. Quantitative data-Following each round of data collection, we exported raw, unidentifiable data files from each computer on which participants took the selfadministered surveys to a password-protected online data storage account and then added them onto our database on a main computer. --- Key challenges and lessons learnt --- Gender and sexuality issues in recruiting out-of-school youth participants Young people identifying as "men" were easier to recruit among out-of-school youth than young people identifying with other gender/sexuality categories, including "women", so men seem over-represented in the out-of-school sample (65.0% self-identified as men and 31.5% as women). Firstly, this may reflect the reverse gender gap in Thai tertiary education -the gross enrollment rate in tertiary education was 55 per cent among women and only 44 per cent among men in 2007 (World Bank, 2009, 35). Secondly, the difficulty in recruiting out-of-school women corroborates the common perception that many Thai women do not spend their free time in public spaces as much as Thai men. Thus, recruiting out-of-school youth only in public places where young people gather during their free time may be insufficient for obtaining a gender-balanced out-of-school sample. Thirdly, most of the research team members were male; this may have contributed to the over-recruitment of male out-of-school youth. Had the team included young female researchers familiar with young women's lifestyles in the district, it might have facilitated data collection among young out-of-school women. To an extent, we countered this obstacle by recruiting more out-of-school young women through enterprises that mostly had female employees. Sexual/gender minority youth (e.g., youth identifying as gay, tom, dee or kathoei) also seemed underrepresented among out-of-school youth. Only 3.6% of out-of-school survey participants self-identified with sexual/gender minority categories, in contrast to 8.4% of participants in educational institutions. A study conducted in Northern Thailand among 17-20 year old youth (Tangmunkongvorakul, Banwell, Carmichael, Utomo and Sleigh, 2010) likewise found a larger proportion of male Thai youth attending educational institutions self-identifying with minority categories, or stating they were unsure of their gender or sexuality (9.8%, vocational schools; 21.4%, universities and general secondary schools) than young men who were currently not attending educational institutions (6.7%). However, the Northern Thai study demonstrated a gender difference as a higher proportion of out-of-school young women (19.3%) and vocational school students (22.7%) identified with sexual/gender minority categories (or were unsure) than female university or general secondary school students (10.7%). Overall, a lower proportion of our participants self-identified with sexual/ gender minority categories than participants of the Northern Thai study. In our study, out-of-school sexual/gender minority young people might have been more concerned about privacy and confidentiality than their counterparts in educational institutions. The social context of educational institutions might facilitate the adoption and disclosure of sexual/gender minority identities, for example because there are more role models. Or, some groups of sexual/gender minority young people might actually have higher participation rates in some educational contexts. In contrast, some sexual/gender minority youth may not feel that the physical spaces in the communities where we collected out-of-school data were welcoming, safe, or interesting places to spend their free time. If this is the case, public spaces in these communities may mostly offer recreational opportunities for gender-normative, heterosexual male young people. More research is needed to explore these possibilities. In any case, the findings from both our study and the Northern Thai study (Tangmunkongvorakul et al., 2010) indicate that when the aim is to find out the proportion of sexual/gender minority youth in a given population (e.g., as part of a needs assessment), this proportion depends heavily on the educational (or out-of-school) context of the youth sampled. --- Inclusion of migrant youth Our study site has visible cross-border migrant populations, especially from Cambodia, Burma, Laos and Vietnam. Like Thai youth, young people from these groups use the Internet and mobile technologies, such as Facebook, YouTube, or sending/receiving video clips through mobile phones and making mobile calls. Although many migrant workers speak good Thai, none of the migrant workers we approached could read and write Thai well enough to complete the survey independently. We therefore did not recruit migrant young people as participants in our study. If migrant young people are to be recruited, self-administered surveys in future studies will need to be translated into each major migrant language. Their appropriateness specifically for migrant youth will need to be checked. However, some migrant workers may not be literate in their own language or the official language of their country of origin, so audiocomputer assisted self-interview (ACASI) may a more appropriate alternative. Similar procedures might also be necessary if any non-migrant linguistic minorities present in a given study site would be recruited as participants. Several young migrant workers we approached seemed afraid of the possible negative consequences of participating in the study, perhaps due to their illegal migrant status and/or previous negative experiences with immigration or other law enforcement officials. Field researchers with matched ethnicity and language skills might facilitate community mapping and participant recruitment. --- Appropriateness of computerised surveys for school-based and out-of-school youth Computerisation made our survey more engaging and interesting to participants because it fit with youth lifestyles that already incorporate computers, the Internet and mobile technologies. Some participants said they felt more comfortable completing the survey on a computer, as there could be no suspicion of their handwriting being identified. Minimal modification would be needed to use our survey program in other Thai contexts or in a nationwide online survey. However, some participants had difficulty taking the computerised survey, mostly out-ofschool youth. Some even declined to participate because they did not think they had the necessary computer skills to take the survey. And so, similar to data collection among migrant populations, ACASI may be more appropriate for data collection outside educational institutions. --- Privacy and confidentiality of data collection During the administration of the computerised survey in educational institutions, we sometimes needed to change seating arrangements or remind other participants and teachers of the importance of privacy, to safeguard participants' privacy and to ensure confidentiality of the data. With out-of-school participants, this was more challenging. Often, friends and family members were curious to see participants use the netbooks. Our requests to respect participants' privacy were sometimes ignored. We did not always feel able to insist on this point given the close relationship between each participant and their friends and/or family. However, many participants themselves invited their friends or relatives to be involved while they took the survey, which suggests they did not find lack of privacy a problem or that they did not think the information they gave needed to be kept confidential from their friends or family members. For example, it was not uncommon for friends of participants to remind or correct participants when they responded to the survey. Participants' lack of literacy skills also became a privacy issue since some out-of-school participants were not literate enough to complete the survey independently. The research team was subsequently faced with the options of compromising privacy by helping to read some questions to participants and type in open-ended answers on their behalf, or excluding these participants from the survey. Our decision was to offer help if it was minimal (i.e., helping to spell or write out responses to open-ended questions), but if the help needed was beyond this (i.e., reading out the entire survey and filling out the survey for participants), we politely explained to participants that the survey inclusion criteria needed to be observed. Yet, among the research team, this was a contested issue since the criteria on when to request participants to stop completing the survey were not very clear. --- Inclusion of minors We understood that asking minors about their sexual behaviour and violence or harassment experiences could be sensitive, and that these sensitivities could result in our IRB refusing to permit data collection. However, offline youth violence and online harassment are characteristically problems involving and affecting minors (Microsoft Corporation, 2012;Pradubmook-Sherer et al., 2008;Songsiri and Musikaphan, 2011). Many Thai youth also experience their sexual debut and engage in sexual risks at a relatively early age. For example, sexually active 18-24 year-olds studied in the 2006 National Survey on Risk Behavior and HIV/AIDS and ART Knowledge stated they had typically had their sexual debut between 10 to 14 years of age (Sabaiying, 2009). Choosing not to study the risks minors face through violence, harassment and sexual behaviours would mean denying them the protection they need, because in the absence of research evidence, interventions may not be launched at all or will be designed and implemented on the basis of misguided assumptions. With this rationale, we were able to convince the IRB for this study to permit data collection with minors. --- Class differences in the appropriateness of the informed consent process In educational institutions, the informed consent process was generally simple. However, in out-of-school settings, where most participants were working-class, several youth seemed intimidated by the amount of text and the formal, legalistic wordings used in the participant information sheet and informed consent form. These wordings were largely mandated by our IRB, so we were unable to change them. Signing a consent form and providing further details (e.g., full postal address and citizen identification card number) was a difficult decision for many out-of-school youth. Besides our assurances that their confidentiality would be upheld, they had no way of knowing if their contact information would be used to link them with the sensitive information they disclosed in the survey. Perpetration data divulged by participants could in theory be used as evidence against them. In practice, the participant code numbers we gave them cannot be linked to any identifying information. The wordings and the process of the informed consent procedure, largely derived from clinical research and intended to protect participants, might increase the confidence of an adult, middle-class, well-educated person to participate in a clinical trial. Yet, these procedures may be less appropriate for social research involving young people, especially out-of-school youth, for whom literacy, command of formal language, and fears about loss of confidentiality may pose issues. This could make such youth under-represented in the scientific literature. Verbal informed consent might be more appropriate and less intimidating to the supposed beneficiaries of the informed consent process. Parental consent should perhaps be possible to waive in surveys where data cannot be linked back to individual participants, and obtaining parental consent may indeed be difficult for youth who do not spend much time with their parents, or live far away from them. In contexts where many young people migrate to work or study elsewhere, young people living far from their parents may constitute a significant proportion of all youth. Even when the parents are accessible, requesting young people to ask their parents to consent to their participation in a research study may actually increase their risks. For example, sexual minority youth asking their parents to participate in a "gay" study would implicitly disclose their sexual orientation identity to their parents and risk negative reactions. Similarly, young people abused by their parents could be put at risk if researchers asked them to obtain parental consent for participating in a study on child abuse. We are planning to investigate and report how Thai out-of-school youth experienced our written informed consent process. --- Definition and measurement issues Violence and harassment-In FGDs, we noticed that participants had a narrow perception of violence. For example, offline violence was perceived to only include physical violence. Verbal violence and most types of online harassment fell outside most participants' definition of violence. We circumvented these problems by framing the survey questions as descriptions of specific behaviours (e.g., "pressing others to have sex or to make a sexual performance over a webcam") rather than as abstract categories (e.g. "online sexual harassment"). Sexual behaviour-Participant interpretations of survey items affect their responses. For example, our question "have you been forced to have sex" may have been less problematic than asking if they had been raped (DeKeseredy and Schwartz, 2001). However, survey takers may still have had different perceptions of what constitutes having sex or being forced. Surveys in Thailand have found that few participants think that non-penetrative or non-vaginal sexual behaviours constitute having sex (Jackson, 1999). This may affect responses to sexual violence and items on sexual behaviour in general, implying underreporting of non-vaginal, non-penetrative sex unless survey items are worded in terms of specific sexual behaviours. Internet and mobile phone use-We measured both Internet and mobile phone use with specific items, for example, how many minutes/hours participants used any given application, or spoke on the phone with certain types of contacts (family, partner, friend etc.) per day. The response choices were in 10-minute increments for the first hour, and in hours thereafter, up to "more than four hours" per program or type of person. This approach may provide meaningful estimates of specific program use or specific types of calls, but our experience suggests that it leads to inflated overall estimates of Internet use or mobile phone calls when the specific categories are summed up. In part, this may be due to the accumulation of inaccurate estimates. More importantly, adding up time estimates for each programme inherently assumes that only one programme is used at a time, while in fact many young people use several Internet or mobile functions simultaneously. Youtng people may have counted the time they were online with each program, rather than the time they actively used each program, so their estimates should not be taken to mean they are not engaged in other activities at the same time, online and/or offline. Thus, the total time spent daily on the Internet or mobile phones might need to be assessed separately from the time spent on specific programs or functions. --- Technical issues in using a computerised survey We initially considered marketing and conducting our survey entirely online. The benefit of an anonymous online survey could facilitate truthful responses to sensitive items, such as illicit substance use. However, unless careful precautions were taken, participants could face the risk of legal repercussions for their past illegal activities, since it is technologically possible, and currently permitted by Thai law, for state authorities to track individuals using their IP addresses. For us, this option was not feasible mainly because we wanted geographically focused data from youth, and verifying the geographic location and age of participants would have been difficult. In a Thai-language nationwide survey with a broader age bracket, these problems could be avoided, as most Thai speakers live within Thailand. However, obtaining written informed

Violence in the physical (offline) world is a well-documented health and social issue among young people worldwide. In Southeast Asia, online harassment (defined as intentional behaviours to harm others through the Internet or through mobile devices) is less well documented. In this paper, we describe and critically discuss the mixed-methods data collection approach we used to build a contextualised understanding of offline violence and online harassment among 15-24 yearold students and out-of-school youth in Central Thailand. We mapped linkages between offline violence and online harassment, and with their possible correlates including gender, sexuality, and mobile media or Internet use. Data collection methods included in-depth interviews, focus group discussions and a custom-built, self-administered computerised survey. Using mixed methods enabled us to collect holistic qualitative/quantitative data from both students and out-of-school youth. In our discussion, we focus on gender, sexuality, class and ethnicity issues in recruiting outof-school youth; definition and measurement issues; technical issues in using a computerised survey; ethical issues surrounding data collection from minors as well as privacy and confidentiality concerns in collecting data in both in-school and out-of-school settings; and the general implications of using mixed methods.

or mobile functions simultaneously. Youtng people may have counted the time they were online with each program, rather than the time they actively used each program, so their estimates should not be taken to mean they are not engaged in other activities at the same time, online and/or offline. Thus, the total time spent daily on the Internet or mobile phones might need to be assessed separately from the time spent on specific programs or functions. --- Technical issues in using a computerised survey We initially considered marketing and conducting our survey entirely online. The benefit of an anonymous online survey could facilitate truthful responses to sensitive items, such as illicit substance use. However, unless careful precautions were taken, participants could face the risk of legal repercussions for their past illegal activities, since it is technologically possible, and currently permitted by Thai law, for state authorities to track individuals using their IP addresses. For us, this option was not feasible mainly because we wanted geographically focused data from youth, and verifying the geographic location and age of participants would have been difficult. In a Thai-language nationwide survey with a broader age bracket, these problems could be avoided, as most Thai speakers live within Thailand. However, obtaining written informed consent (if necessary from parents) would be challenging with this kind of survey. A waiver of parental consent would thus need to be in place for such studies. We also felt that it was necessary to include young people who did not use the Internet to be able to make comparisons between Internet users and non-users. We therefore chose to operate our survey program offline. Doing so meant additional workload in transferring data from netbooks to our central database. However, it also helped to circumvent data loss due to network failure, which would have been likely had we relied on wireless Internet connections, especially when collecting data outdoors among out-of-school youth. Schatz and Williams (2012) have argued that uniform, multi-country surveys would greatly benefit from the addition of a qualitative component to assess the validity of survey questions and to culturally contextualise quantitative findings. Ideally, the qualitative component in mixed methods studies should be implemented before, during and after survey data collection to develop and validate survey questions, contextualise the findings, and finally, help to interpret survey data. --- Implications of mixed methods Correspondingly, we benefited from conducting IDIs and FGDs before collecting survey data, as it helped us to develop and validate our survey items. We added culturally specific phenomena (e.g., specific types of violence or online harassment) as survey items and adjusted the wordings of items adopted from previous research to make them more culturally appropriate. However, the qualitative data that helped us make sense of our survey findings were not only gathered formally through IDIs and FGDs. Also important were the notes we made during survey data collection about procedural issues, for example on how the youth we asked to participate in the study felt about our computerised survey or about the informed consent process. As explained above, these issues sometimes determined how likely each group of young people was to participate in the study, and consequently, how well these groups are represented in the resulting data. --- Conclusions Youth researchers have a responsibility to reflect diversity among young people in their work. School-only samples may be easy to obtain but only represent students. Similarly, studies that do not involve minority ethnic participants or questions about gender and sexuality fail to represent important minorities and bias the research literature on youth. Yet, capturing this diversity involves methodological challenges. We have presented one approach of studying offline violence, online harassment, gender/sexuality and media use among students and out-of-school youth. We feel the present study greatly benefited from the use of a mixed methods approach, the computerised survey that permitted inclusion of a large number of survey questions, coverage of both Internet users and non-users, a holistic understanding of youth violence, and the linkages between offline violence, online harassment, gender and sexuality. However, our approach was less successful in including youth with low levels of literacy, computer or Thai language skills. We discussed alternatives, such as ACASI or surveys in multiple languages. We also reflected on how an excessively legalistic informed consent process can intimidate its supposed beneficiaries and how the creation of overall media use estimates by summing up specific variables can lead to unrealistically inflated estimates. In conclusion, the experiences we have presented in this paper reflect the challenges involved in a mixed methods study but also the strengths of mixed methods in creating culturally relevant and statistically representative data on violence, gender/sexuality, and media use.

Violence in the physical (offline) world is a well-documented health and social issue among young people worldwide. In Southeast Asia, online harassment (defined as intentional behaviours to harm others through the Internet or through mobile devices) is less well documented. In this paper, we describe and critically discuss the mixed-methods data collection approach we used to build a contextualised understanding of offline violence and online harassment among 15-24 yearold students and out-of-school youth in Central Thailand. We mapped linkages between offline violence and online harassment, and with their possible correlates including gender, sexuality, and mobile media or Internet use. Data collection methods included in-depth interviews, focus group discussions and a custom-built, self-administered computerised survey. Using mixed methods enabled us to collect holistic qualitative/quantitative data from both students and out-of-school youth. In our discussion, we focus on gender, sexuality, class and ethnicity issues in recruiting outof-school youth; definition and measurement issues; technical issues in using a computerised survey; ethical issues surrounding data collection from minors as well as privacy and confidentiality concerns in collecting data in both in-school and out-of-school settings; and the general implications of using mixed methods.

Introduction Individual performance, which refers to the effectiveness and productivity of an employee in fulfilling their job responsibilities and contributing to the overall goals and objectives of the company, is a key factor impacting the success of organizations. As explained by (Mangkunegara, 2001), "Employee Performance (Work Achievement)" refers to the standard of the job carried out by an employee, comprising both the quality and quantity of tasks accomplished while fulfilling their assigned obligations. Every institution consistently anticipates excellent staff, as this trait can significantly enhance their performance. The labor force in Indonesia has changed over time as evidenced by the employment data provided by the Central Bureau of Statistics (BPS). Based on the obtained data, it was observed that the Female Labor Force Participation Rate (TPAK) in 2021 expanded by 0.21%, from 53.13% in August 2020 to 53.34% in August 2021. Following this, women employees often have limited time, which is usually torn between the demands of both their jobs and families. As stated a previous study, the tremendous problem faced by women with regards to the allocation of their time to both the needs of job and family is a significant result of this conflict (Rabenu, Tziner, & Sharoni, 2017) Similarly, (Greenhaus & Beutell, 1985) defined Work-Family conflict as inter-role conflict, where the needs of work and family are inherently inconsistent in various aspects. It is important to note that performing job-related tasks becomes increasingly challenging when they conflict with domestic responsibilities, and handling family responsibilities becomes more challenging when work-related pressures rise. In this context, it can also be seen as an intra-role conflict, where the job demands are perceived as conflicting with home responsibilities and contending with forces from other life domains. BPS is an institution (ministry) responsible for ensuring the availability of statistical data. This means that employees in this institution should be able to provide up-to-date statistical data that must reach all areas within its scope of operation. In addition, the workload that should be borne by this institution is related to the publication of official statistics on inflation, tourism, transportation, employment, and poverty, among others, which must be published and uploaded within a certain time frame. As of December 31, 2021, the total number of employees in this institution consisted of 487 state civil servants (ASN), with 232 being men and 255 women. Following this, since 2020, BPS office in West Sumatra has been headed by a woman who is also the first female leader since the establishment of the office. It is also important to clarify that the tendency of women to work has many implications. According to research conducted by (Akgunduz, (2015), work pressure or employee stress is primarily contributed by conflict and overload, which leads to an imbalance in these roles, thereby resulting in conflicts. Based on comparative data on attendance and performance achievements of BPS throughout West Sumatra for the period from June to December 2021, it was evident that the percentage of female employees coming late to the office was greater than that of male employees, with a 30.81 percent for the females compared to 29.54 percent for the males. The data also showed that the performance achievements of women (96.14%) were lower than men in workplaces (97.86%). As established in previous research, Work-Family conflict refers to the challenges and tensions that arise when the demands of work and family responsibilities are incompatible. Within the context of female employees in BPS, this type of conflict may arise due to long working hours, inflexible schedules, and the necessity to juggle both job and family duties. Consequently, this conflict can adversely influence the performance of women, as it enhances the feelings of stress, fatigue, and reduced job satisfaction (Surbakti & Devasahayam, 2015) The discussion of women has perennially been a topic of significant interest, especially with regard to the equilibrium between their professional careers and their roles as homemakers. While women traditionally fulfill responsibilities as wives and mothers within the household, this does not preclude the possibility of pursuing gainful employment beyond the domestic sphere. This is evidenced by the prevalent phenomenon occurring in the present society where many married women work to earn additional income or express themselves in the midst of both family and society. However, a significant number of scholars tend to concentrate on investigating workplace stressors as the primar origins of Work-Family conflict. This is predominantly due to the limited control of female employees over their work life, which is in contrast to their moderately greater control over household matters (Higgins & Duxbury, 1992;(Rabenu, Tziner, & Sharoni, 2017) Considering these circumstances, women employees are frequently in a dilemma, juggling the growing obligations of their roles as parents to children and caregivers to aging parents, alongside escalating demands from employers for employees to excel in their positions and make additional contributions beyond their official job responsibilities. One notable consequence of these multifaceted positions is the occurrence of Work-Family conflict (Neal & Hammer, 2007;(Rabenu, Tziner, & Sharoni, 2017). From the research conducted by (Diane & Gabrielle, 2016), workload showed an indirectly positive impact on work pressure when moderately mediated by both Work-Family conflict (WFC) and Family-Work conflict (FWC). For instance, employees in the hospitality sector dealing with substantial workloads and limited resources, might undergo setbacks in terms of time, physical health, and psychological well-being. This vulnerability to resource loss, stemming from Work-Family conflict, can lead to a downward spiral affecting other life aspects, such as household wellbeing, which is in accordance with the concept of the downward spiral of resource loss. The workload of BPS employees is classified as physically and mentally heavy, and this is primarily because the tasks assigned by the institution often come with strict deadlines considering the fact the agency deals with public services. Accordingly, the statistical data presented by BPS is required to always be on time in order to be effective. It is also important to acknowledge that in the current era of bureaucratic reform, all government agencies are mandated to undergo comprehensive changes and reform. These changes include all aspects, extending beyond mere performance allowances, to comprise holistic organizational improvements and the enhancement of human resources. In accordance, the responsibility of BPS in the West Sumatra province is to ensure that the development of human resources is carried out in line with the pace of bureaucratic reform. With substantial workloads, an employee may feel the psychological impact of work pressure when engaged in a routine job. Referring to the description above, the hypothesis was formulated as follow: H1: Work-Family conflict negatively influences the performance of female employees According to (Siswanto, 2003), prolonged conflict adversely and significantly impacted both work behavior and the entire performance of employees. Accordingly, a favorable correlation was noticed between the presence of Work-Family policies and job performance. This finding was in contrast to the observations of (Singh & Nayak, 2015) who indicated a direct negative association between Work-Family rules and the job satisfaction of police officers. Subsequently, another research on Indonesian female employees revealed that Work-Family conflict had a substantial and adverse impact on job satisfaction, but did not significantly showed an impact on job performance (Purwanto, 2020). This conclusion is in line with a previous investigation conducted in Saudi Arabia by (Almohammed Saleh, Alotaibi, & Al-Alawi, 2021). H2: Work-family conflict positively influences job stress Workload stress is linked to the perceived volume of tasks and can be classified in relation to both quantity (the workload's extent) and quality (the complexity it entails), Jex, 1998. In accordance with this theory, the findings from research conducted by (Amiruddin, 2019) indicated that Work-Family conflict had a significant and positive impact on Turnover Intention, Job Stress, and Audit Quality Reduction Behavior. Moreover, high levels of this conflict were found to be associated with elevated levels of Job Stress, Turnover Intention, and Audit Quality Reduction Behavior. (Obrenovic, Jianguo, & Shafique Khan, 2020) stated that Work-Family conflict was observed to exhibit an indirect influence on work performance. According to their research, the phenomenon usually occurs when the demands of work and family life are incompatible, leading to tension and stress. In addition, (Rabenu, Tziner, & Sharoni, 2017) established in their exploration that stress is positively related to Work-Family conflict. H3: Workload positively influence female employee performance Workers are often faced with the challenge of having to simultaneously complete two or more tasks within a speculated time. Considering this challenge, a theory was introduced by Huey and Wickens, which was adopted in the research conducted by (Kusuma & Soesatyo, 2014). This theory posits that performance is influenced by workload, with high workloads potentially resulting in errors stemming from the inability of employees to manage their assigned tasks in the workplace. In line with this theory, an investigation was carried out by (Yosiana, Hermawati, & Mas'ud, 2020) where it was found that nurses experienced high workloads, and thiz led to numerous challenges such as instability of health, mental illnesses, lack of sleep, night shifts, excessive work, and numerous tasks to be completed. Following this finding, the direct influence of workload on the performance of nurses was both significant and detrimental. (Bruggen, 2015) examined the correlation between workload and performance, which yielded an inverted U-shaped relationship. In the same vane, the results obtained by (Ramadhani, Ramli, & Akbar, 2022) supported the notion that workload adversely affected the performance of employees at PT Mahalona. Aanother research also indicated that workload had a significant negative effect on the performance of female employees in both small and medium-sized enterprises. Lastly, (Msuya & Kumar, 2022), observed the connection between workload and the performance of bank workers, which was found to be significantly positive. --- H4: Workload positively influences work pressure Nurses typically experience work pressure when assigned a workload that surpasses their capacity, which makes it challenging to fulfill responsibilities. As observed in previous research, when stress reaches a level close to the maximum capability, assigning further tasks would only reduce their performance (Maharani & Budianto, 2019). In accordance with the research conducted by (Diane & Gabrielle, 2016), it is evident that the impact of workload, as well as family, leader, and organizational support on work stress, mediated through Work-Family conflict, is statistically significant. (Kusuma & Soesatyo, 2014) examined the impact of workload on work pressure and its subsequent effects on employee performance. This investigation was conducted among permanent employees of the production department at PT Apie Indo Kurnia. --- H5: Work pressure negatively influences Female Employee Performance As reported by Smeltzer et al., (2010), and referenced in the investigation performed by (Sharma & Srivastava, 2022), stress is frequently referred to as sensations of being overwhelmed, an after-effect of working under tight deadlines, tension, and feelings of fatigue. This sensation is a disorderly state that frequently arises in reaction to unfavorable influences from either the internal or external environment. Accordingly, (Ahmed & Ramzan, 2013) stated in their investigation, that the level of work pressure in a company corresponds to a detrimental and severe impact on the performance of its employees. This means if employees experience work pressure, it is most likely that their performance will decrease. Following this theory, the results of the exploration carried out by (Muis, Nai'em, & Arsin, 2021) showed that out of the surveyed participants, 84.2% encountered significant stress and demonstrated a decline in performance, compared to those who experienced only mild stress. Furthermore, (Sharma & Srivastava, 2022) also established that stress at the workplace had an adverse impact on the health and overall well-being of employees. This factor was observed to have a negative influence on job performance and productivity, as well as organizational goals and strategies. Based on this established fact, it is important to note that the absence of proper management of work stress significantly influences worker productivity and morale. H6: Work-Family conflict affects the performance of women employees mediated by job pressure According to (Greenhaus, Callanan, & Godshalk, 2000), Work-Family conflict causes high levels of absenteeism and stress, both of which can adversely affect the productivity of an organization. This primarily occurs because employees often strive to strike a harmony between work tasks and family life, and one way to achieve this is by making career choices that allow the attainment of a better quality of life (Greenhaus, Callanan, & Godshalk, 2000). This condition showed that Work-Family conflict is a determinant of life that needs serious attention not only from individuals who experience it but also from the organizations who employ these individuals, specifically those who come from dual-earner families. In accordance with this, (Greenhaus, Callanan, & Godshalk, 2000), also stated specifically that Work-Family conflict is predominantly experienced by women than men. This is essentially because women have greater responsibility for taking care of both household activities and children than men. Furthermore, this usually occurs because society tends to consider women to have more responsibility for matters that are internal to the family such as cooking and taking care of the family, while men are responsible for fulfilling public roles by becoming successful workers (Abbott, Cieri, & Iverson, 2013). In line with this theory, research conducted by (Karatepe, 2013) indicated that employees who are emotionally fatigued are more likely to demonstrate displeasure as a responding attitude toward their business and less devotion to their job. This observation evidenced the fact that emotional burnout acts as a comprehensive mediator for the impacts of excessive workload, Work-Family conflict, and family-work conflict on job attachment and job performance. H7: Workload affects the performance of female employees mediated by job stress Women employees frequently have difficulties in being good housewives or workers simutaneously (Noor, 2004;(Fuadiputra & Novianti, 2020). This is primarily because these personnel are frequently saddled with the responsibility of saving both their work life and privacy (Fuadiputra & Novianti, 2020) Zhang et al., 2017;Zhang, Griffith & Fried, 2012). As rightly observed in a previous exploration, when employees are tasked with workloads that surpass their capacity, their physical well-being is more likely to deteriorate, leading to increased feelings of tension (Maharani & Budianto, 2019). --- Research Methods The method of this research used a quantitative design at BPS of West Sumatra Province, with a focus on married women who were employed at the agency. The research was conducted between October and December 2022, with a total population of 188 employees, out of which a sample of 128 employees was selected for the investigation. The measurement of Work-Family conflict was carried out using three indicators namely Strain-based, Time-based, and Behaviorbased conflicts, with 13 statements adapted from (Karatepe, 2013). Work pressure was also assessed through three indicators, including psychological symptoms, physical symptoms, and behavioral symptoms, consisting of 18 statements adapted from a previous exploration. Furthermore, employee performance was evaluated using eight indicators, comprising 17 statements drawn from previous examinations. A questionnaire was used as an instrument, specifically designed to offer respondents five alternative answer choices, with a five-point Likert scale. This scale enables participants to indicate their degree of agreement or disagreement with a set of statements regarding their opinions on the topic being investigated. In accordance, the sampling method used was Cluster Sampling, with city districts serving as the clusters. This method is a commonly utilized probability sampling technique and it is particularly effective when studying large and geographically dispersed populations. To ensure representative sampling, each sample size of the sub-population was adjusted based on Probability Proportional to Size (PPS), which accounted for the varying sizes of these sub-populations. In addition, the selection process was conducted independently within each functional area in every district or city and the sample requirements for each stratum were calculated using the formula introduced by (Sugiyono, 2019). In this research, validity testing was conducted to assess the congruence of the instrument items that met the predefined criteria. The test aimed to determine if the instrument items effectively measured the intended variables. The obtained correlation coefficient resulting from this test, known as the validity coefficient, indicated both the degree and direction of the association between the instrument items and the criteria under consideration. Furthermore, the reliability of the instrument was evaluated through the calculation of the Cronbach Alpha coefficient value. Using this measure, an instrument is considered to have high reliability if the reliability coefficient equals or exceeds 0.60. The results of the reliability measurement showed that all constructs in this research possessed instruments with high reliability. Lastly, hypothesis testing was conducted through the utilization of Partial Least Square (PLS), a technique within the framework of Structural Equation Modeling (SEM). --- 3. Results and Discussions --- Respondents Characteristics All 128 selected female BPS employees in West Sumatra Province completed the online questionnaires in full, making the response rate 100 percent. Regarding age, the majority were in the 30-39 years age group, at 58.6 percent of the sample population. This indicated that most of the observed employees were relatively young and in their productive years. Accordingly, in terms of education, over half of the respondents held a DIV/S1 diploma, with the majority generally having ten years or more of experience working at BPS, and approximately 57 percent held functional positions. In regard to household income, 1.6 percent of the participants had an income of Rp. 4,999,999, 14.8 percent had Rp. 5,000,000 to Rp. 7,999,999,-, 38.3 percent ranged from Rp. 8,000,000 to Rp. 11,999,999, 14.8 percent was within the range of Rp. 12,000,000 to Rp. 14,999,999, and 30.5 percent had an income exceeding Rp. 15,000,000. --- Measurement Model (Outer Model) In this research, convergent and discriminant validity, convergent reliability, and Cronbach's alpha were used to evaluate the external model. The visual representation of the external model testing is presented in Figure 1 --- Convergent Validity Test The standardized loading coefficient was used to measure the intensity of the relationship between each measurement point (indicator). Furthermore, convergent validity concepts were employed to evaluate the connection between the target (component) and construct points. To establish convergent validity, the correlation between the reflecting variable and the measured construct should be more than 0.7, and the external loading value should be between 0.5 and 0.6, as shown in Table 1 (see appendix). From the information presented in Table 1, it can be observed that Discriminant validity was used to ensure the distinctiveness of all concepts within each latent variable. In this regard, discriminant validity is considered to be satisfactory in a model when each loading value of an indicator within a latent variable exceeds the loading values linked to other latent variables (crossloadings). Moreover, the validity criteria were assessed based on the Average Variance Extracted (AVE) value for each construct. It is important to clarify that the constructs, in this context, are only considered valid if their AVE values surpass 0.5. Below, Table 2 summarizes the results of the AVE and the outer loading test. Table 2 shows the computed AVE value for the respective variable, all of which exceeded 0.5, signifying the validity of the variables or constructs used in the research. Furthermore, the composite reliability values for all reflective constructs in the model, as shown in Table 2, exceeded 0.8, which was considered satisfactory based on Hair, Hult, G., Ringle, and Sarstedt (2016). Source: processed data The results presented in Table 2 showed that the composite reliability for the variables of Work-Family conflict, workload, work stress, and female employee performance all exceeded 0.80, thereby confirming that the composite reliability criteria were met in this research. --- Structural Model (Inner Model) Assessment The R2 value is essential for evaluating the strength of a model as it indicates the extent to which the factors that influence an endogenous variable explain the variation in that variable. This measurement is essential for assessing model robustness. Accordingly, for an endogenous latent variable, an R2 score of 0.75 indicates a significant and excellent, 0.50 suggests a moderate and average, while 0.25 signifies a weak and poor model (Hair et al., 2016). Table 3 shows the R-Square values obtained from data processing with the Smart PLS 3.2.3 application. The obtained R-Square value for the path 1 model was 0.647, indicating that the combined ability of the variables, Work-Family conflict, and Workload, mediated through job pressure, to explain the performance of female employees was approximately 64.7 percent, which fell within the moderate to medium range of explanatory power. In contrast, the obtained R-Square for the path 2 model was 0.439, implying that Work-Family conflict and workload variables could explain work pressure by 43.9 percent, and this signified a weaker explanatory power. In accordance, the F-square, which measures the relative influence of an influencing variable (exogenous) on the influenced variable (endogenous) was also considered in this investigation. It is important to note that an F2 value of 0.02 indicates a small or weak effect, 0.15 suggests a medium influence, and 0.35 denotes a large or strong impact. A detailed compilation of the obtained the obtained results concerning F-Square is presented in Table 4 (Hair et al., 2016). Source: processed data Additionally, the Q-square, also known as Prediction Relevance or Stone-Geisser's, was used to evaluate the targeted capability through the blindfolding procedure. When evaluating the Qsquare, a value of 0.02, 0.25, and 0.35 indicates a small, moderate, and big predictive capability each (Hair et al., 2016). --- Path Analysis Results A path analysis test was carried out to determine the path coefficients within the structural model. Its primary goal is to assess the significance of relationships and perform hypothesis testing. In addition, an examination was conducted on both direct and indirect influence individually. This examination was carried out by analyzing the probability value and the tstatistic. Accordingly, a t-statistic value of 1.96 was utilized for a significance level of 5%. Statistical significance was determined by accepting the alternative hypothesis (Ha) when tstatistics exceeded 1.96 and rejecting the null hypothesis (H0) when the probability value fell below 0.05. This process helped assess the significance of the observed relationships within the analysis. The path analysis (H1) conducted in this research showed that Work-Family conflict has a direct unfavorable and significant influence on the performance of female employees at BPS. Accordingly, the assessment of the first hypothesis showed that the connection between the Work-Family conflict variable and the performance of female employees had a path coefficient of -0.243, along with a t-value of 1.535, which resulted in the confirmation of hypothesis I. Based on these findings, it can be seen that this conflict had a negative significant correlation with the performance of female employees. The test results also showed a proportional connection between the Work-Family conflict among female employees at BPS of West Sumatra Province and the decrease in their performance. Furthermore, the direct impact of the observed independent variable on the performance of women workers was quantified at -0.243. This showed that women employees at BPS of West Sumatra Province are likely to perform worse as Work-Family conflict grows. During the path analysis (H2), Work-Family conflict was observed to have a direct positive and significant influence on job stress. The test on the second hypothesis indicated a path coefficient and t-value of 0.602 and 8.714 respectively, leading to the acceptance of hypothesis 2. These results showed that the independent variable exhibited a positive and significant impact on the level of job stress experienced by female employees at BPS of West Sumatra Province. This suggested that when female employees at BPS encountered Work-Family conflict, their job stress tends to increase. Furthermore, the direct effect of Work-Family conflict on job stress was quantified at 0.602. These observations are similar to the theory proposed by Judge et al (Karatepe, 2013), that this type of conflict often leads to increased job stress when work-related demands interfere with family life, placing pressure on individuals to allocate more time to their families. In accordance, the examination of hypothesis H3 showed that the correlation between workload and the performance of female employees displayed a path coefficient of 0.330, along with a t-value of 1.910. These observations suggested that workload had a positive and significant impact on the performance of female employees, leading to the acceptance of hypothesis 3. The findings indicated a significant and positive association between the workload and the performance of female employees at the Central Bureau of Statistics of West Sumatra Province. This implied that the workload experienced by female employees at this organization had the potential to negatively impact their performance. Moreover, the direct influence of workload on the performance of female employees was quantified at 0.330, with a corresponding P-value of 0.028. It is important to acknowledge that these results are consistent with (Karatepe, 2013), who determined the impact of work overload and Work-Family conflict on job commitment and job performance in the hotel industry in Romania. This suggested that employees burdened with excessive workloads tend to exhibit subpar achievement in service delivery. The test of hypothesis 4 (H4) showed a favorable and meaningful connection between workload and work pressure, which yielded a path coefficient of 0.155, with a corresponding tvalue of 1.656. These observations led to the acceptance of hypothesis 4. The obtained results implied that the workload experienced by female employees at BPS of West Sumatra Province directly and positively impacted their work pressure. In this regard, the yielded coefficient value was 0.155, with a P-value of 0.049, indicating that as the level of workload felt by female employees increases, their work pressure also tends to increase. These findings are supported by (Sari Mansour Diane et al., 2016) the relationships between workload, social support, occupational stress, and Work-Family conflict were studied in the hotel business in Quebec, Canada. The results of the research revealed a significant effect exhibited by workload on job stress through Work-Family conflict, indicating that high workloads can reduce the energy and time of employees, making it difficult to reconcile work and family duties. Hypothesis testing (H5) indicated a significant unfavorable connection between work pressure variables and the performance of women employees, with a path coefficient of -0.230 and a t-value of 1.442, leading to the acceptance of hypothesis 5. These observations revealed that job stress, represented by work pressure, directly and significantly diminished the achievement of women employees BPS of West Sumatra Province. When female employees experience increased work pressure, their performance tends to decline. In this regard, the quantified impact of work pressure on female employee performance was -0.230, indicating that higher stress levels among female employees led to a direct and negative effect on their performance. This was in line with the notion that elevated stress levels among female employees in this context negatively affect their overall job performance. Likewise, (Roboth, 2015) investigated the impact of dual role conflict and work pressure on performance. However, it is important to note that the investigation performed by Roboth focused solely on married women employed at the Compassion Indonesia Foundation. The research yielded substantial and relevant results, which supported the hypothesis that "Work stress sighnificantly influences the performance of women in a dual role." This implied that work pressure adversely affects the performance of women juggling multiple responsibilities at the Compassion East Indonesia Foundation. Therefore, the current research is compatible with and corroborates previous analyses in this field. The results of the H6 path analysis, which investigated the indirect impact of Work-Family conflict variables on the performance of women employees through work pressure, revealed a path coefficient and t-value of -0.139 and 1.434 respectively. These results indicated that the variable exhibited a negative and indirect connection with the performance of female employees, mediated by job stress. Based on this observation, hypothesis 6 was confirmed. In essence, the findings indicated that Work-Family conflict had an adverse and substantial indirect influence on the performance of women employees. It is crucial to acknowledge that this indirect effect was found to operate through the mechanism of job stress. Essentially, when female employees at the Central Bureau of Statistics of West Sumatra Province face Work-Family conflict, it often leads to decreased performance, primarily as a result of the increase in work pressure. In addition, the quantified magnitude of this indirect influence of this form of conflict on achievement through job pressure was -0.139. Based on these observations, Work-Family conflict perceived by female employees indirectly and negatively impacted their performance through the intermediary factor of work pressure. These findings are in accordance with research by (Karatepe, 2013), which explored the consequences of work overload and Work-Family conflict on job embeddedness and performance, with a focus on the function of emotional tiredness as a moderator. The results of the present investigation showed that the indirect impact of t 1<unk>4 22.04),t 1<unk>4 21.70) on job attachment, mediated through emotional tiredness, was meaningful referring to the Sobel test. Besides, it is also important to acknowledge that the influence of work-family conflict (20.08,t 1<unk>4 21.96),t 1<unk>4 21.66) on work performance through emotional tiredness were meaningful referring to the conducted Sobel test. These results suggested that emotional exhaustion fully mediates the effects of both work-family conflict and family-work conflict on job attachment and performance. The results of the H7 path analysis, which was performed to analyze the indirect outcome of workload variables on the performance of female employee performance through work pressure, delivered a path coefficient of -0.036 and a t-value of 0.895. These observations indicated that the impact of workload on performance through work pressure was not statistically significant, leading to the rejection of hypothesis 7. The results continually supported the notion that Work-Family conflict showed an unfavorable and meaningful indirect influence on the performance of women employees through job stress, as discussed in hypothesis 6. The influences of Work-Family conflict on performance, moderated through job pressure, remains substantial, with a quantified magnitude of -0.139. In summary, Work-Family conflict experienced by female employees was found to indirectly and negatively affect their performance through work pressure, while the consequence of workload on performance through work pressure was not statistically significant in this research. --- APPENDIX

Purpose -The main purpose of this study was to assess how Work-Family conflict, workload, and work stress function as mediating factors influencing the performance of female employees at BPS (Central Bureau of Statistics) in the West Sumatra Province. Methodology -This quantitative investigation was conducted using a survey approach, with the sample consisting of 188 married or formerly married female employees out of a total of 128 participants. A questionnaire was used as an instrument which was designed using Google form and consisted of 58 questions. Furthermore, the sampling was carried out using Cluster Sampling, with districts/cities serving as the clusters. Descriptive statistical and Partial Least Square (PLS) analyses were adopted for the data analysis process using the Smart PLS 3.2.3 program. Findings -The results showed that workload and Work-Family conflict had a positive influence on both work pressure and the performance of female employees. Meanwhile, Work-Family conflict and work pressure negatively influenced the performance of female employees. A negative influence was also observed on the performance of women employees due to Work-Family conflict, mediated through work pressure. Originality -This research investigated the influence of Work-Family conflict and workload on the performance of women employees, mediated by job pressure.

INTRODUCTION & BACKGROUND The process of pregnancy and the early months of being a parent are fraught with challenges and often require input from a variety of health professionals. Unsurprisingly there have been many different interventions designed by researchers to support women who face challenge during this period of transition. In particular this has come from psychology and medical fields with potential treatments including medical drugs, cognitive behavioural therapy and structured social support amongst others. The HCI field has in the past been slower to take notice of this period of transition, the majority of the focus on family/parental involvement in technology has focussed on the use of technology by children and teenagers and how their parents can respond to this. Now we have reached a point in time in which the millennial generation -generally accepted to be those people born between 1980 and 2000 (Strauss, Howe 1991) -and original digital natives, who were the teenagers in these original studies are entering their late 20s and 30s and becoming parents themselves. There is now a need to consider how technology is impacting on this experience from a HCI perspective to complement and collaborate with research from other fields in this area. This requires us as HCI researchers to begin to shift our focus from examining only the experiences of parents who have not grown up with technology, and instead also explore the experiences of those who have grown up with it, who used technology as part of their everyday lives prior to becoming parents and who continue to use it during the early years of childrearing. Decisions made by mothers during this time have long term implications upon the health of their child, and health providers have begun to develop interventions in this area. However, an understanding of how new mothers use and are motivated to use technology is still limited and as yet an underexplored area. Recent years have started to show an understanding of this development and we have seen investigation in this area. The 2013 CHI Workshop on 'Motherhood and HCI' (Balaam et al. 2013) is representative of this new area of interest. Gibson and Hanson (2013) conducted an ethnographic study into new mother's use of technology. Centred around five mother and baby social groups they found that new mothers used their smart phones to go online for emotional wellbeing more than they were used for traditional forms of communication. Work done by De Choudbury (2013) has examined how social media posts by new mothers on Twitter can be analysed in order to predict their risk of postnatal depression. This early stage study proposes to expand upon these previous studies and explore how these digital natives use a variety of online technology during the transition to motherhood. --- METHODOLOGY A survey was developed to be completed online. This survey was available for one month between November and December 2015. This study was approved by the institutional ethics committee and the online survey began with an informed consent process. Inclusion criteria for the survey were being a mother of a child under the age of 2 years old and having used online technology during the first 6 months of their child's life. The survey was composed of eleven questions. Five questions focussed on demographic information, two on their experiences of using technology prenatally, and four on their experience of technology postnatally. During the time period that the survey was available for 103 participants took part. The average age of a participant's youngest child within the survey was 15 months (minimum 3 months, maximum 24 months). The maximum number of children any participant had was four with an average of one. The majority of participants were between the ages of 26 and 30 (n=68) meaning that they fitted into the millennial generation, this is slightly lower than the national average age of 30 for first time mothers. --- DISCUSSION One key finding from the initial analysis of the quantitative questions was that new mothers increased the time they spent online by 19 minutes per day (df=99, p<unk>0.05). A thematic analysis of the results of the survey revealed 7 themes (Maintenance of contact with the world outside of the "Baby Bubble"; To pass time while breastfeeding the baby; To develop new relationships and support other new mothers; Searching Internet Websites for Information and Reassurance; Updating contacts on information relating to baby and taking/sharing photos; To pass time separately from tasks related to child rearing, and; To carry out daily tasks such as shopping more conveniently.). Several themes pointed to a desire for socialisation. This suggests that despite having more demands upon their time, mothers are looking to the internet to provide the social support they require rather than more traditional sources. The free text motivations made frequent references to different forms of socialisation and a desire to seek this out. There was a decrease in the number of participants using Twitter following childbirth; this is interesting given the ongoing debate as to whether Twitter is a social network or a form of news broadcasting. Twitter provides less opportunity for group discussions due to the character restriction and is more public than other social networks. In contrast many parenting groups on Facebook are either set to private (meaning that only members can see what is being posted) or secret (meaning that another member has to invite a user to become a member -the group will not appear in a Facebook search). This suggests that it is personal connections and the wish to strengthen these which is motivating mothers to go online. Mothers are using these social networks to get reassurance on topics which they would previously have looked for from members of their physical community. The reduction in support from local health professionals such as General Practitioners and health visitors (Gordon-Walker 2014) has been occurring concurrently to the growth in online parenting support and may be a factor in this increase. This social support has the potential to reassure mothers but those wishing to develop digital tools should give careful consideration as to how health guidance is given. Survey participants made reference to asking for advice on how to treat a child's symptoms or for suggestions as to the cause of a rash. Incorrect medical advice in this area could have potentially fatal consequences. Of course this has been challenge in other eHealth studies, but is of particular concern in this area. The development of new relationships suggests the formation of community is important. As discussed previously this can be seen in contrast to the breakdown in communities in the physical world (Swigger 2012). This is important for medical professionals, looking to provide new mothers with social support, to consider. --- CONCLUSION Recent years have seen a growth in online resources for new parents and this is only likely to increase as the millennials continue to age and become parents. This survey has demonstrated that during the period of time following the birth of a child, mothers increase the time they spend online. They are motivated to do this for a variety of reasons but in particular for socialisation. This suggests that there is potential to harness these new forms of community when delivering healthcare interventions and we strongly encourage HCI researchers to consider entering discussions around the challenges and opportunities in this area. Health providers have already begun to take advantage of this familiarity with technology and provided detailed medical advice through their websites. However as this study shows, many mothers are motivated by making connections and socialising with others in a similar situation. More work is now needed to fully understand the reasons behind this desire for socialisation and what the impact of this is upon those looking to design eHealth interventions for this user group.

Becoming a mother presents a woman with new challenges and a need to access new sources of information. This work considers the increase in the use of online parenting support as the first group of millennials become parents. Initial results from a survey comparing the use of technology pre and post the experience of childbirth is presented. The survey reveals that mothers are likely to increase the time they spend online and are strongly motivated by seeking social contact. The paper concludes by considering the implications of this survey for healthcare professionals wishing to give information and support through online media and suggests how HCI professionals can become involved in this work.

understand how they modify the influence of touch (called the Midas touch effect) of embodied agents. Traditional masculinity is associated with toughness, physical strength, dominance, and financial success. It also implies rejection or even hostility towards anything associated with femininity, which may sometimes lead to violence; for example, towards non-heteronormative men or men with more effeminate characteristics [2]. On the other hand, femininity is traditionally related to warmness and submissiveness [3]. A woman who does not follow these roles may face criticism for being selfish, overly masculine, or aggressive [4]. These stereotypes have shaped societies for centuries and still penetrate invisibly interpersonal communication, including mediated human-human and human-computer communication. For example, we know that "the gender stereotypes people have for individual tasks and social roles influence their preference for agent form" [5,14], and in a Japanese study on perceived femininity and masculinity in agents, men and women preferred respectively feminine female and masculine male agents [6]. Touch behaviour, essential in social interactions, is also subject to gender norms. Henley [7] observed that men initiate one-way touch more frequently than women, which reflects masculine control and dominance (e.g. the supervisor touching the shoulder of his secretary). Moreover, men feel uncomfortable being touched by another man and avoid same-gender touch, which is associated with male homophobia [8,9]. Differences in touching behaviours are also reflected in the efficiency of the Midas touch effect, a social influence technique which describes a situation when a light touch of a shoulder or arm increases chances for obtaining spontaneous help or complying with a request [10]. It is most efficient when the request is relatively straightforward [11] -for example, customers who were touched on their shoulder tend to tip more [12]. The efficiency of this technique may be modified by the characteristics of the touching and the touched. Women's touch seems to be more influential than men's [13]. Sometimes, the strongest effect was obtained when the interaction occurred between people of opposite genders [14]. There is also some evidence that high-social-status cues (such as clothing, profession) influence the Midas touch effect [15]; nevertheless, it is important to take Guéguen's work (as the only author) with caution in the light of recent criticism [16]. In Poland, a highly homophobic country [17], women and men complied to a request of a female confederate more frequently when she added a touch than when she did not. Interestingly, this effect was reversed when both the confederate and the participant were men-in such a situation, a touch accompanying the request significantly reduced compliance compared to a no-touch request. This effect was linked to strong male homophobia [18,19]. Another factor influencing the efficiency of the Midas touch effect is the social context of the interaction. For example, compared with a supportive environment, touch in a competitive environment may reduce helping behaviour [20]. The influence of cooperative vs collaborative situations on touch was also investigated in the mediated touch. This type of touch has recently drawn particular attention of researchers due to the COVID-19 pandemic, which has restricted drastically human physical contact [21]. Some early studies showed, for example, that embodied agents that used touch were seen as warmer than non-touching agents, while no effect of the situation was found [22]. Touch also increases human likeness of embodied agents [23]. One of the wellknown paradigms to study collaboration and competition is the Ultimatum game [24]. In this game, two players need to divide between each other a given pie (for example, some amount of money). One of them, the proposer, offers the split and the other one, a responder, can either accept it or reject it. When the offer is accepted, both players gain the agreed amount. Rejection means none of them gets anything. This seemingly straightforward paradigm has been used in multi-ple studies, including human-computer interaction [25,26]. A repeated Ultimatum game was also used as a measurement of compliance in the mediated Midas touch effect [27]. The authors found a significant effect of touch on compliance compared with no stimulus, but no significant effect compared with a sound. A similar effect was demonstrated using immersive virtual reality, where a touch initiated by an embodied agent increased compliance in men [28]. Influential embodied agents play a crucial role in gaming and in any situation where the presence of a human is not safe or feasible, for instance in military or medical training. In these situations, the level of social influence elicited by an agent directly impacts the performance level of the user. Touch may serve as a useful way to influence user behaviour or draw their attention. Nevertheless, human-agent touch remains understudied and underdeveloped in comparison to the visual and auditory elements of human-agent communication [29] which creates an urgent need to investigate the dynamics and factors influencing touch between humans and agents. Here, we present a series of three studies which aim to understand better the influence of embodied agents' touch and traits in a virtual Ultimatum game. The research questions and hypotheses are the following. --- Q1. Do people perceive a touch of various agents differently? H1. Perception of an agent's masculinity and social status will influence the evaluation of the agent's touch: H1a. A female agent's touch will be perceived more positively than a male agent's touch. (study 1). H1b. A lower masculinity of the male agent will result in a more negative perception of touch. (study 2). H1c. The higher the male agent's social status, the more positive the agent's touch will be perceived. (study 3). --- Q2. Does gender influence the efficiency of the Midas touch? (study 1) H2.1 Touch will evoke higher compliance than no stimulus or a buzz. --- H2.2 Compared to trials with no stimulus or a buzz, the efficiency of touch will be moderated by the participant's and the agent's gender: H2.2a. Women will be more prone to accept offers when touched by both agents. H2.2b. Men will be less prone to accept offers when touched by the male agent and more prone to accept it when touched by a female agent. --- Q3. Does stereotypical masculinity/femininity of the agent influence the efficiency of the Midas touch effect? (study 2) H3 Compared to trials with no stimulus or a buzz, the efficiency of touch will depend on the masculinity/femininity of the agents: H3a. A feminine female agent's touch will evoke the highest compliance. H3b. The effeminate male agent's touch will evoke the lowest compliance. --- Q4. Does the social status of the agent influence the efficiency of the Midas touch? (study 3) H4 Compared to trials with no stimulus or a buzz, the highstatus agent's touch will evoke higher compliance to touch than low-status agents. The method section contains a joint description of the procedure in all studies, while the results section reports data from each study separately. In the last part of the manuscript, we summarise and discuss the results. We also mention several shortcomings and propose future directions for studies. --- Method --- Study design Study 1 had a mixed design: 2 PARTICIPANT (female/male) <unk> 2 AGENT (female/male) <unk> 3 ACTION (none/buzz/touch). In study 2, we applied a 2 AGENT (female/male) <unk> 2 STEREOTYPE (masculine/feminine) <unk> 3 ACTION (none/buzz/touch) within-subject design with repeated measures. In study 3, we used the same design, replacing STEREOTYPE with STATUS (high/low). In study 1, women and men played with two agents each, one female and one male; the game consisted of 40 trials, out of which the participant played 20 trials as a proposer. In studies 2 and 3 only men participated; they played with four agents, two females and two males; each game consisted of 88 trials, out of which the participant played 48 as the responder, equally distributed between the agents. In study 1, the order of trials was fully random, in study 2 and 3 the participant always played the first round as the proposer, so that they could familiarise themselves with the interface of the game. --- Sample Data collection took place in Warsaw (Poland), from May 2016 to March 2017. In study 1, we recruited women and men, while in study 2 and 3, we recruited only men between 18 and 35 years old with no physical nor psychological disorders. It was possible to participate only in one study. After we informed participants about the possible negative consequences of using a virtual reality (VR) headset (e.g. dizziness, headache, nausea), they signed an informed consent form. None of the participants had previous experience with VR. Every participant was rewarded at the end of the study with one (study 1) or two (study 2 and 3) cinema vouchers worth <unk>5e each. In the first study, 19 women aged 19-33 (M 23, SD 3) and 15 men aged 21-33 (M 27, SD 3) participated. In the second study 40 men aged 18-33 (M 23, SD 4) participated, and in the third one, 39 men aged 19-34 (M 24, SD 4) participated. In study 2 and 3, we decided to recruit only men due to gender differences in touch behaviours and homophobia in Poland [19]. Because of these differences, our hypotheses would not be relevant for female participants. Most of the participants had graduated high school (study 1: 54.5%, study 2: 77.5%, study 3: 51.3%) or university (36%, 22.5%, and 38.5% respectively). We obtained ethical approval from the Ethics Committee of the Institute of Psychology, Polish Academy of Sciences. --- Measures --- Behaviour Compliance was measured by counting accepted by the participant offers (0-rejected, 1-accepted). --- Self-report measures In the post-experimental questionnaire, we tested the perception of touch and the agents. First, participants saw a picture of the agent in randomised order, which was followed by two questions: 1. In your opinion, how feminine/masculine is this person? (perceived masculinity) (0-very feminine to 100-very masculine); 2. In your opinion, how low/high on a social ladder is this person? (perceived social status) (0-very low to 100-very high). Participants responded using a visual analogue scale. Touch perception of each agent was measured by asking, Please indicate, how much the touch of (name) was for you. There were nine adjectives (natural, surprising, pleasant, weak, adequate, well synchronised with the animation, strange, frightening, nice) which participants assessed on a 5-point Likert scale from 1-totally disagree to 5-totally agree. All questionnaires were in Polish. --- Procedure --- Overall procedure The general procedure was identical in all experiments. The participant came to the laboratory at the agreed time where the experimenter welcomed them, informed about the procedure and potential health risks, and asked them to sign the informed consent form. Next, they entered the laboratory where the experimenter helped them with the placement of the bioelectrodes1 and donning the head-mounted display (HDM), headphones, and vibrating band on the left arm (in the middle between the elbow and shoulder, on a t-shirt's sleeve if possible), which was fixed with a Velcro strap. After testing the signal and recording the baseline for 5 min, participants entered the virtual environment. At the beginning of the game, the experimenter explained how to use the game interface and then left the laboratory. When the game was over, she returned and helped the participant to remove the bioelectrodes, HMD, and vibrating band, and asked the participant to fill in the questionnaires displayed on a computer screen. The experimenter monitored the participant by streaming the virtual environment and psychophysiological signals to the second room. For safety reasons, the participant was advised that the door will remain open and, in case of feeling unwell/experiencing any inconvenience/having doubts about the procedure, that they should immediately call the experimenter, who was in a room in the immediate vicinity of the laboratory. Every 10-15 min or in case of inactivity/strange behaviour, the experimenter checked on the participant. The whole procedure lasted around 90 min, including <unk>20 min in study 1 and <unk>40 min in study 2 and 3 inside the virtual Ultimatum game. None of the participants complained about feeling unwell, the length of the procedure in VR or any other problems. This effect was obtained through the VR design, mainly reduced light stimulation and a relatively simple, static environment. Moreover, no evidence was found that the VR optical arrangement affected the binocular status of the eyes in a 40-min-long exposure [30]. In the end, the experimenter debriefed the participant and rewarded them. Due to a more prolonged procedure in study 2 and 3, whether the participant received one or two cinema vouchers depended on the number of coins collected during the game. Participants who gained more than 200 coins received two tickets (more than 50% of participants). Partic-ipants did not know the threshold for receiving two tickets before the game. --- Ultimatum game The Ultimatum game was built by Blue Brick2 in Unity 2016, while the 3D models of agents were designed in Make-Human. Participants used a keyboard in study 1 and Xbox controllers in study 2 and 3 to navigate through the environment. They could feel touch while seeing the agent leaning towards them and reaching with their hand to the place where participant's real left arm was. Agents were moving delicately, but they did not interact with participants otherwise-they had no facial expression and did not talk, but they did maintain eye contact randomly in 70/30 ratio (see video). Due to technical limitations, participants did not have a virtual body, which is why they could "touch" the agent by pressing a button in the menu before making an offer. In study 1, we were interested in gender differences between women and men and their compliance to touch of a female and male agent. We designed two stereotypical, averagely attractive female and male Caucasian agents (Table 1). Having observed several procedural problems in study 1, we applied some changes in the game in study 2 and 3. 3 First, we changed the sound to a more delicate one, because several participants complained about it. Second, we changed the keyboard to an Xbox controller to make the interface more user-friendly and intuitive. We limited the full trials randomness by adding a rule that in the first trial, the participant always plays as a proposer to make sure he has time to learn the interface. In study 2, we manipulated the stereotypical femininity/masculinity traits, such as haircut, height, size of the jaw, waist, and shoulders. In study 3, we manipulated the characteristics stereotypically associated with high and low social status, the outfit and haircut (Table 1). Agents characteristics selection 3D models, names, and professions for all agents were selected in an online survey to make sure they match the stereotype. We presented in a randomised order 28 various models of both genders, which online volunteers rated on their attractiveness, masculinity, and social status levels on a 0-100 scale. Then they rated, in the same way, a list of 57 male and 36 female names and 47 professions. In the survey participated 38 Polish people (including 18 women). Based on these results, we selected the following models (Table 1). --- Proposer and responder In the first step, the participant could see the agent, with which he was playing, sitting in front of him at a small table (Video). He could also read the name, the age, and the profession of the agents. As a proposer, after a few seconds, he could see the menu screen where he could choose an action: "none", "play a sound", or "touch". Below, he could also select the offer he wanted to make. The role of proposer served in our study to (1) hide the real aim of the study, and (2) make the game more interesting for the participant. Players had to split ten coins in any configuration from 1:9 (extremely generous) to 9:1 (extremely selfish). Several seconds after the decision (randomised value between 4 and 7 s), the agent accepted or rejected the offer. In the role of a responder, the participant saw the agent, then was touched, or heard a buzz or just waited for a few seconds (also randomised) and at the end, saw the proposed offer which they could accept or reject. The number of trails with no stimulus, buzz, and touch was balanced in all studies. After the acceptance, players gained the agreed amount of coins; in case of rejection, neither of them won anything. In the background of the environment, participants could see how many coins they gained so far with a given agent. In the final screen, they saw a summary with the total amount of gained coins. --- Apparatus and data analysis We carried out the studies on a computer with operational system Windows 10, the Intel Core i5-6500 Skylake processor and the MSI GeForce GTX 960 graphic card. The participant used Oculus Rift; the vibrating band consisted of a 3 V vibration motor placed using a Velcro band. It was connected to the Arduino Leonardo, which received the signal from the PC through a USB cable. The manipulation check was tested using ANOVA (study 1) and Tukey's multiple comparisons test (study 2 and 3). In study 1 and 2, the dependent variable (DV) was the perceived masculinity/femininity, in study 3, the perceived social status. In all studies, the independent variable (IV) was the agent. We analysed touch perception in three steps: (1) We carried out a principal component analysis (PCA); (2) We tested differences for each study with ANOVA (study 1, IV: participant's gender, agent) and Tukey multiple comparisons test (study 2 and 3, IV: agent) using PCA factors as DV; 3. We calculated Pearson's r correlations between obtained factors and masculinity (study 1 and 2) and status (study 3). --- Compliance Analysis of compliance from all three experiments was built using logistic regression models in which the dependent variable was the acceptance of the offer (1-accepted, 0-rejected). In study 1, the predictors were the offer (standardised), the perceived masculinity (standardised), agent's gender (AG), participant's gender (PG), touch, sound and two interactions: PG <unk> masculinity and PG <unk> touch. The model in study 2 included the offer (standardised), the perceived masculinity (standardised), AG, touch, sound, and the AG <unk> offer interaction. In the last study, the predictors were the offer (standardised), the perceived masculinity (standardised), the perceived social status (standardised), AG, touch, sound, and the status <unk> offer interaction. Other interactions were also considered but discarded from the final model for being not statistically significant (widely variable and small average effect), not increasing the model's likelihood function or not being of interest. However, we kept all strong (statistically significant) interactions as well as interactions that are of interest, whether or not statistically significant [31]. The accuracy of each model was compared to that of a null model; that is, the proportion of accepted or rejected offers in the dataset, whichever was higher. This corresponds to a model with only the intercept term, thus a model that does not use any information from independent variables. We estimated parameters from all models using data pooled from all subjects together. We then used crossvalidation to assess the robustness of all models to variations in the data. The data from these experiments require crossvalidation for grouped data since there is natural grouping by participant imposed by the repeated-measures design. In this case, random permutation cross-validation could produce training and test set with a correlation higher than would be expected by chance. Here we used a leave-one-participantout cross-validation, thus for data from each experiment we had k folds where k is the number of participants in that experiment. In each fold, we estimated parameters of the model using the training set composed of all but one participant and assessed the accuracy (proportion of correct predictions) on the test set composed of the trials from the held-out participant. In every fold, a different participant was used as a test set. To ensure that no information from the test set could influence the estimation of parameters, we considered the model as the full set of parameters, including both the logistic regression and variables transformations. Thus, the mean and standard deviation used for standardisation were estimated only using the training set. --- Results --- Study 1 --- Agents' perception In study 1, we aimed to use a female and a male agent representing an average woman and man of equal social status (Table 1). ANOVA revealed significant differences in perceived masculinity (F(1,70) 39.11, p <unk>.001), with the male agent scoring on average 63.6 (SD 16) and the female agent scoring 33.5 (SD 23.8). The variances did not overlap; therefore, our manipulation was successful. --- Touch perception The PCA for the touch perception scale was used to reduce the number of factors. Bartlett's test of sphericity was significant (<unk> 2 736, p <unk>.001) and the Kaiser-Meyer-Olkin test score was.72. We built the model with the "varimax" rotation. The PCA revealed three factors with eigenvalues > 1, which we called pleasantness, awkwardness, and adequacy based on the item loadings (Appendix Table A1 and Figure A1). The three-factorial model explained 45% of the variance. H1a was verified by analysing the perception of touch in study 1. Touch of a female agent was significantly more pleasant than that of a male agent (F(1,66) 38.31, p <unk>.001, <unk> 2.36) equally for men and women (p.082). There was also a small effect of participant's gender in awkwardness, with women judging the touch of both agents as slightly more awkward than men (F(1,66) 4.07, p.047,<unk> 2.05). We found differences in the perception of the adequacy of touch. Additionally, for the female agent, the more masculine the agent was seen to be, the more adequate her touch felt (Pearson's r.50, p.037), while for the male agent no correlations between masculinity and the pleasantness, awkwardness, nor adequacy of touch were found. These results may partially confirm H1a: female agent's touch was seen as much more pleasant; how adequate her touch felt was also related to her perceived masculinity. We acknowledge though that the H1a was only partially confirmed because no relationships were found for the male agent. --- Compliance The pooled logistic regression model was built with 660 observations and eight degrees of freedom; the pseudo R 2 was.16. Model's prediction accuracy was high (.81, the accuracy of the null model was.76) when calculated using the full dataset. Across cross-validation folds, the accuracy was also higher than the null-model in the majority of folds (Table 2). The most important predictor for accepting the offer was the offer's value, where an increase of one coin corresponded Offer-coins offered to the participant (standardised), masculinity-perceived agent's masculinity (standardised); social status-perceived social status (standardised), AG-agent's gender (1-female, 0-male), PG-participant's gender (1-female, 0-male) to a maximal difference in acceptance of almost 20% (coef..79, SE.10, p <unk>.001). The touch effect was not significant, although interestingly, it had a different direction for men (negative) than for women (positive) (Fig. 1); nonetheless, we cannot confirm H2.1. As predicted in H2.2a, women accepted statistically more offers than men (coef. -.90, SE.25, p <unk>.001). There was also a large effect of the interaction between the PG and the perceived masculinity of the agent. While the perceived masculinity did not affect women's choices, it strongly influenced acceptance in men (coef..89, SE.25, p <unk>.001). Therefore, even though the hypothesis H2.2b was not directly confirmed, we observed some evidence for the role of masculinity in male compliance. Leave-one-participant-out cross-validation shows that coefficients were stable to variations in the dataset (removal of all trials from one subject) (Fig. 2, for coefficient values across CV folds, see Appendix, Figure A2). --- Study 2 --- Agents' perception In study 2, participants played with agents that differed in stereotypical masculinity/femininity traits. Tukey test revealed significant (p <unk>.01) differences between all agents in both studies (Fig. 3). The largest difference was, as expected, between the feminine female and masculine male agents, which refer to the stereotypical image of Caucasian man and woman (Mean difference 69.70, SD 4.29). On the other hand, the masculine female agent was rated as more masculine than the effeminate male agent (Mean difference 7.60, SD 4.32). Although the differences are in expected directions, there is considerable overlap among distributions. For this reason, we chose to use in the compliance model the perceived mas- --- Touch perception We investigated further the relationship between masculinity and the perception of touch. In H1b, we predicted that the masculinity of the male agents would be related to their touch perception. Tukey's test yielded the effeminate male agent' touch to be significantly less pleasant than the feminine female agent's (Mean diff..85, SD.64, p.001) and from the masculine female agent's (Mean diff..55, SD.049, p.02). Feminine female agent's touch was also significantly more pleasant than the masculine male agent's (Mean diff..70, SD.49, p.001). Moreover, the effeminate agent's touch scored on average lower on the adequacy and higher on the awkwardness than all the other agents; nevertheless, none of these differences was statistically significant, nor any correlations for the agents' masculinity level and the perception of their touch; therefore, H1b can be confirmed only partially. --- Compliance The pooled logistic regression model contained 1914 observations, six degrees of freedom, and the pseudo R 2 equalled.30. The prediction accuracy of the model was.84, while the accuracy of a null model was.77 (Table 2). As in study 1, the offer's value influenced the acceptance strongly, with a maximal increase of chances of 50% (coef 1.99, SE.14, p <unk>.001), although a large interactional effect of the offer and AG demonstrates that when playing with a female agent, the offer's value was less important than when playing with a male agent (coef. -.42, SE.19, p.025) (Fig. 4). Nevertheless, the main effect of gender was not significant. There also was a trend suggesting that the perceived masculinity slightly increased the probability of accepting the offer (coef..13, SE.08, p.08). We did not find any Fig. 5 Model accuracy in study 2 Fig. 6 Distribution of perceived social status for male and female agents in study 3 main nor interactional effect, neither of the touch nor the sound. Therefore, H3a and H3b are not supported by the obtained results. Cross-validation showed that the patterns found on the whole dataset are stable across folds (Fig. 5, for coefficient values across CV folds, see Appendix Figure A3). --- Study 3 --- Agents' perception In study 3, all agents differed from each other (p <unk>.005), the largest mean difference was found between the female agents (Mean difference 47.27, SD 2.98) in the expected direction (Fig. 6). The smallest difference was found between the low-status male and high-status female agent, with a mean difference equal to 3.19 (SD 2.46). Regardless of the mean differences between low and high agent status, the distributions overlapped considerably. There was also a larger difference for the female character, and the estimated status of the low-status female agent was lower compared to the male character. For this reason, we used the perceived status instead of the dichotomous variable based on our study design. --- Touch perception The H1c hypothesis, regarding the role of social status in touch perception, was rejected-we did not find any differences between agents in Tukey's test and the only significant result was a weak correlation between pleasantness and status for the female agents (Pearson's r.31, p.019). Summarising the analysis of touch perception from all three studies, we conclude that there is some evidence that gender and masculinity traits might play a role in the way agent's touch is perceived, but further studies are needed since some of the effects are small and not all predictions were confirmed. --- Compliance The pooled logistic regression model was built on 1965 observations and seven degrees of freedom, the pseudo R 2.28. The prediction accuracy was.79, while the accuracy for a null model was.67 (Table 2). As in study 1 and 2, in study 3 the strongest positive effect was observed for the value of the offer. A difference in one offered coin was related to a maximal increase of chances for the acceptance of 40% (coef. 1.60, SE.08, p <unk>.001). Moreover, for agents with a perceived social status below Fig. 7 The dependence on offer's value on compliance and the interaction between the offer and perceived social status (dots are coloured according to agent's designed status although we do not use it to build the model) Fig. 8 Model accuracy in study 3 123 average, the offer effect was weaker (coef. -.15, SE.08, p.051) (Fig. 7). The main positive effect of social status was also significant, with a maximal increase in chances for acceptance of 4% for a 1% increase in perceived social status (coef..16, SE.07, p.011). We did not find any significant effects of touch nor sound. Therefore, H4 cannot be supported. Nevertheless, the perceived social status did influence compliance. Cross-validation showed that the patterns found on the whole dataset are stable across folds (Fig. 8, for coefficient values across CV folds, see Appendix Figure A4). --- Discussion The study aimed to analyse the influence of touch of virtual agents that varied in gender, traits stereotypically associated with gender, and social status on economic decisions. We found that even though the manipulation of the agent's characteristics was somewhat successful in all three studies, touch did not significantly increase compliance. The analysis of touch perception demonstrated some relationships between how pleasant, and how adequate touch of various agents felt. For example, in study 1, the female agent's touch felt more pleasant than the male's and its adequacy was positively related to the masculinity (though this not the case for the male agent). Moreover, in study 2, we found that the effeminate agent's touch was significantly less pleasant than the rest of the agents. Nonetheless, there was no correlation between the pleasantness or awkwardness of touch and the perceived masculinity of the agents. Regarding the social status, the only significant relationship was a correlation between the pleasantness and perceived status for the female agents. Interestingly, all touch animations and haptic feedback for all agents were carried out in the very same manner. The agents were also not very interactive-they did not speak, maintained eye contact at random 30/70 ratio, and had no facial expressions, and yet we found some significant relationships and differences. We hypothesise that the touch of more advanced embodied agents could evoke even more significant effects in their touch perception. In all studies, the critical factor was the value of the offer made by the agent-the more generous the offer, the higher the chances of acceptance with the maximal change in chances reaching even 50% for one unit increase. These results stand in line with those of Spapé et al. [27]. In this study, the value of the offer was a strong predictor of compliance, while touch effect was much smaller-significant in comparison to no signal but insignificant in comparison to the effect of a buzz. Perhaps the Ultimatum game paradigm creates a situation of a relatively easy choice based on profit and loss account, which can be only slightly modified by any simple and unthreatening stimulus. There was no touch effect; however, in study 1, women accepted more offers than men and men were more affected by the perceived masculinity, which confirms gender differences in compliance. Study 2 also yielded an interactional effect between the agent's gender and the offer, suggesting that when playing with a female agent, the offer was less critical. Unfortunately, the perceived masculinity effect was not significant. H4 found the main positive effect of perceived social status. The perceived level of the agent's social status increased the chances of the offer acceptance. Perhaps the perceived social status discrepancy is more crucial than merely representing a high social status group member. It seems plausible that participants compared their own and agent's social status, and thus the more significant the discrepancy was, the more compliant they were. Moreover, <unk>widrak et al. [28] found a negative effect of social status importance for Polish men but only for touch trials: men for whom the social status was important accepted less likely offers after being touched. These two results together suggest that an "objective" social status matters less than our attitudes. We believe the relationship between social status and touch requires further studies which could explain the mechanism in depth. Since the participants could have perceived the decision as a "simple" profit and loss account and players could have been primarily motivated to maximise their score, a subtle touch did not affect their decisions. The fact that they repeatedly played with each agent might have reduced the effect of touch through habituation effect, although Spapé et al. [27] did find significant effects of touch even though the game and the touch was repeated multiple times. At the same time, in other studies where repeated mediated touch was studied, it was not always significant [32,33]. Another explanation is that participants aimed to please the experimenter [34]. To avoid the experimenter demand effect, the experimenter left the room when the game started and assured the participant about the anonymity of the collected data. From the participants' declarations collected after the debriefing, we concluded that they did not discover the aim. Nevertheless, we cannot exclude this possibility because we did not control for these factors. Our results are in line with the literature suggesting that Polish men are less compliant with other men's requests when compared to women (study 1) [18]. Moreover, to some extent, they are influenced by perceived social status, which contributes to the literature proving that people of high social status are more influential than those of low status [15]. Our study provides partial evidence that this can also be true for embodied agents, perhaps in a situation where the decision is more complex and therefore less likely to be automatic. These results can be discussed not only in the context of the power of touch as a social influence technique used by agents but also in the context of future agent design. With more and more humane agents and an increasing number of applications resulting in more diverse groups of users, developers and designers need to know what characteristics and behaviours of agents are essential for smooth humanagent communication. Here, we demonstrated that the same animation and vibration-based mediated touch could evoke different sensations or associations in participants. The study had several shortcomings. The touch mediated by a vibrating band lacks realism. Nevertheless, social touch is quite robust and sometimes physical parameters of touch do not need

Traditional gender roles that define what is feminine and masculine also imply that men have higher social status than women. These stereotypes still influence how people interact with each other and with computers. Touch behaviour, essential in social interactions, is an interesting example of such social behaviours. The Midas touch effect describes a situation when a brief touch is used to influence one's behaviour. Our study aimed to analyse the influence of virtual touch on compliance in men in a decision-making game called Ultimatum. In a series of three studies, we investigated whether social cues such as gender, stereotypical masculine/feminine appearance, and high/low social status modify compliance to offers from embodied agents. We built an immersive version of a repeated Ultimatum game in which a proposer offers how to split ten coins, and a responder accepts or rejects the offer. In study 1, men and women played with a female and a male agent. In study 2 and 3, men played with four agents each, differing in gender and levels of stereotypically seen masculinity and social status. There was no significant touch effect. Compliance was secured mostly by the value of the offer: the more generous the offer, the higher the compliance rate. We also found evidence for the perceived masculinity and social status influence. We also describe relationships between agents' characteristics and the perception of their touch. The results are discussed in the context of social characteristics that are important in agent design and the effectiveness of social influence techniques in virtual reality.

factors. Our results are in line with the literature suggesting that Polish men are less compliant with other men's requests when compared to women (study 1) [18]. Moreover, to some extent, they are influenced by perceived social status, which contributes to the literature proving that people of high social status are more influential than those of low status [15]. Our study provides partial evidence that this can also be true for embodied agents, perhaps in a situation where the decision is more complex and therefore less likely to be automatic. These results can be discussed not only in the context of the power of touch as a social influence technique used by agents but also in the context of future agent design. With more and more humane agents and an increasing number of applications resulting in more diverse groups of users, developers and designers need to know what characteristics and behaviours of agents are essential for smooth humanagent communication. Here, we demonstrated that the same animation and vibration-based mediated touch could evoke different sensations or associations in participants. The study had several shortcomings. The touch mediated by a vibrating band lacks realism. Nevertheless, social touch is quite robust and sometimes physical parameters of touch do not need to be simulated truthfully, if at all [35]. Another significant limitation is the lack of the participant's avatar. Embodiment is an essential element of building experience in virtual reality, especially one including social touch [36]. Nevertheless, the game was designed in a way to minimise gazing at one's own body. For example, the touching hand extended beyond the participant's field of view. To make sure they felt the touch realistically and that the lack of an avatar was not an issue, the experimenter asked the participants during the debriefing about their impressions. Participants reported that it was not relevant to them, and usually, that touch felt realistic and natural which confirms the vibration gave a sufficiently realistic impression and that participants were simply too focused on increasing their score in the game. Due to budget limitations, we were not able to remove these and other minor problems with the procedure, nor collect more data, which might have affected the power of the experiments. Future studies should explore further the efficiency of an agent's touch on various kinds of behaviour, including spontaneous and altruistic help. The lack of effect of touch found in our study and the small effect sizes of touch in Spapé et al. [27] suggest that economic decisions may be relatively resistant to some social influence techniques. It is crucial to understand in which circumstances mediated touch can modulate behaviour in immersive virtual reality and when it cannot. We expect that soon money transactions might be available directly in VR games and applications with embodied agents offering services and goods. How we use touch in such contexts can play an essential role in the commercial success of these products. A second, equally important line of future research, seems to be the social context of embodied agents. In order to build a more inclusive and open immersive VR community, we need to investigate deeper how stereotypes and prejudice influence user-agent interaction and how can it be improved. To conclude, our study demonstrates that the influence of social cues, like gender, masculinity/femininity, or social status, on the efficiency of touch seems to be subtle, implicit, transitory, and challenging to grasp. We believe that with the advancement and a growing number of applications of the technology in various fields and social groups, the ques-tion of what kind of agents (including their gender, physical appearance, nonverbal and verbal communication, and culturally sensitive traits) should be used remains more critical than ever. --- Author's contribution Authors J <unk> and GP contributed to the study conception and design. Material preparation and data collection were performed by J <unk>. Data analysis was carried out by J <unk> and AI. AI carried out the analysis of compliance based on the logistic regression model. The first draft of the manuscript was written by J <unk>, and all authors commented on the manuscript. All three authors read and approved the final manuscript. --- Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Traditional gender roles that define what is feminine and masculine also imply that men have higher social status than women. These stereotypes still influence how people interact with each other and with computers. Touch behaviour, essential in social interactions, is an interesting example of such social behaviours. The Midas touch effect describes a situation when a brief touch is used to influence one's behaviour. Our study aimed to analyse the influence of virtual touch on compliance in men in a decision-making game called Ultimatum. In a series of three studies, we investigated whether social cues such as gender, stereotypical masculine/feminine appearance, and high/low social status modify compliance to offers from embodied agents. We built an immersive version of a repeated Ultimatum game in which a proposer offers how to split ten coins, and a responder accepts or rejects the offer. In study 1, men and women played with a female and a male agent. In study 2 and 3, men played with four agents each, differing in gender and levels of stereotypically seen masculinity and social status. There was no significant touch effect. Compliance was secured mostly by the value of the offer: the more generous the offer, the higher the compliance rate. We also found evidence for the perceived masculinity and social status influence. We also describe relationships between agents' characteristics and the perception of their touch. The results are discussed in the context of social characteristics that are important in agent design and the effectiveness of social influence techniques in virtual reality.

Introduction As social media has become embedded into our daily lives, researchers have taken on the task of unpacking its myriad implications for our health. Studies of social media have often focused on examining psychosocial harms from exposure to social media, such as loneliness [1], negative social comparisons [2], and worsening of mental health status [3]. Perhaps because of negative public and scientific perceptions of social media, less attention has been paid to identifying ways that social media could be used to improve mental health [4]. In reality, both positive and negative consequences of social media coexist and are influenced by how individuals-and society collectively-interact using social media. An especially delicate but important health concern in the social media landscape is suicide prevention. Suicidal individuals are more likely than nonsuicidal individuals to spend time online [5]. Expressions of suicidal ideation on social media have been widely reported and, at times, are followed by suicidal behavior [6,7]. Disclosures of emotional distress on social media reflect real-life concerns, with studies showing links between depressive language in Facebook posts and self-reported symptoms of depression and medical record-confirmed diagnoses of depression [8,9]. Even more visible to the public are media reports about suicide, which are relatively common on social media compared with reports of deaths from other causes [10]. Analysis of Twitter data has found that large reactions to this reporting, measured through increased mentions after the death of a celebrity by suicide, are linked to subsequent increases in deaths by suicide [11]. Amidst this contemporary reality, the notion of a "concerning post" has emerged, which we define as a display of a user's emotional crisis or other indication of an acute mental health concern on a social media platform. Little is known about individuals' attitudes and responses to concerning posts. Among the available studies, results have conflicted at times. For instance, one study found that youth lacked confidence in how to respond to a concerning post [12], while another study found that sharing emotional distress activated supportive responses [13]. While much of the research in this area has focused on youth, military veterans are another key target population for suicide interventions. Veterans in the United States are disproportionately affected by suicide. Their rate of suicide is 50% (1.5 times) higher than that of nonveterans, according to the most recent available data [14]. Suicide exposure (knowing someone who has died by suicide) is also very common and may occur via social media; an estimated 57% of veterans [15] and 65% of National Guard personnel [16] have been exposed to suicide. Social media plays an important role in maintaining veterans' social networks, with one contributor being the physical separation from family and friends that occurs during deployment or active duty, as well as separation from their servicemember peers after leaving the military. Social media serves to sustain connection and communication over time and in particular through periods of transition [17]. Using data from interviews with veterans who use social media, our objectives in this study were (1) to obtain insight into whether and how veterans respond to "friends" and family members on social media who are experiencing substantial emotional distress, and (2) to identify potential interventions that could assist veterans in responding to concerning posts. --- Methods --- Setting and Sample This research was conducted as part of a mixed-methods study focused on understanding opportunities to use social media platforms, particularly Facebook, to reach and provide support to veterans at risk of psychiatric problems. We interviewed Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans with a service separation date after October 1, 2001, who were in the metropolitan area of Portland, Oregon, United States. Thirty participants were interviewed-a number chosen based on the literature, feasibility, and our research team's experience reaching thematic saturation with such a sample size [18,19]. --- Data Collection Participants who had responded to Facebook advertisements and completed an online survey were eligible for participation in the current study. The survey that was administered has been previously described [20,21]; in brief, it included items on sociodemographic characteristics, frequency of social contact, use of social media platforms, screening for psychiatric problems and health service utilization, and interest in potential online interventions for social support and suicide prevention. Among participants who used Facebook daily, we purposively sampled veterans that varied in the extent to which they used the Department of Veterans Affairs for their health care and varied in their interest in learning more about suicide prevention. Fifty individuals were contacted to participate, and 30 of them completed an approximately 40-to 60-minute interview between June and December 2017. Twenty-three interviews were completed in person; the remaining seven interviews were conducted over the phone, which allowed for participation by individuals who could not present in person to participate in the study. Two research team members (HM and AT) conducted the interviews using a semistructured interview guide (Multimedia Appendix 1). Questions were organized into three primary domains: (1) participants' social media use and preferences, (2) discussion of health issues on social media, and (3) suicide prevention in a social media context (including experiences with concerning posts and preferences related to suicide prevention training). Interviews were audio recorded and transcribed. --- Data Analysis Survey responses were used for participants' descriptive characteristics. For qualitative analysis, we first created a summary template for rapid analysis of each interview [22,23]. We then created a codebook based on topic domains from the semistructured interview guide and informed by notes from the summary templates. Two research assistants (RB and WS) coded the interviews using qualitative analysis software (Atlas.ti; ATLAS.ti Scientific Software Development GmbH) for data management. As the primary coder, RB met weekly with the lead investigator (AT) to discuss general impressions and emergent themes. As the secondary coder, WS reviewed the primary coding, adding any codes that may not have been applied, with the goal of ensuring robust coding. AT adjudicated coding disputes as needed. Members of the research team (AT, RB, WS, SD, and SO) met regularly to discuss emerging patterns in the data, generate themes, and select representative quotes for inclusion in the manuscript. We assigned pseudonyms to the participants to maintain confidentiality. --- Results --- Principal Findings A summary of participants' characteristics is presented in Table 1. The 30 participants (23 men, 7 women) came from all military branches, with 3 participants serving in two branches over their careers. The average age of participants was 41 years (range 24-64 years), 73% (22/30) were White, 60% (18/30) were married, and 57% (17/30) had a college or postgraduate degree. In terms of their mental health, 5 of 30 (17%) participants received a score of 3 or greater on the Patient Health Questionnaire-2, which is indicative of a positive screen for major depressive disorder [24]; 15 of 30 (50%) participants had considered suicide, and 5 of 30 (17%) participants had previously attempted suicide. While 90% (27/30) of participants used Facebook several times a day, the majority never or rarely used social media for sharing information about their health (23/30, 77%), symptoms such as mood swings, depression, anxiety, or sleep problems (21/30, 70%), or thoughts about suicide or self-harm (28/30, 93%). Veterans were reluctant to disclose emotional and health issues on social media but were open to reaching out in response to others' concerning posts. Interviews revealed multiple reasons for veterans' reluctance to share negative emotional states or information about their health. First, Facebook was viewed as a venue for positive self-presentation; thus, they were disinclined to use it as a place to "air dirty laundry." Second, when veterans did need support, they usually preferred to obtain it from other avenues in the "real world" that involve "person-to-person interaction," or they preferred to be self-reliant. Also, veterans believed that sharing personal health information was "risky" to their privacy. Lastly, participants noted that Facebook friends were not necessarily "real friends." While most veterans were cautious about disclosing their own health issues, a number of veterans were understanding of others who chose to post about health issues. One participant summarized this distinction: I think for some people they find that they can post about their bad day, and they get a bunch of people "like" it, a bunch of people put the sad face on, a bunch of people say, "You're amazing. You're brilliant. You --- go girl." That kind of thing. I've definitely seen a ton of people do that, but at the same time I would never do that. And it's not like I don't want support, but I feel like I would be negatively judged for that. [Oscar] Further, many veterans were open to responding when others disclosed personal information in a post, particularly emotional struggles or suicidality. --- I've seen other friends do it, and I've come to the aid of other friends because they have shared it on Facebook out in the open just to their timeline or whatever. I've also helped friends who have reached out to me personally and [sent] Facebook messages and said, "I'm having this crisis. I can use some words of encouragement or some words of advice or some help just in general." [Bryan] Participants identified a post as concerning in several ways. Most obviously, this was direct language expressing emotional distress, particularly when the distressed person had a known mental health condition (eg, post-traumatic stress disorder or an anxiety disorder), when the person was acting out of character (eg, getting rid of their possessions), or if the person had one or more recent psychosocial stressor, such as divorce/breakup, death of a loved one, or loss of a job. Several veterans also expressed a feeling of concern without an identifiable cause, noting, for instance, "[The post] just seems off" [Seth]. Veterans occasionally did not interpret a post as concerning if they felt the post was "venting" [Natasha] or that the person was seeking attention. There was a complex calculus behind whether and how individuals responded to a concerning post. Once veterans had determined a post to be concerning, they wanted to be there for a peer in distress, but they did not always know if and how they should respond. Before they reached out, veterans went through a series of considerations. Elements of this complex calculus included (1) physical proximity, (2) relationship closeness, (3) existing responses to the post, and (4) ability to follow up with the person in crisis. While the weight given to each consideration varied across situations and circumstances, each factor influenced decisions related to whether veterans responded, how they chose to reach out, and how urgently and directly they responded. When a friend posted something on Facebook that appeared to indicate suicidal ideation, participants reported that the preferred response was to attempt to make direct, one-on-one contact to talk with the friend. This direct contact could be through Facebook itself (using a private message), email, a phone call or text, or meeting up in person. Multiple methods of contact could be combined, typically with the goal of having the online contacts lead to an in-person contact. b Survey item asked, "Have you ever seriously considered attempting suicide at some point in your life?" c Survey item asked, "How many times in your life have you attempted suicide?" --- Physical Proximity When veterans saw a concerning post on Facebook, one of the first considerations for how they chose to respond was their physical proximity to the individual in distress. If the friend was within a reasonable travel distance, veterans often indicated it was optimal to visit them or call immediately to arrange an in-person meetup as soon as possible. If a friend expressed loneliness or concerning thoughts, participants felt responding through Facebook alone was insufficient. By meeting up in person, veterans felt that they could "get them out and let them know that there are still people for them" [Jamie] and "read more in a person by watching their body language" [Robert]. If the friend was not in close proximity and the level of concern was high, some veterans noted that they might try to get a next-of-kin or other person who was physically closer to check in on the friend. --- Depends on physical proximity, if it's somebody within driving distance, within a few hours I'll be at their house banging on the fucking door. If not, there's going to be phone calls and emails and text messages and that's the way I would react. [Alyssa] --- Relationship Closeness Veterans varied in their responsiveness to concerning posts depending on the closeness of their relationship with the person in crisis. For instance, if the concerning post was from an acquaintance or someone that was on the periphery of their life, they were more likely to respond in a less direct or less immediate fashion. --- I'll send them the phone number for the veteran's suicide hotline, that's really about as far as I'm willing to go unless I know the person. [Andrea] --- If I don't know them personally, I try to give an encouraging thought. [Natasha] For a close relationship, efforts to respond were more direct and more intensive. One veteran said that in the case of a close friend or family member, he would respond as follows: --- I probably wouldn't even be on social media in that case. I would've just gone to the person and, you know, physically gone to see them. [Conrad] For relationships that fall somewhere between acquaintance and close friend or family, participants tended to communicate their availability but ultimately left the onus of further connection on the person in crisis. These efforts were often made under the assumption that there was someone closer who could help the person in crisis but also acknowledged that they were unsure of this and were thus willing to provide support if needed. ---...you can reach out to them and just give them a little love and then you instant message him and say, "Here's my phone number and call me if you need to." [Jerry] --- Existing Responses to the Post A third consideration in the response calculus related to the interactions and activity in response to a concerning post, including "likes," comments, and shares that were visible to others. Often, the timing of the post relative to when it was being seen was a factor. Veterans stressed the importance of timing for two reasons: first, the circumstances surrounding the crisis may have changed, and second, others may have already intervened. --- I've seen it a couple times or I've been, for lack of better term, late to the conversation and you've seen other people comment before that and someone said, "Hey, I've talked to 'em." [Neal] Recognizing that timing of a post and actions by others might have resulted in resolution by the time they saw a concerning post, participants also described assessing if there had already been direct and supportive responses to the friend when deciding if they should respond. --- I'm usually not the first person to come along by it, so usually I'll check the comment section and see what's being done. Typically, someone will comment and then they'll say: I've got ahold of them, or got them talking. [Richard] --- And after somebody posts, there's some likes and dislikes and maybe a "hey, what's up, call me." I imagine in those situations there's four or five personal conversations going on with that person. And then they decide who is understanding the situation, talk with them. [Yolanda] --- Ability to Follow Up Some veterans emphasized both the need to initially reach out and the importance of following up with a friend in crisis. Veterans who discussed the importance of follow-up considered whether they had the capacity to continue to maintain contact and actively provide support. One veteran responded that she had a friend who posted on Facebook "reaching out about how lonely they were." She went on to say the following:...they're obviously looking for that public acknowledgment, so, I did that. And kept it... you know, more... general, I guess, and supportive, and then, messaged them more. You know, specifically relating to it and then scheduling a follow-up visit with them. [Jamie] She let the friend know they weren't alone and scheduled a time to meet up with them....it was the next day or something. Just for a quick coffee date, you know, just to get them out and let them know that there are still people for them. [Jamie]...you don't just listen and walk away. You still have to follow-up with them and keep talking with them. It might not even be someone that you actually really know, but if you come across someone in that state of mind, it's usually kind of obvious that something's not quite right so don't ignore them. [Bryan] --- Suicide Prevention Training Veterans desired suicide prevention training that would prepare them to assist others in emotional crisis. The suggestion for training on how to respond to concerning posts, specifically if suicidal ideation was suspected or indicated, was raised by participants as well as asked about by the interviewer. Veterans indicated a desire for training in suicide prevention skills to help a peer in crisis. A common reason they cited for wanting training was a sense of being unprepared to assist others in crisis or even worry about exacerbating the situation. --- I have no idea what to say but just trying to make myself available, trying to say as little damaging stuff as I can... It's mostly that I have no idea what should I do to help?...I got pretty much nothing else. [Alyssa] I don't know how to sometimes get the point across to them without sounding judgmental. [Lynn] --- Training as an Ongoing Process Even veterans who indicated having prior suicide prevention training, often during military service, felt that the training was inadequate or insufficient. This seemed especially vital for veterans who were interested in helping others but worried about how to initiate conversations with more socially distant individuals. --- Would I want more? Yes. Just to let me know I've got the basics down. I'm not a licensed mental health professional so I can't go about helping them solve their problems, but I can get [someone in crisis] in the right direction. [Edward] I'd like to recognize more warning signs, and I would like to have some conversation items that I could take as far as how to talk about it, or how to bring it up. [Lewis] --- Preferred Features for Suicide Prevention Training Veterans identified two features of suicide prevention training that would make it especially appealing. First, training sponsored or delivered by community-based veteran organizations was believed to "carry more weight" [Neal] and be "a good source of credibility" [Edward]. Many participants who followed at least one veteran-centric Facebook page or group (eg, Dysfunctional Veterans, Lift for the 22, Gulf War Veterans, etc) felt these groups could act as trusted sponsors of suicide prevention training. One veteran described the kind of support he's encountered in one such private Facebook group:...every 22nd of every month, we do a check in. We'll post a thing, check in with our veteran friends because it comes out that there's 22 vets that commit suicide every day. And we started a program called "22 to None," so we support each other. I've made a couple friends with some other vets, and other Navy vets. And, one guy... he told me, gave me his number, he says you ever start feeling really bad, give me a call. He was a trained counselor as well. [Keith] Second, veterans were most willing to receive training targeted at helping their veteran peers. Their shared experiences, military background, and camaraderie as a result of service made a difference in their level of comfort and trust when talking about the topic of suicide with other veterans. --- It's very easy for me to have a relationship or an exchange of information between another person who's in the service. It's easier than it is for me to sometimes talk with my wife, or members of my family because they don't have that background like we have-those who've served. [Meghan] Have you ever had two different people tell you the same piece of information? One is Bob who you don't really know particularly well, but the other one is somebody who is close to you-[you] know and respect-they repeat that same information, you place a lot more weight on it. With somebody who you've had a lot of those shared experiences with, I may not know them particularly well, but they've been in the same places I have, they've faced the same problems I've had, and if they say that this is helpful, I place a lot more weight on it. [Alyssa] --- Discussion --- Principal Findings In the daily course of their lives, veterans are likely to encounter others in emotional crisis, and this can manifest through concerning posts on social media platforms such as Facebook. When presented with a concerning post, veterans go through a complex calculus-involving an assessment of physical proximity, relationship closeness, activity on the post, and ability to follow-up-which informs the extent and manner in which they reach out to provide support. The order of the complex calculus and the weight of each element varies in each situation. Veterans are often inclined to help their peers in some way, but they often feel unprepared as to how to respond to a concerning post. Given these circumstances, veterans desire suicide prevention training that extends beyond what they received during military service. They seek additional training that is germane to responding to concerning posts on social media, backed by community-based veteran organizations, and tailored to providing assistance to their veteran peers. --- Links to Existing Research on Social Media and Suicide Prevention Our finding that veterans are thoughtful and potentially motivated to respond positively to concerning posts suggests a key exception to prior research on displays of negative emotions on social media. Experimental and observational studies have shown that emotions are transmitted through social media posts [25,26]. Individuals who frequently post on social media are more likely to post about health issues and to have a diagnosis of depression [27]. Moreover, early research on Facebook posting suggested that depressed individuals see the platform as an appealing venue for self-disclosure, but their posts are often met with undesirable responses due to the negativity of the posts [28]. It may be that military culture around altruism and stewardship toward veteran peers (eg, taking care of "our own," leaving no one behind, etc) [29] contribute to the positive intentions we found toward responding to concerning posts. Our findings also comport with research showing that individuals often fear personal expressions of vulnerability but tend to react more positively to those who express it [30]. --- Training Models Applicable to Social Media-Based Suicide Prevention Training Our findings complement the use of two education and training intervention models in the literature: gatekeeper training and bystander education. Both gatekeeper training and bystander education train individuals to recognize the signs of crisis and develop skills to triage such a situation and assist with accessing subsequent professional assistance [31,32]. Gatekeeper training has been specifically designed to support "upstream" suicide prevention. Reviews have found evidence of gatekeeper training's ability to increase knowledge and foster self-efficacy and other beliefs adaptive to suicide prevention [32]. In a recently published pilot intervention, a gatekeeper training approach helped prepare adults to support American Indian and Alaska Native youth who post or view concerning messages on social media [33]. Bystander interventions, also called bystander education, have been primarily used for prevention of sexual violence, and they emphasize a five-step model: (1) awareness of an issue that requires intervention; (2) identifying when the bystander should intervene; (3) deciding to take responsibility; (4) deciding how to help; and (5) taking action [31]. Education about all five steps is meant to increase the likelihood of a bystander taking action at multiple time points. Both of these educational approaches would seem highly applicable to craft training for veterans and others in how to identify and respond to concerning posts. Gatekeeper training and bystander education might be strengthened if future research identifies how expressions of vulnerability and peer support could normalize help-seeking and dialogue about suicide. --- Limitations Our findings are constrained by several study limitations. Participants were recruited from a sample of locally recruited veterans from Facebook, and thus our findings may not be entirely generalizable to veterans nationally, individuals less inclined to participate in research or to use Facebook, or individuals who have experiences on other social media platforms. The last constraint is particularly relevant given rapid shifts in the social media landscape. There are other facets of Facebook posts, such as posts within private Facebook groups or automatic identification of concerning posts using machine learning models [34], that were beyond the scope of this study but merit closer investigation as part of a larger social media suicide prevention strategy. Finally, as with all qualitative work, we took participants on their word that they accurately represented themselves and their experiences. --- Conclusions Social media is an important venue through which many connect with their social network. One consequence of this, particularly among veterans who are disproportionately affected by and exposed to suicide, is encountering concerning posts. Our findings call for expanding access to ongoing suicide prevention training opportunities-in partnership with community-based veteran organizations-and incorporating features into existing suicide prevention training programs that will help veterans in their response to concerning posts from their veteran peers. --- Conflicts of Interest None declared. --- Multimedia Appendix 1 Interview Guide. [DOCX File, 29 KB-Multimedia Appendix 1]

Background: A "concerning post" is a display of a user's emotional crisis on a social media platform. A better understanding of concerning posts is relevant to suicide prevention, but little is known about social media users' attitudes and responses to concerning posts. Military veterans in the United States are disproportionately affected by suicide, often use social media, and may have exposure to individuals with elevated suicide risk via concerning posts.The objective of the study was (1) to obtain insight into whether and how US military veterans respond to members of their social network on social media (ie, "friends") who are experiencing substantial emotional distress, and (2) to identify potential interventions that could assist in users' response to concerning posts.We recruited veterans through Facebook and conducted semistructured interviews with 30 participants between June and December 2017. We used a summary template for rapid analysis of each interview, followed by double-coding using a codebook based on topic domains from the interview guide. Members of the research team met regularly to discuss emerging patterns in the data, generate themes, and select representative quotes for inclusion in the manuscript. Results: Veterans were reluctant to disclose emotional and health issues on Facebook, but they were open to reaching out to others' concerning posts. There was a complex calculus underlying whether and how veterans responded to a concerning post, which involved considering (1) physical proximity to the person posting, (2) relationship closeness, (3) existing responses to the post, and (4) ability to maintain contact with the person. Veterans desired additional training, backed by community-based veteran organizations, in how to respond to concerning posts from peers.There is a need to incorporate features that will help veterans effectively respond to concerning posts from peers into suicide prevention training and to expand access for veterans to such training.

Introduction Tobacco use is the leading preventable cause of death in developed countries (World Health Organization, 2002) such as Canada, the United States, the United Kingdom, and Australia, as well as a leading contributor to the socioeconomic disparities in health observed in these countries (Jha et al., 2006;Siahpush, English, & Powles, 2006). This unequal burden of tobacco use and related illness is due to a disproportionate share of smokers in lower socioeconomic status (SES) groups: a clear gradient has been observed in smoking prevalence by income, education level, occupational class, and various other measures of disadvantage, and those with lower SES have about twice the odds of smoking compared to those of higher SES (Bobak, Jha, Nguyen, & --- Socioeconomic disparities in smoking cessation A major contributor to existing disparities in tobacco use is socioeconomic variation in smoking cessation (Kotz & West, 2009;Schaap & Kunst, 2009). Studies examining SES and smoking cessation in Western countries generally indicate that lower SES smokers are less likely to be successful quitters, although findings are varied with respect to specific SES measures and the magnitude of these relationships. In the United States, numerous studies have documented a relationship between increased quitting success and higher education level (de Walque, 2004;Gilman, Abrams, & Buka, 2003;Gilman et al., 2008), and noted greater proportions of former smokers among those with higher educational attainment (Barbeau, Krieger, & Soobader, 2004; Centers for Disease Control and Prevention, 2002;Fagan, Shavers, Lawrence, Gibson, & Ponder, 2007). A similar relationship has been observed with income, with lower quit rates among those below the poverty line (Agrawal, Sartor, Pergadia, Huizink, & Lynskey, 2008;Barbeau et al., 2004; Centers for Disease Control and Prevention, 2002, Flint & Novotny, 1997) and lower likelihood of being a former smoker among those with low income (Fagan, Shavers, et al., 2007). Further, some U.S. studies have found mixed results for odds of successfully quitting, with income but not education as a significant predictor (Fagan, Shavers, et al., 2007;Hymowitz et al., 1997) or, in contrast, education but not income as a significant predictor (Lillard, Plassmann, Kenkel, & Mathios, 2007). European studies have also found up to double the odds or rates of quitting smoking between the highest and lowest SES groups, including occupational class in the United Kingdom (Kotz & West, 2009) and Sweden (Lindstrom, Hanson, Ostergren, & Berglund, 2000); social class in Denmark (Albertsen, Hannerz, Borg, & Burr, 2003;Osler & Prescott, 1998); and education in Finland (Broms, Silventoinen, Lahelma, Koskenvuo, & Kaprio, 2004), Spain (Fernandez, Garcia, et al., 2001), Denmark (Osler, Prescott, Godtfredsen, Hein, & Schnohr, 1999), and the United Kingdom (Graham & Der, 1999), and in an analysis of 18 European countries (Schaap et al., 2008). Higher education was also linked to increased odds of cessation in an Australian analysis, although this relationship became nonsignificant when other individual and environmental factors were controlled (Siahpush, Borland, & Scollo, 2003). The literature also suggests that socioeconomic disparities may be increasing; analyses of smoking cessation patterns over time have documented a trend toward increasing cessation in higher SES groups, widening inequalities in smoking in Western countries. Historical data from the United States indicate that while quit rates have increased over time, they have been lowest among the less-educated (Gilpin & Pierce, 2002) and among blue-collar workers (Covey, Zang, & Wynder, 1992), leading to increased educational and occupational class differences in current smoking. U.K. studies of social class differences have observed cessation rates in the highest social classes that were at least twice those observed in the lowest groups (Jarvis & Wardle, 2006;Jefferis, Power, Graham, & Manor, 2004). European studies on smoking cessation show a similar pattern of increasing inequalities over time: a 12-country study noted a stronger relationship between education and prevalence for current smoking than ever smoking, suggesting higher educated groups have had higher rates of quitting (Cavelaars et al., 2000), and analyses in Spain and Italy have also identified increasing educational inequalities due to higher quit rates/ratios among the higher educated (Federico, Costa, & Kunst, 2007;Fernandez, Schiaffino, Garcia, & Borras, 2001;Schiaffino et al., 2007). Several studies in the United States and Europe have also identified increasing socioeconomic differentials in smoking and cessation among younger age cohorts, suggesting that tobacco-related health disparities will be larger in the future (de Walque, 2004;Federico et al., 2007;Gilpin & Pierce, 2002;Schaap et al., 2008). While it is important to document these socioeconomic disparities in cessation, quit success represents the end point of a smoking cessation process. Looking further upstream in the pathway to quitting, at measures such as quit intentions and quit attempts, may be useful for identifying where and how such disparities could be reduced through effective intervention. However, few studies have explored the associations of SES with quit intentions and quit attempts, and findings in this area have been mixed. Regarding quit intentions, studies in the United States (Fagan, Augustson, et al., 2007), the Netherlands (Dotinga, Schrijvers, Voorham, & Mackenbach, 2005), and the United States, the United Kingdom, Canada and Australia combined (Siahpush, McNeill, Borland, & Fong, 2006) have found that smokers with higher income and/or education were more likely to intend to quit. On the other hand, another Dutch study (Droomers, Schrijvers, & Mackenbach, 2004) and a recent Canadian analysis (Reid, Hammond, & Driezen, 2010) both failed to find a significant association between education and intentions to quit in the next month or 6 months, respectively. Existing evidence on quit attempts has also been varied. Some studies in the United States have observed differences in quit attempts by socioeconomic measures, with lower likelihood of quit attempts in the past year among smokers with lower education (Gilman et al., 2008;Hatziandreu et al., 1990;Levy, Romano, & Mumford, 2005;Lillard et al., 2007;Shiffman, Brockwell, Pillitteri, & Gitchell, 2008) and income levels (Levy et al., 2005); conversely, others have found no association with income (Barbeau et al., 2004;Lillard et al.) or education (Barbeau et al.). Recent studies in Canada (Reid et al., 2010) and the United Kingdom (Kotz & West, 2009), as well as an analysis including the United States, United Kingdom, Canada and Australia (Hyland et al., 2006), have also failed to find an association between education (in Canada and in the four countries), income (in the four countries) or social class (in the United Kingdom), and likelihood of having made a quit attempt. Overall, these findings indicate that lower SES smokers are either equally or less likely to make quit attempts than their higher SES peers. Overall, the existing literature has identified considerable, and potentially growing, socioeconomic disparities in smoking, whereby higher SES smokers are more likely to successfully quit. The few studies on the relation between SES and the steps toward quitting-quit intentions and quit attempts-are less clear, but suggest that the same disparities may exist. However, it is unclear how these differences may have changed in more recent years as the tobacco control landscape has evolved, and how they may vary in between countries with different policy environments. --- Objectives Using data from the International Tobacco Control (ITC) Four Country Survey (Fong et al., 2006), this study examined socioeconomic patterns in smoking cessation and in stages on the path to quitting among smokers in Canada, the United States, the United Kingdom, and Australia over a 4-year period. Specifically, we examined the extent to which income and education were related to (a) intentions to quit smoking; (b) incidence of quit attempts, overall and among those who intended to quit; and (c) abstinence from smoking among those who attempted to quit. We also considered differences over time in the associations between SES variables and cessation measures, and whether the relation between SES and cessation measures varied between the four countries. --- Methods --- Sample This study analyzed data from the first five waves of the ITC Four Country Survey (2002-2006/2007), a longitudinal cohort survey conducted via telephone interviews with nationally representative samples of over 2,000 adult smokers in each of the four countries (Canada, the United States, the United Kingdom, and Australia). Eligible respondents were identified and recruited via randomdigit dialed telephone surveys, using probability sampling methods. To be eligible, participants had to be 18 years or older, have smoked at least 100 cigarettes in their lifetimes, and have smoked at least once in the 30 days prior to recruitment. Cooperation rates (proportion of those screened and eligible who agreed to participate) were high (78.7%-83.2%) in Wave 1, although overall response rates were much lower (from 25.6% in the United States to 49.5% in Canada) but comparable with other telephone surveys in the same countries when calculated using the same measures (see Hammond, Fong, Thompson & Driezen, 2004). Respondents were re-contacted in subsequent waves, with between-wave retention rates of 61%-75%. To replenish respondents lost to follow-up, additional individuals were sampled at each wave using the same design and protocol as in Wave 1. Respondents who quit smoking were retained in the sample for future waves. Figure 1 shows sample size, retention, and replenishment over survey waves. The sampling design was intended to provide a random, unbiased, and representative sample of adult smokers within each country, and sampling weights were used to account for any uneven representation (Thompson et al., 2006). Comparisons with national benchmark surveys indicated that the demographic profile of each sample resembled the overall distribution of sociodemographic characteristics within each country (Hammond, Fong, Thompson & Driezen, 2004). The sample for the current study was limited to respondents who were daily smokers at the time of recruitment; nondaily smokers constituted less than 10% of the overall sample, and present some difficulty in applying conventional definitions of cessation. This analysis included data from Waves 1 through 5 and included all observations for eligible respondents, regardless of their time of entry or exit. Additional details regarding the methods are provided in Thompson and colleagues (2006) and in the ITC Four Country Survey Technical Reports (accessible at http://www.itcproject.org). --- Study protocols Interviews were conducted over the telephone by trained interviewers at professional research firms and according to standard protocols. Respondents initially completed a 10-min recruitment survey and were re-contacted for the 35-min main survey about 1 week later. Further details of survey protocols and methods are provided elsewhere (Thompson et al., 2006) --- Measures Outcome variables Quit intentions were derived from the survey item, "Are you planning to quit smoking... within the next month, within the next 6 months, sometime in the future beyond 6 months, or are you not planning to quit?" A dichotomous variable for any intentions (first three response categories) compared with no intentions (last category) was created. In addition, a 6-month intentions variable was created to compare those who intended to quit within the next 6 months (first two categories) with those who did not intend to quit within the next 6 months (last two categories). Incidence of quit attempts since the last survey was measured at each wave (starting in Wave 2) based on response (yes/no) to "Have you made any attempts to stop smoking since we last talked with you, that is since [last survey date]?" Smoking status was self-reported and derived from up to seven survey items regarding current smoking behavior and frequency, and included six categories: 1) daily smoker, 2) weekly smoker, 3) monthly smoker, 4) quit within the last month, 5) quit within the last 6 months, and 6) quit more than 6 months ago. Three abstinence measures were created, for 1, 6, and 12 months. The 1-month abstinence measure included smoking status categories 5 and 6 (vs. 1-4) and similarly, the 6-month abstinence measure included smoking status category 6 (vs. 1-5). The 12-month abstinence measure was determined using additional survey items. Those who were quit (smoking status 4-6) at the previous wave were asked if they had stayed quit in the following two items: "The last time we spoke to you in [last survey date], you were not smoking. Are you back smoking or are you still stopped?" and for those who answered that they were still quit, "So you have been quit the entire time since [quit date] --is that correct?" Respondents who were quitters both at the time of the survey and at the previous wave and answered positively to these abstinence items were classified as 12-month quitters. --- Independent variables The independent variables of primary interest were education and income. Education level was coded into three categories: low (high school or less), moderate (technical/trade/college completion or some university), and high (university degree or higher). Income level was coded as low (<unk>$30,000/<unk>15,000), moderate ($30,000-59,000/<unk>15,000-30,000), high ($60,000+/><unk>30,000), and refused/not stated. Income and education collected at the time of each observation were used in the analysis, with one exception: Wave 2 values for income and education were imputed from Wave 1 values due to missing data. In this way, any changes to SES variables that occurred over the course of the study were captured. All analyses included the following demographic covariates: country (Australia, Canada, United Kingdom, United States), age (continuous), sex (male, female), ethnicity (minority, nonminority), and marital status (married/common-law, separated/divorced/widowed, single). Survey wave (1-5) was included as a measure of calendar time. To control for the potential effects of repeated testing, time in sample (number of waves that the respondent had been in the sample) was also included. A measure of dependence, the heaviness of smoking index (HSI), was also included to account for the potential effects of dependence on the relationship between the outcomes and SES. The HSI was calculated as the sum of the scores from two categorical variables, time to first cigarette and cigarettes per day (CPD; Hyland et al., 2006): time to first cigarette was assigned a value of 0 for >60 min, 1 for 31-60 min, 2 for 6-30 min, or 3 for 5 or fewer min; CPD was assigned a value of 0 for 0-10 CPD, 1 for 11-20 CPD, 2 for 21-30 CPD, or 3 for >30 CPD. Possible HSI values ranged from 0 to 6. Depending on the outcome being analyzed, the HSI variable reflected either current HSI (for quit intentions), HSI at the previous wave (for quit attempts), or HSI at entry into the study (for abstinence). --- Analysis The analyses used generalized estimating equations (GEE) modeling (Liang & Zeger, 1986;Hardin & Hilbe, 2003), which accounts for repeated measurements on the same subjects and allows analysis of overall group trends without relying on individuals to be present at all timepoints. Separate GEE models were created for each of the outcome variables. Each model included country, age, sex, ethnicity, income, education, marital status, HSI, survey wave, and time in sample. Income and education were added to the models concurrently, as independent variables, to measure the effect of each in the other's presence; an interaction term for education by income was also created to test their combined influence. As a second step, in addition to these covariates (the base model), all two-way interactions between the SES variables and covariates, plus the interaction of country and wave, were screened for significance at p <unk>.05 with the base model and added sequentially to the models using forward selection until no other interactions were significant. Models for quit intentions included all current smokers (former smokers were not asked the question) at all five waves. Models for quit attempts since the last survey were conducted using data for Waves 2 through 5 for respondents who were smokers at the previous wave, first with the entire sample, and also only for those who intended to quit at the previous wave, in order to answer the question of whether there were SES differences in progressing from intending to quit to making an actual quit attempt. Models for smoking abstinence included respondents from Waves 2 through 5 for the 1-and 6-month measures, and respondents from Waves 3 through 5 for the 12-month measure; only those who had attempted to quit since entry into the study were included, to see whether abstinence rates differed by SES given a quit attempt. The samples were weighted cross-sectionally on country, age, sex, and ethnicity (only in the United States) using standardized weights to ensure representative samples from each country. Each respondent's weight at time of entry into the study was applied to their observation(s) in each subsequent wave. All analyses were conducted in SAS version 9.1 (SAS Institute Inc., Cary, NC). --- Results --- Sample The full ITC sample for Waves 1 through 5 consisted of 18,090 unique respondents, providing 42,263 observations. Of these 18,090 respondents, 1,630 were excluded due to not being daily smokers at recruitment (1,315 nondaily smokers; 315 quitters), and 2 were excluded due to missing smoking status at wave of recruitment. The sample available for analysis thus consisted of 16,458 unique respondents, providing 35,532 observations. Respondents/observations with missing values on any of the variables included in particular analyses were excluded on a casewise basis. Table 1 shows the unweighted sample characteristics for unique respondents, by wave of recruitment. --- Outcomes Table 2 shows the weighted proportions of smokers in each education group, income group, and country, (a) who planned to quit (at all, and in the next 6 months), (b) who attempted to quit since last surveyed, both among all eligible respondents and among only those who intended to quit, and (c) were quit for at least 1, 6, and 12 months at the time they were surveyed, both for the total sample and only for those who had attempted to quit since entry into the study. --- Quit intentions Overall, the majority of smokers in the sample (71.5%) were planning on quitting sometime, although only one third of the sample (33.3%) planned on quitting within the next 6 months (Table 2). In the GEE model for planning to quit at all (Table 3), smokers with moderate and high education had 32% and 36% greater odds, respectively, of intending to quit than those with low education. Quit intentions also increased with income. Similar effects of SES variables were observed in the model for planning to quit within the next 6 months (Table 3): moderately educated smokers had 21% greater odds of intending to quit than smokers with low education, and highly educated smokers had 38% and 14% greater odds of intending to quit than smokers with low or moderate education, respectively. High-income smokers were also more likely than those with low or moderate income to intend to quit in the next 6 months. Those who did not provide income information were less likely to intend to quit in both models. Intentions to quit also varied by country for both outcomes: Canadian smokers were more likely to intend to quit than smokers in all other countries, whereas U.S. smokers were less likely than Australians and Canadians, and U.K. smokers were less likely than all others. Notes. Data are presented as weighted percentages. a Among all eligible respondents (observations). b Among only those who intended to quit at the previous wave. c Among only those who had attempted to quit since the previous wave. When interactions were tested, in the model for any quit intentions, interactions between country and wave (p =.0007), age and education (p <unk>.0001), and ethnicity and income were significant (p =.016). The effect of age was significant at all education levels but was stronger with increasing education. Intentions to quit increased with income only for respondents of minority ethnicity, although both minority and nonminority respondents who did not state income were less likely to intend to quit. In the model for intending to quit within the next 6 months, significant interactions were found between country and wave (p <unk>.0001), country and income (p =.013), age and education (p =.015), and HSI and education (p =.024). In Canada, intentions to quit increased with income, although no differences were seen between those who did not provide information and those with low income. In the United Kingdom, high-income smokers were more likely to intend to quit in the next 6 months compared with low-income smokers, with no differences between the other levels. In Australia and the United States, those who did not provide income information were less likely to intend to quit compared with those with low income, but no significant differences were found for other income levels. As with the model for any intentions, the effect of age was significant at all education levels but was stronger with increasing education. For all levels of HSI except 1 and 6, high-education smokers were more likely to intend to quit than low, and moderate education smokers were not significantly different. --- Quit attempts More than one third of the full eligible sample (37.4%) had attempted to quit smoking since the last survey date (Table 2). Among respondents who had intended to quit at the previous wave, quit attempts were more common, at 45% (Table 2). GEE models were conducted first with the full eligible sample (daily smokers at recruitment and still smokers at the previous wave), Notes. Data are presented as odds ratios (95% CI). Each model also included the following covariates: age (p <unk>.01 for both planning to quit models and quit attempts among eligible respondents: lower odds with increasing age), sex (p <unk>.01 for planning to quit at all: lower odds for males), ethnicity (ns), marital status (p =.01 for planning to quit at all: lower odds for single vs. married; p <unk>.01 for quit attempts among those who intended to quit: higher odds for separated/divorced/widowed vs. married), HSI a (p <unk>.01 for all models: lower odds with greater HSI scores), survey wave b (p <unk>.01 for planning to quit in the next 6 months and both quit attempts models: higher odds in more recent waves), and time in sample (p <unk>.01 for planning to quit at all and in next 6 months, lower odds with more waves in sample). CI = confidence interval; GEE = generalized estimating equations; HSI = heaviness of smoking index. *Significantly different at p <unk>.05, in weighted GEE models (with binomial variation and logit link) conducted separately for each outcome. **Significantly different at p <unk>.01, in weighted GEE models (with binomial variation and logit link) conducted separately for each outcome. a HSI at current wave for quit intentions, HSI at previous wave for quit attempts. b Wave 1 and first wave in sample were excluded from quit attempts analyses due to the question about quit attempts only being asked of cohort respondents. and also with only those who intended to quit at the previous wave. In the model with the full sample (Table 3), there was no difference in the odds of attempting to quit for moderate education compared with low, but those with high education had 20% greater odds of having made a quit attempt. There were no differences in quit attempts by income. When only those who intended to quit at the previous wave were included (Table 3), although some other covariates were different, the effects of education and income were the same. Considering country differences, in the full sample, U.K. respondents were less likely to have made a quit attempt than Australians or Canadians, and U.S. respondents were also less likely than Canadians to have attempted to quit. Among those who intended to quit, U.S. respondents were again less likely than Canadians to have attempted to quit. In the interactions model with the full sample, significant interactions were found between country and wave (p <unk>.0001), age and income (p =.0008), sex and income (p =.018), country and income (p =.033), and wave and income (p =.028). In the interactions model including only those who intended to quit at the previous wave, the interactions between country and wave (p <unk>.0001), age and income (p =.005), and sex and income (p =.012) were significant. The effect of age was only significant for high income. In addition, the effect of income depended on sex, with stronger effects seen for males. --- Smoking abstinence Table 4 shows the odds ratios for predictor variables in the models for smoking abstinence of at least 1, 6 and 12 months, among those who had attempted to quit since entry into the study. --- Quit for at least 1 month Overall, 12% of the eligible sample, and 24% of those who had made a quit attempt since entry into the study, had quit for at least 1 month (Table 2). In the model including those who had attempted to quit since entry into the study (Table 4), those Notes. Data are presented as odds ratios (95% CI). Each model also included the following covariates: age (p =.03 for 1 month; p =.02 for 6 and 12 months; higher odds with increasing age), sex (ns), ethnicity (ns), marital status (p =.02 for 1 month, lower odds for single vs. married), HSI (p <unk>.0001 for all models, lower odds with greater HSI scores), survey wave b (p <unk>.01 for all models: higher odds in more recent waves), and time in sample c (p <unk>.0001for all models, greater odds with more waves in sample). CI = confidence interval; GEE = generalized estimating equations; HSI = heaviness of smoking index. *Significantly different at p <unk>.05, in weighted GEE models (with binomial variation and logit link) conducted separately for each outcome. **Significantly different at p <unk>.01, in weighted GEE models (with binomial variation and logit link) conducted separately for each outcome. a Among those who had attempted to quit since the previous wave. b Wave 1 and first wave in sample were excluded from 12-month abstinence due to the quitting measures only being applicable to continuing cohort respondents. c Due to the timeline for the outcome (i.e., respondents needed to be quit for two consecutive waves), only Waves 3 through 5 and time in sample of at least three waves were included. with high education were more likely to have quit than those with low or moderate education, as were those with high income (and income not stated), compared with low or moderate income. U.K. respondents were more likely to be quit than smokers in Australia, Canada, and the United States, which were not significantly different from one another. When interactions were tested, a significant interaction was observed between age and education (p =.006): age was not significantly associated with quitting among moderate-and high-education groups, but low-education respondents were more likely to quit with increasing age. Quit for at least 6 months Overall, 7.5% of the eligible sample, and 15% of those who had attempted to quit since entry into the study, had quit for at least 6 months (Table 2). In the GEE model (Table 4), those with high education had about aone third greater odds of having quit than those with low or moderate education, while no significant differences were observed by income. Differences by country were also observed: U.K. respondents were more likely to be quit than Australians and Canadians. The effects of wave and time in sample were particularly strong in this model. As in the model for 1-month abstinence, a significant interaction was observed between age and education (p =.001). --- Quit for at least 12 months Overall, 7.2% of the eligible sample, and 12% of those who had attempted to quit since entry into the study, had quit for at least 12 months (Table 2). In the GEE model (Table 4), neither the SES variables nor country had significant effects. As in the models for 1-and 6-month abstinence, a significant interaction was observed between age and education (p =.05). Due to the number of outcomes and models, only the main effects models are reported in the tables. Details of the models including all interactions are available elsewhere (Reid, 2008). In general, the addition of interactions to the main effects models did not substantially change the patterns of results for other variables. --- Discussion This research capitalizes on a unique opportunity to study the relationship of SES and smoking cessation in four Western countries during a time of considerable policy change. It is also among the first to examine a spectrum of quitting outcomes, using longitudinal analysis. The findings indicate socioeconomic patterns in a number of cessation-related outcomes, including quit intentions, quit attempts, and varying lengths of smoking abstinence, as well as variations by country. --- Quit intentions Although the majority of smokers in the four countries intended to quit at some point, there appears to be a substantial gap between intending to quit at all and committing to doing so in the near future. Smokers who say that they would like to quit sometime in the future may not be willing or ready to make a firm commitment to quitting, or they may be waiting for the right time or support. Smokers with lower education or income were less likely to report intending to quit than those with higher education or income. The effects of SES variables were similar, and even slightly stronger, for intending to quit at all compared to within the next 6 months. When interactions were considered, the effects of income were modified somewhat by ethnicity and country: intentions to quit at all increased with income only for minority ethnicity respondents, and intentions to quit within the next 6 months were greater for higher income respondents in Canada and the United Kingdom only. The current findings are consistent with studies documenting a relationship between intentions to quit and level of education (Dotinga et al., 2005) and income (Fagan, Augustson, et al., 2007). However, other studies have not found educational differences in intentions to quit (Droomers et al., 2004;Reid et al., 2010); this inconsistency may be due to differences in the samples, variable definitions, or study methods. Lower intentions to quit among lower socioeconomic groups may be due to lower levels of knowledge (Siahpush, McNeill, Hammond, et al., 2006) or less concern about the harms of smoking, different attitudes and social norms around smoking and cessation (Dotinga et al.;Manfredi, Cho, Crittenden, & Dolecek, 2007;Rise, Kovac, Kraft, & Moan, 2008;Sorensen, Emmons, Stoddard, Linnan, & Avrunin, 2002), greater stress (Manfredi et al., 2007;Stronks, van de Mheen, Looman, & Mackenbach, 1997) and dependence on smoking to cope, lower self-efficacy for quitting (Dotinga et al.;Droomers et al.;Siahpush, McNeill, Borland, et al., 2006), less social support (Sorensen et al., 2002), or some other factors. Intentions to quit also differed by country: Canadian smokers were the most likely to intend to quit, followed by Australians, while smokers in the United States and particularly the United Kingdom were less likely to intend to quit. In addition, although "any" intentions were not related to time, intentions to quit within the next 6 months were greater in the two most recent waves; this finding indicates that smokers' commitments to quit strengthened in the past few years, potentially due to increased tobacco control activity and changing social norms in the four countries. --- Quit attempts A substantial proportion of smokers surveyed had made a quit attempt since the last survey, but some socioeconomic variation was observed. Highly educated smokers were more likely to have made an attempt than those with low education, although quit attempts did not differ by income level. Income, however, interacted with a number of variables in the models (age, sex, country, and wave in the full sample analysis, and age and sex in the analysis of those who intended to quit), making its association with quit attempts difficult to characterize beyond its average effect across groups. The effects of SES variables were the same for both the full sample and only those who intended to quit, suggesting that fewer attempts to quit among lower SES groups is not simply due to lower intentions to quit, and that SES differences exist independently for both intentions and attempts. SES differences in quit attempts may be due to the same factors underlying differences in intentions to quit. Access to cessation assistance and perceptions of its effectiveness (Hammond et al., 2004;Roddy, Antoniak, Britton, Molyneux, & Lewis, 2006) may also vary by SES and contribute to whether a smoker moves from intending to quit to making a quit attempt. These results are consistent with U.S. studies that have reported decreased likelihood of attempting to quit among lower education smokers, and inconsistent effects of income (Gilman et al., 2008;Hatziandreu et al., 1990;Levy et al., 2005;Lillard et al., 2007;Shiffman et al., 2008). However, other studies in the United States, the United Kingdom, and Canada have found no SES differences in quit attempts (Barbeau et al., 2004;Kotz & West, 2009;Reid et al., 2010;West et al., 2001). Differences in quit attempts between countries followed the same pattern as quit intentions, although with fewer significant findings: U.K. smokers were less likely to attempt to quit than Australians or Canadians in the full sample analysis, and U.S. respondents were also less likely to have attempted than Canadians in both samples. With respect to time, respondents were more likely to have made a quit attempt in more recent waves (compared with Wave 2); this is likely due to the shorter time period between Waves 1 and 2 compared with between the other waves. --- Smoking abstinence Although

The results suggest that socioeconomic disparities exist at multiple stages in the path to smoking cessation. Potential effects on socioeconomic disparities should be considered when implementing cessation interventions.

s, and inconsistent effects of income (Gilman et al., 2008;Hatziandreu et al., 1990;Levy et al., 2005;Lillard et al., 2007;Shiffman et al., 2008). However, other studies in the United States, the United Kingdom, and Canada have found no SES differences in quit attempts (Barbeau et al., 2004;Kotz & West, 2009;Reid et al., 2010;West et al., 2001). Differences in quit attempts between countries followed the same pattern as quit intentions, although with fewer significant findings: U.K. smokers were less likely to attempt to quit than Australians or Canadians in the full sample analysis, and U.S. respondents were also less likely to have attempted than Canadians in both samples. With respect to time, respondents were more likely to have made a quit attempt in more recent waves (compared with Wave 2); this is likely due to the shorter time period between Waves 1 and 2 compared with between the other waves. --- Smoking abstinence Although direct comparisons with other studies are difficult due to varying study situations and definitions, abstinence rates in this study were relatively high (6-month rates of 8%, or 15% of those who attempted; and 12-month rates of 7%, or 12% of those who attempted) when compared with background unaided quit rates, which are estimated at 3% to 5% for 6-12 month abstinence after a given quit attempt (Hughes, Keely, & Naud, 2004). Success in remaining abstinent from smoking varied by education and income for 1-month abstinence and by education for 6-month abstinence, although 12-month abstinence was not related to either socioeconomic measure. More specifically, respondents with high education and income were 20%-30% more likely to quit for at least 1 month than those with low or moderate education and income. In addition, respondents with high education were 30% more likely to quit for at least 6 months compared with those with low or moderate education. The results suggest that lower quitting success among lower SES groups is not simply due to fewer smokers attempting to quit. Previous findings regarding SES and cessation are mixed, with more studies showing a relationship with education and/or income than not, but with considerable variation in the significance and magnitude of such associations. This creates some difficulty for comparing the current study with existing literature. However, the findings for 1-and 6-month abstinence are consistent with studies showing an association of higher income and/or education with greater cessation success in the countries studied (Agrawal et al., 2008;Barbeau et al., 2004;Fagan, Shavers, et al., 2007;Flint & Novotny, 1997;Gilman et al., 2003Gilman et al.,, 2008;;Graham & Der, 1999;Hymowitz et al., 1997;Kotz & West, 2009;Lillard et al., 2007;West et al., 2001, Wetter et al., 2005). Socioeconomic variation in 1-and 6-month abstinence may be affected by factors similar to those discussed for quit intentions and attempts: knowledge, attitudes and norms, stress, dependence, self-efficacy, and social support. In a study that also measured demographics, tobacco dependence, environmental and job-related characteristics, and transtheoretical modelbased variables, there was an effect of education on smoking cessation regardless of the inclusion of any of these factors (Wetter et al., 2005), suggesting that relationship of education and cessation may operate through other variables. Cessation differences may also be due to variation in social support (Droomers, Schrijvers, & Mackenbach, 2002), quit methods, use of cessation assistance, and access to such assistance (Bobak et al., 2000;Moolchan et al., 2007). The finding that SES variables were important for the shorter time periods but not 12-month abstinence may be due to the smaller and more select population eligible to be quit for two consecutive survey waves. Lower SES respondents and those who had quit were both more likely to be lost to follow-up, so the relationships observed between SES measures and longer term quitting may have been distorted. However, greater attrition among low-SES respondents alone would not likely result in the pattern of results observed unless a disproportionate number of those lost were continuing smokers (e.g., unless more low-SES quitters stayed in the sample), if in fact there were underlying differences by SES in smoking abstinence. The remaining sample may also be subject to some other selection bias. Alternately, SES differences in abstinence may diminish over time after a quit attempt; however, given the amount of existing research indicating that smokers of lower SES are less likely to quit, this is unlikely. One notable country difference was observed in shorterterm abstinence: among those who had attempted to quit, respondents in the United Kingdom were more likely to be quit for at least 1 month and at least 6 months than those in other countries. So, although United Kingdom smokers were less likely to attempt to quit, those that did attempt were more successful at remaining abstinent. The higher abstinence rates observed among U.K. smokers may be due to the comprehensive smoking cessation services offered by their national health authority (Judge, Bauld, Chesterman, & Ferguson, 2005). Respondents' odds of quitting increased over the 4-year survey period, particularly with respect to 6-month abstinence rates. This may be due to the greater length of time between surveys after Wave 2 and/or an actual increase in quitting over time in the population of smokers, potentially due to tobacco control activity. --- Limitations Although this study has a number of strengths, including its large, representative samples of smokers from multiple countries and the ability to examine multiple outcomes and covariates over time, this analysis is subject to some general limitations common to survey research, such as attrition and potential biases in the sample, and reliance on self-report. The selfreported nature of the data introduces the possibility of reporting inaccuracies in the outcomes; for example, errors in recalling quit date or past-year quit attempts, potential bias toward recalling only successful or recent quit attempts, and the potential of social desirability to cause over-reporting of intentions to quit. Although these issues could lead to overestimating the prevalence of the outcomes, there is no reason to believe they would vary by SES, so the relationships between the outcomes and SES would not be affected. In addition, previous research has indicated that self-report of smoking behavior is generally accurate when compared with biochemical validation, particularly for observational studies (Patrick et al., 1994). Two SES measures, thought to measure unique aspects of SES, were tested in this study, strengthening its findings; however, each has limitations. An absolute measure of household income was used as a general indicator of material circumstances, although the adequacy of this income level depends on other factors such as household composition and or local cost of living. As with all longitudinal studies, sample attrition is a concern. Preliminary analyses of between-wave attrition (data not shown) indicated that there are some significant relationships between attrition rates and several variables of interest. Attrition varied over time and by country and was greater among respondents who were younger, male gender, of minority ethnicity, had quit smoking, smoked less frequently, and who did not intend to quit. Of particular interest to the current study, moderateand high-income respondents were more likely to remain in the sample (compared with those who did not provide income information) as were those with moderate education (at Waves 1 and 2), or high education (at Wave 3) (compared with those with low education levels). The patterns of attrition observed in this study are similar to others that have found greater attrition among respondents who were men, younger, less educated, and had lower income (Bull, Pederson, Ashley, & Lefcoe, 1988;Psaty et al., 1994). In this study, differential attrition by SES or other demographic characteristics would only change the findings if some characteristic(s) associated with attrition was also related to SES and the outcomes, thus distorting their relationship (e.g., if the lower SES respondents that dropped out of the study were different from those who stayed in the study in a way that is related to the outcomes). Any biases that may have been introduced into the proposed analysis by attrition are not quantifiable; however, such biases may be reduced by including the covariates associated with attrition in the analyses, and thus partially controlling for their impact. In addition, attrition could have decreased power in this study by decreasing the size of the sample available for analysis, leading to more conservative conclusions and estimates of the effect of income and education on the outcomes. --- Conclusions Socioeconomic differences favoring the more advantaged were found for a number of quitting-related outcomes: smokers with lower education were less likely to intend to quit, make a quit attempt, or be abstinent from smoking for at least 1 month or 6 months, and smokers with lower income were also less likely to intend to quit or be abstinent from smoking for at least 1 month. The findings indicate that SES differences in quit attempts extend beyond differences in intentions to quit, and differences in quit success extend beyond differences in quit attempts, suggesting that there are barriers related to SES at several stages along the spectrum of smoking cessation. Associations between SES variables and the outcomes varied, with education showing stronger relationships. Country differences were observed for several outcomes. Canadian smokers were more likely to intend to quit than smokers in all other countries, whereas U.S. smokers were less likely than Australians and Canadians, and U.K. smokers were less likely than all others. Quit attempts followed the same pattern, although fewer comparisons reached significance. However, U.K. respondents who had attempted to quit were more likely to be abstinent from smoking for at least 1 or 6 months than smokers from other countries. These country differences may be due to varying policy environments, or to differences in social, cultural, or individual-level factors. --- Implications This research contributes to a better understanding of the relationship between SES and quitting smoking in four Western countries that include tobacco control leaders. Although the results show fairly modest differences by SES, when applied to whole populations, these differences translate to substantial numbers of smokers. Given that current smoking rates are higher in lower socioeconomic groups, cessation rates among lower SES smokers would need to be not only equal, but greater than those seen in higher SES groups in order to decrease existing disparities. Thus, socioeconomic disparities in tobacco use are unlikely to be diminished if current trends continue. As new policies and interventions are implemented, particular attention should be paid to their effects on smoking, cessation, and tobacco-related disparities. For instance, it remains unclear whether low-SES smokers would benefit from making existing cessation services more accessible, or if implementing targeted services and policy interventions is warranted. This analysis focused mainly on sociodemographic variables in order to characterize the extent of SES disparities. However, the associations of these variables with the outcomes may be complex, and act through specific (and likely multiple) pathways to influence the outcomes. Research is needed to understand and identify these pathways and other variables (psychosocial, environmental, and otherwise) that may be related to both sociodemographics and the outcomes. Identification of these factors may provide insight into targets for intervention. Furthermore, research and subsequent interventions aimed at reducing smoking will be limited in their ability to do so unless they also alter the aspects of SES that are related to smoking and cessation; underlying issues that lead to inequity will need to be addressed in order to eliminate tobacco-related health disparities. --- Declaration of Interests None declared.

The results suggest that socioeconomic disparities exist at multiple stages in the path to smoking cessation. Potential effects on socioeconomic disparities should be considered when implementing cessation interventions.

Introduction Infertility can affect any woman or man in their reproductive years. The most recent statistics show that in the UK 8% of infertile people are non-white, with 51% of these being Asian or Asian British, 26% Black or Black British, 12% Chinese or other ethnic groups, and 11% Mixed (HFEA, 2006). Ethnic and religious minority groups are underrepresented in European infertility psychosocial research (Culley et al., 2009a), despite research showing that ethnicity is associated with some reproductive health problems (e.g., miscarriage, Harb et al., 2014) and worse treatment outcomes (Dhillon et al., 2016). The consequences are a lack of understanding of these patients' infertility and treatment experiences and a lack of available guidance about how to meet their specific support needs. In this study we used a participatory drawing-based method, DrawingOut (Gameiro et al., 2018), to explore the views, experiences and healthcare needs of a group of infertile women from a minority ethnic or religious background living in Wales, UK; and to co-develop an engaging booklet that minority groups can use to share their infertility experiences and advocate for support with their communities and health professionals. It has been claimed that the need for fertility care of ethnic and religious minority groups has received little political and academic attention (Culley et al., 2009a). This is certainly the case for European research focusing on psychosocial adjustment to infertility and its treatment. Most psychosocial research has been conducted with white middle-class heterosexual infertile couples undergoing fertility treatment (Greil et al., 2010b), and very! 3 few studies have investigated how ethnicity and religion (compared to other sociodemographic factors such as gender and education) influence adjustment to infertility and associated support needs. Stated reasons for the inadequate representation of minority ethnic and religious groups in research include these groups' lack of access to healthcare settings where research tends to be conducted; language and socio-cultural barriers, for instance stigma around infertility, that make it harder for minority groups to participate; and selfexclusion, for instance, due to lack of experience with or distrust in health research (Johnstone et al., 2009). Some researchers were able to overcome language and socio-cultural barriers to research participation by using community facilitators (Culley et al., 2007), or by conducting qualitative research with specific minority groups. In the Netherlands and Germany, the focus has been on Turkish immigrant communities (van Rooij et al., 2009;Vanderlinden, 2009Vanderlinden,, 2011)); in the UK, on British South Asian -Indian, Pakistani and Bangladeshi (Culley and Hudson, 2009;Culley et al., 2009a), British Turkish (Gürtin-Broadbent, 2009), and British Pakistani Muslim groups (Blell, 2017;Hampshire et al., 2012;Simpson et al., 2014). All these minority groups have distinctive histories within Europe, as well as specific sociocultural and religious beliefs that shape the way infertility is experienced at an individual and social level. However, there are also some commonalities of their experiences. For example, within these communities, most people are expected to marry early, sometimes in the context of arranged marriages, and to have their first child within one year of marriage. According to participants, their cultures share a strong investment in children, and male children are of special importance to ensure the continuation of the family lineage. In the study of South Asian and Pakistani communities in the UK, some individuals talked about a generational 'gap', whereby younger people were starting to delay parenthood for a short! 4 while to pursue other goals, and highlighted individual motivations to have children (e.g., desire to develop an emotional bond) beyond the need to meet family expectations (Culley and Hudson, 2009;Hampshire et al., 2012;Simpson et al., 2014). Nonetheless, having no children at all or only one child is still negatively perceived in many of the researched ethnic minority communities in Europe, especially if the only child is a girl (Culley et al., 2009b;Simpson et al., 2014). Consistently, infertility tends to be highly stigmatized and seen almost exclusively as the woman's fault. Its social consequences are more severe for women than for men; they can include being gossiped about, ostracized, and sometimes even ill-treated by family members. Some male respondents also reported that they were being put under pressure to divorce their wives and remarry because their marriage had not produced any children (e.g., Culley and Hudson, 2009). These data suggest that minority groups experience higher social burden of infertility. However, infertility social distress is also commonly reported by non-minority groups (Gameiro and Finnigan, 2017), and quantitative studies using US samples have not shown that ethnicity, religion and high social value placed on motherhood are associated with higher infertility distress (Greil et al., 2011;Jacob et al., 2007), which suggests that distress may depend on how individuals perceive their circumstances. As shown by McQuillan et al. (2012), it may also be that social expectations about parenthood are only distressing when internalised by individuals. Another explanation is that these qualitative studies' samples are not representative of the full heterogeneity of experiences and socio-cultural attitudes present in ethnic and religious minority groups. All the studies mentioned above found that some of their respondents had experienced difficulties when seeking fertility healthcare. These were related to a range of issues, including a lack of language proficiency that led to problems understanding doctors or! 5 relying on a family member's translation; being exposed to information that contradicts religious beliefs; having to undergo potentially humiliating or demasculinizing procedures (e.g., testing for male infertility); and a lack of cultural sensitivity and prevalence of cultural stereotypes on the part of healthcare providers. These data suggest that minority groups may experience a high burden of treatment. One study showed that Turkish migrant infertile patients reported higher depression, self-blame and guilt, and more sexual problems due to infertility than Dutch patients (van Rooij et al., 2007), but it did not identify the sources of burden. Dissatisfaction with treatment can also lead to dropout. For instance, many of the Turkish patients who travel home for fertility treatment are critical of the Dutch healthcare system (Gürtin-Broadbent, 2009). Despite this negative portrayal of fertility treatment experiences, little research has been conducted to understand what these patients' support needs and preferences might be. One research team tried to address the lack of guidance for healthcare practitioners by developing educational materials (Culley and Hudson, 2004). However, systematic reviews of patients' preferences (Dancet et al., 2010) and European and UK national (NICE) evidence-based guidelines (Gameiro et al., 2015;National Institute for Clinical Excellence, 2013) give no information on how to address ethnic, cultural and religious specificities in care, with both guidelines calling for further research to address this research gap. In sum, evidence suggests that at least some people from minority ethnic or religious groups perceive increased pressure to conceive from their communities, higher social costs when they are unable to have children, and stressful interactions with the fertility healthcare system while attempting to conceive. The current study used DrawingOut (Gameiro et al., 2018) to explore the views, experiences and healthcare needs of nine infertile women from a minority ethnic or religious background living in Wales, UK. DrawingOut is a participatory! 6 visual research method that consists of a one-day metaphor-centred drawing workshop to collect visual and textual data about a particular health related topic, in this case infertility. We hypothesised that DrawingOut would be successful in engaging participants from diverse cultural and religious backgrounds and with varying levels of language proficiency. Its nondirective (using activities instead of questions) and group character should also empower participants to bring their own agendas into the research setting and to construct meaning about their experiences and needs both individually and collectively, through groupnegotiation (Guillemin, 2004;McNicol, 2014). Finally, DrawingOut was expected to enable the creation of engaging outputs for dissemination that communicate individual experiences in an immediate and striking way (Hodgins and Boydell, 2013). --- Materials and Methods --- Design This study was based on a one-day drawing workshop to collect visual (artwork produced by participants) and textual (all conversations and discussions during the workshop) data about the participants' experiences and views of infertility and their fertility care needs. --- Participants Participants were nine adult women with a minority ethnic or religious background living in Wales, UK, who were currently experiencing or had experienced infertility in the past. The average age was 42 (range 30-59). Five women were South Asian Muslims, two were Sub-Saharan African Christians, one was a North African Muslim, and one a British Muslim married to a North African Muslim man. Seven women had migrated to and two had grown up in the UK; all had transnational extended families. Six women reported that they! 7 had experienced fertility problems in the past. Of these, five had managed to conceive, but one had not and was still childless when she entered menopause. In addition, one of these women was trying to conceive again and experiencing secondary infertility. The remaining three women were childless and currently experiencing fertility problems. In total, of the nine participants, five already had at least one child. The participants had different levels of English proficiency, ranging from native-and near-native to very limited skills only. --- Procedures The study received ethical approval from the Ethics Committee of the School of Psychology, Cardiff University. A convenience sample was recruited in partnership with a local charity, Women Connect First (womenconnectfirst.org.uk). Potential participants were contacted by phone by a staff member of the charity and informed about the general aim of the project. Those women who provided oral consent were asked about their fertility status, to ascertain if they were eligible participants. All the women who attended the workshop were asked to sign an illustrated consent form and given a debrief form at the end; we also invited participants back for a second session to share the research findings and give feedback. As a token for their participation, women were offered a £50 voucher. The DrawingOut method is described in detail elsewhere (Gameiro et al., 2018). In short, the workshop started with an ice-breaking activity, followed by the presentation of the workshop structure and discussion of rules of good conduct to ensure consideration and confidentiality during and after the workshop. The workshop itself consisted of five carefully structured activities: (1) Discussion of infertility-related drawings. Women were asked to 'choose the drawing they most identified or connected with' among a set of infertility-related illustrations and comic! 8 strips by illustrator Paula Knight (available online https://paulaknight.wordpress.com/ comics-3/), to describe the chosen drawing, and explain to the group why they had selected it. These strips covered the main themes relating to our research questions (impact of infertility, relationship with others, healthcare experiences and needs). (2) How to draw things and people. Participants were introduced to the basics of drawing objects and people in a slide-based lecture and guided through some simple drawing exercises. This session ended with the request to 'Draw yourself thinking or talking about infertility' (self-portrait exercise). (3) How to draw thoughts and feelings. Participants were introduced to the concept of visual metaphor, defined as the use of something visible to show something that is invisible. Examples of visual metaphors were presented and their meaning was discussed. This section ended with four drawing activities, in which the participants were asked to produce visual metaphors for their infertility experience, using the following instructions: 'If infertility was a creature or animal, what would it be?'; 'If it was a place or situation, what would it be?'; 'If it was weather, what would it be?'; and 'Draw how infertility affects your relationship with other people'. (4) Free drawing session. The women were given one hour to produce a large-scale drawing about any aspect of their infertility experience. (5) Group sharing. The workshop ended with a group session, in which the women were invited to present their artwork and comment on the different emerging views. Multiple simultaneous audio recordings captured the small-and large-group discussions. One researcher took notes to support the transcription process. The audio recordings were transcribed verbatim. Occasionally some of the women would have brief! 9 interactions in other languages, often explained as helping to translate for each other, but only conversations held in English were transcribed. --- Data Analysis Thematic analysis was implemented by two of the authors (SG and BBG), following the procedures recommended by Braun and Clarke (2006). Thematic analysis was chosen because data gathering was complete at the time of the analysis, the data consisted of textual material, and there was no strong theoretical perspective driving the analysis (Howitt, 2010). Although participants came from different minority groups, we were interested in identifying common views and experiences of infertility and healthcare. Therefore, we worked to identify themes that captured a patterned response or meaning within the data, defined as something that was mentioned by at least two participants (Braun and Clarke, 2006). A bottom-up approach to the data was adopted: first, SG and BBG familiarised themselves with the full workshop transcript; second, they individually assigned textual descriptors to relevant passages in a line-by-line coding; and third, they discussed the descriptors and grouped them into themes. Finally, the themes were grouped into higher-order themes, which were to a certain extent led by the research questions (e.g., emotional burden of infertility, relational burden of infertility) but also set by participants' own agendas (e.g., coping strategies). Each participant was allocated a random letter to ensure anonymity, and that is how they are represented in the results section. SG has expertise in the topic of infertility and assisted reproduction, having researched the topic for over 10 years. Although this was the first time she conducted research with minority groups, she was familiar with the existing literature. Due to her expertise, she was able to differentiate general experiences of infertility from the specifics of! 10 these women's experiences, but this might have made her biased towards identifying themes that had emerged in previous research. BBG has no expertise in infertility, but biases in her analysis may have arisen from everyday knowledge about infertility (newspaper reports, friends' experiences). Separate individual coding, followed by joint discussion, was adopted to counterbalance these potential individual biases. Finally, to ensure triangulation, SG and BBG presented their coding to the other members of the research team (LER and AP, who had attended the full workshop) for a final review. LER is an expert in visual and health metaphors and AP had been developing academic work with minority ethnic women in Wales for 4 years. At a later stage, a booklet was produced on the basis of the results obtained and was presented to the workshop participants, who were asked to comment on whether they felt the booklet represented their views and experiences accurately. --- Results We identified a total of 41 themes that we grouped into eight higher-order themes. Six of them concerned the women's wellbeing and relationship with others, and two their fertility healthcare views and experiences. All themes are presented in Table 1. They are also represented in a co-produced comic booklet using the women's own drawings and words that is available online (Thorns and Flowers -Infertility experiences of Black and Minority Ethnic women, https://www.cardiff.ac.uk/psychology/about-us/engagement/thorns-andflowers). This 16-page A5 booklet, produced in English and Welsh, aims to increase awareness about the infertility experiences of women from a minority ethnic or religious background and can be easily printed and used by anyone for their own purposes. The booklet was posted to more than 100 relevant stakeholders, including health charities and professionals and policy makers. It was also presented at a community event organized by! 11 Women Connect First and at several national and international academic and health conferences. In the text below we first describe the higher-order themes identified in our analysis and then the women's evaluation of the booklet. Table 1 around here. --- The emotional burden of infertility All participants expressed a range of negative emotions caused by their infertility, especially when they were asked to draw infertility as an animal or creature, weather or place (activity 3: how to draw thoughts and feelings). They tended to use dangerous animals to represent feeling frightened, confused or overwhelmed. The following participant, for instance, explained: "I have put like a monster hippopotamus ape, because the moment you are told, the moment you are infertile you become so scared, it's something scary, something that can cause you to be depressed or to have poor mental health." (A, 39 years old, childless) Another participant drew what she described as a'shadow monster' (Figure 1), in order to show how infertility affects all areas of her life and to emphasize the need for more education and awareness: "Infertility is always there, wherever you go, like a shadow. If we educate people the shadow will still be there but much smaller. We can be bigger than our fears." (B, 38, children) Figure 1.near here! 12 Participants also drew different types of weather to represent their emotions, mostly drawing gloomy weather to represent negative emotions such as sadness, anger, loss of hope and uncertainty about the future. In this context, participants stated that infertility causes low mood and poor mental health, and that these mental states are exacerbated by the social burden associated with infertility. Participants referred to this as a 'double pressure': "Those who have infertility, who are infertile they, they lack confidence, they have low self-esteem and they've poor mental health, some not all of them." (A, 39, childless) "[...] --- The relational burden of infertility Several of the participants agreed that men were generally less affected by infertility and could sometimes be dismissive of their partner's suffering. They thought that infertility could either damage or strengthen a marriage, depending on the couple's relationship and coping strategies. However, they all held that it was likely for the partnership to be negatively affected by the social pressure placed on the couple. "A division, it creates a division between that the husband and wife or the woman with the, with the husband's family." (A, 39, childless) In this context, the women agreed that their partner's support was essential. For instance, one childless woman described how support from her partner was important to both herself and her family:! 13 "You can see, that's my husband and that's me and he says -Be happy, don't worry. [...] So my family is also happy, so he's happy with me [...] In the future I will conceive baby... Inshallah..." (H, 30, childless) --- The social burden of infertility Most women related that they often experienced a burden stemming from multiple difficult and stressful social interactions around the theme of parenthood, especially with their partner's close family: "Every time we would go home to, I say home, this is my home, but back to my husband's, they'd say to me so where's your children? Why have you only got one? What's going on with you?" (D, 43, children) "You are, your in-laws are so hard, in fact life becomes really hell." (E, 38, children) Interactions with friends or other members of the community can also be stressful because children are a central topic in everyday conversations. These interactions included transnational family and friends visiting or calling from 'back home'. The women reported that they were constantly asked about their parenthood status, a difficult experience that could make them feel isolated from their partner, family and community, and likely to withdraw in order to avoid painful situations. They said that members of the older generation, in particular, were often confrontational, making insensitive comments: "I don't have children, so it has been a very difficult question for me everywhere I go. You know it's like, you get to meet with other ladies and they start talking about their children." (A, 39, childless) Most women identified with an image that represented strained social interactions resulting from infertility by means of a rift metaphor (activity 1). Some of the participants! 14 used this and other similar metaphors such as a rift, a valley, a wall or a prison to express their own sense of social isolation. One participant described her deeply painful sense of being separated from her family and community: "This is the community [...] and there's like family, friends, schoolmates, in-laws. So this is me here, [...] there is this unconscious divide, this rift valley existing in terms of the stereotypes that they think about you, the stigma that they think you have, a problem. [...] So in a way it affects your love because when they influence your husband to be against you somehow, it might not be obvious, but somehow there is an indirect influence, especially from the in-laws." (E, 39, children) Some of the women said that their partners were also subjected to family and/or community pressure, which typically took the form of advice to leave their childless partner. Several participants knew of couples that had got divorced due to family pressure to have children, either because they were infertile or because the woman did not want to have children immediately. One older participant reported her own experience: "Some people, ah, say to my husband, why don't you marry again? Because your wife doesn't bring for you children. Because in our culture you can marry again, yes? And take a new wife to bring, ah, children." (F, 59, childless) Several participants expressed a desire for other people to be more sensitive when discussing parenthood, and to stop asking questions when it was clear that someone was feeling uncomfortable: "Mmm, the extended family members should mind their business, they shouldn't intrude." (E, 39, children)! 15 --- The community The specific ways in which women's communities perceive and react to childlessness and infertility was one of the most prevalent topics of the workshop. We did not ascertain what exactly participants meant by 'community', or if it meant the same for everyone. Some participants referred to 'our community', the 'BME community' or 'BME communities' and some referred to it as being distinct from the 'British community'. One participant represented her community as a spider and its web: "I think our community is just like a spider, like a net. [...] I am here, the very small thing and the spider...the spider net is very big." (I, 52, children) The women considered the social burden they experience (described in the previous section) to be the result of socio-cultural norms and traditionalist views of family and parenthood, whereby children are highly valued and women perceived almost exclusively as caregivers. "Their mind-set is that women should have children, stay at home, and the man works." (D, 43, children) "There's a culture of being interrogated and not knowing the boundaries of personal privacy issues. And that's higher in our community rather than in the British community." (B, 38, children) According to the participants, the expected norm in their communities is for couples to have children soon after marriage. When this does not happen, women are put under pressure to have (more) children, especially if they do not have boys. When there is suspicion or evidence of infertility, women tend to be blamed, in part because male infertility is taboo, so the possibility that infertility may be due to a male factor cannot be discussed, as expressed in the following quotes:! 16 "And, and so there was this, ahm, every monthly cycle my mother in law used to check whether, you know, I've come on [menstruated], [...] and I used to feel really bad, and I used to hate telling my husband at the time that I've come on." (G, 40, children) "Even if the male is the one who has the problem, maybe low sperm count, they always see the woman as the problem." (E, 39 years, children) Most women agreed that the described attitudes and social norms were not related to their community's religious beliefs and that, in fact, they derived a great sense of comfort from their religious faith. --- Views and concerns about infertility Several participants discussed their infertility experience in terms of a journey: at the start there is the hope of becoming a mother, and difficulties conceiving are imagined as impediments on a long, arduous journey. At the end of the journey there is either the longedfor child, or, in some cases, a sense of having achieved contentment by focusing on other goals. Most participants expressed the belief that women could be fulfilled in life even without having their own children, particularly through education and a professional career. This journey metaphor was also present in many of the drawings. For instance, one woman drew her experience of infertility in terms of climbing up a mountain, while others represented themselves as ducks swimming on a river or birds flying into the sky (see Figure 2). Some women expressed a desire to know more about the biological causes of infertility and took advantage of the workshop to ask questions on the topic. --- "This [comic] appeals to me because what I am thinking is that [...] the person who drew this image is that maybe she had problems with her fallopian tube, the problem I have? --- So I have a really keen interest on it [...] and I am a bit curious about it, what could be done to flow them out to get clearer and to open the fertilization." (E, 39, children) Their comments also reflected some common myths and misconceptions about infertility. For instance, many believed that relaxing and trying not to worry too much might, in itself, be enough to facilitate conception: "Yeah, I would agree with that, just relax and go with the flow and, ah, it will happen." (D, 43, children) Their comments also revealed a lack of awareness of the detrimental effect of age on fertility; for instance, some seemed to agree that up to the age of 45 there is no need to worry about decreasing fertility. When one woman (H, 30,) expressed concerns about being childless at the age of thirty, other women reassured her by stating that as long as she ovulated and had a regular period it meant she was able to conceive: "Don't worry. As long as the period continues..." (I, 52, children) "Oh no you are young! You are young, you still ovulate, that's fine." (C, 38, childless) Finally, the women also expressed some concerns regarding fertility treatment, focusing in particular on its low success rates and high costs. --- Coping strategies Individual strategies to cope with infertility emerged in the flow of the conversation, particularly when participants were asked to draw themselves thinking about infertility! 18 (activity 2). One of the most prevalent strategies involved taking comfort in prayer and in accepting God's will. Other participants coped by 'thinking positively' or 'focusing on the good things'. Commenting on her drawing (see Figure 3), one participant said: "One of the, like my solution was to have to trust God and put your faith in it, in your, you know, what you're destined to have, pray, there's hope, um, if you're blessed then you'll get a child, but if you're not then I think this is, like, just be happy with whether you have a child or not, relax and enjoy life." (C, 38, childless) "That's why I have, just need to thinking about the good things. [...] Not easy, yeah, it's not easy but we need to think the good things, be positive." (I, 52, children) Figure 3. near here Women also considered that it was important to be persistent and keep trying to get pregnant, either by continuing to have unprotected sex or by undergoing fertility treatment. Indeed, the women in our study did not express any ethical reservations about using assisted reproduction as long as they could use their own gametes. --- "Fail one time, second...Try again. It is not the end... if it is from the first time that is ok, try again and again and you will get pregnant. [Laughter]" (F, 59, childless) Other coping strategies included taking good care of one's physical appearance, both as a form of self-care and as a way of not revealing distress and suffering to others, and keeping busy and focusing on other life goals. In general women agreed that one can have a fulfilled life with or without children. Describing her drawing, one childless participant said:! 19 "These are glasses, this is a book, and this the moon. This is me. I am very happy with children or without children. [...] --- Healthcare experiences In the first activity (discussion of infertility-related comic strips) a few women chose a picture depicting a healthcare interaction, which triggered a long discussion about healthcare experiences. The women agreed that they were not the object of discrimination within the British (universal) National Healthcare System (NHS) and that they had experienced a lot of good care, although some also reported being ignored or misunderstood by individual care professionals, who, for example, showed a lack of appreciation of the women's desire to have more than one child or their reservations about using donated sperm. Participants also commented on a perceived lack of interpersonal skills, particularly among younger doctors. "Because I had a daughter, a baby girl before that, and she was, she was about eight years old at that time, I felt that they [health professionals] kind of looked down at me? You know. Why are you even thinking of another one? You know if it's not working, there are people who don't even have one, kind of thing?" (B, 38, children) "I also think that health professionals should listen more because at times they miss out on what the patient is saying and they, they, they give advice that is not appropriate! 20 because they didn't listen, they should listen more than talking because some of them they like talking a lot [laughter]." (A,39, children) --- Support needs When asked about the type of support they wanted for themselves and other infertile women from their community, many stated that healthcare professionals should be more sensitive to socio-cultural issues and could benefit from training on this and on interpersonal skills. In addition, some also advocated counselling for women and men, including before the start of fertility treatment. Overall, it was felt that women needed more support to cope with the stigma associated with childlessness and the abuse to which they are sometimes subjected. Limited sexual knowledge was also thought to contribute to some couples' inability to conceive, so sexual education was seen as beneficial. Finally, there were comments about the inability of GPs to detect infertility cases properly and refer them for specialist assessment. "She mentioned good point about, ah, counselling taking into consideration religion and culture. What happened, like for me and my husband, when we were filling forms for having IVF there was one question, if you like to, ah, have the sperm of another man, and this is not, uhm, allowed in, ah, Islam. It is like, is it the same as adoption." (C, 38, childless) "One advice I'd have for health professionals is to look out for other signs of psychological or emotional abuse, because if they've got to that stage where they are being referred it's in the majority of the cases they're more likely to have been victimized, belittled, you know, emotional abuse, psychological abuse." (G, 40, children)! 21 "There's another area, it's sex education, because a lot of our couples, especially from Muslim backgrounds, they're sexually inexperienced, so often the infertility is due to their lack of knowledge and skills." (G, 40, children) Finally, throughout the workshop the women repeatedly stressed the importance of education as a way of achieving greater autonomy and gender equality, overcoming traditionalist views of women and parenthood, and increasing awareness about the impact of infertility and thereby encouraging men and the community to be more supportive. They referred specifically to the need to increase awareness of male infertility and to encourage men to seek treatment. In this context, one participant suggested that initiatives should try to liaise with religious leaders or institutions, as men would be more receptive in those contexts: "I have noted that all these, you know, social and general things from the health board they kind of ignore the religious places? And men are usually more, ah, you know, functional at religious places, for example temples and mosques [...], and all the people who run these places they are educated and they can, they've got religious education as well as the other, they can better reach them there rather than, you know, us women getting together and dragging them ourselves [laughter]." (B, 38, children) --- Participants' evaluation of the booklet A preliminary version of the booklet was presented to six of the workshop participants. Overall they were very pleased with it and suggested only two minor changes, namely increasing the font size and adding colour to one drawing that included a verse in Arabic stating "women bring colour to the world". These changes were incorporated before the final production of the booklet. ---! 22 --- Discussion Results from this study support the view that women from ethnic and religious minority backgrounds consider that their communities have highly pronatalistic attitudes and stigmatize infertility,, to which they attribute (most of) their infertility-related stress. Our results advance current knowledge showing that women were critical of such cultural attitudes, considered that fertility education was needed to overcome these, and put forward concrete proposals on how to implement change. In addition, women distinguished between cultural attitudes and religion, which they found comforting. Women's overall evaluation of their fertility health care was positive. Nonetheless, they desired more culturally competent and interpersonally sensitive fertility care and recommended for fertility staff to be trained in these areas of practice. Women also desired more infertility education (e.g., on the biological causes of infertility). Overall results suggest that these women present high levels of resilience and effective coping strategies (with religious coping being highly prevalent) in the face of infertility and the personal and social adversity it creates. Finally, the DrawingOut method proved suitable to work with this group of women, whose levels of English proficiency ranged from native-and near-native to very limited skills only, and they felt well represented in the booklet produced. Our study replicates previous findings regarding the perception of highly pronatalist attitudes among some minority ethnic communities (Culley and Hudson, 2009;Gürtin-Broadbent, 2009;Simpson et al., 2014). All the women in our study agreed that their communities placed more pressure on young couples to procreate than what they perceived to be the norm in the British majority population. All could recall at least one instance when they had felt ostracised or blamed for their childlessness and/or pressurised to have (more! 23 and/or male) children. Specific themes mentioned were the exacerbation of personal suffering by an adverse social context, intense feelings of isolation, having to cope with stressful interactions around childlessness on a

Study question: What are the views, experiences and healthcare needs of infertile women from a minority ethnic or religious background living in Wales? Summary answer: Women from ethnic and religious minority backgrounds consider that their communities have highly pronatalistic attitudes and stigmatize infertility, and express the need for more infertility education (for themselves and their communities), as well as more socio-culturally and interpersonally sensitive fertility care. What is already known: Some people from minority ethnic or religious groups perceive pressure to conceive from their communities, experience social costs when they are unable to have children, and stressful interactions with the fertility healthcare system while attempting to conceive. Study design, size, duration: This study was based on a one-day drawing workshop to collect visual (artwork produced by participants) and textual (all conversations and discussions during the workshop) data about the participants' views and experiences of infertility and their fertility care needs. Participants/materials, setting and method: Participants were nine adult women with a minority ethnic or religious status living in Wales, UK, who were experiencing or had experienced infertility in the past. The workshop comprised five activities: 1) small and large group discussion of infertility-related drawings, 2) Slide-based lecture consisting of an introduction to the basics of drawing objects and people and 3) thoughts and feelings, 4) free drawing session, and 5) group sharing. Audio recordings of the workshop were transcribed verbatim. Textual data was analysed with thematic analysis. Risk for bias was addressed via individual coding by two authors followed by joint presentation and discussion of results with the research team and participants. Main results and the role of chance: Forty-one themes were identified and grouped into 8 distinct higher order themes. These themes described the emotional, relational and social burden of infertility experienced by women, which they perceived to result from their communities' highly pronatalistic attitudes and stigmatization of infertility. Themes also captured women's adaptive coping strategies and critical attitude towards pronatalist ideologies. Lastly, themes captured their overall positive evaluation of their fertility health care, their desire for more infertility education (for themselves and their communities), and for culturally competent and interpersonally sensitive care. Limitations, reasons for caution: Our participants were a small, non-random sample recruited in collaboration with a local charity, which may mean that all participants were well integrated in their communities. Analysis focused on capturing commonalities in participants' experiences and this may sometimes result in homogenising diverse experiences. Wider implications of the findings: More education about the infertility experiences of minority ethnic and religious groups at the community and healthcare delivery level may translate into lessened negative attitudes towards infertility and more culturally competent care, which can be beneficial for women.

these women present high levels of resilience and effective coping strategies (with religious coping being highly prevalent) in the face of infertility and the personal and social adversity it creates. Finally, the DrawingOut method proved suitable to work with this group of women, whose levels of English proficiency ranged from native-and near-native to very limited skills only, and they felt well represented in the booklet produced. Our study replicates previous findings regarding the perception of highly pronatalist attitudes among some minority ethnic communities (Culley and Hudson, 2009;Gürtin-Broadbent, 2009;Simpson et al., 2014). All the women in our study agreed that their communities placed more pressure on young couples to procreate than what they perceived to be the norm in the British majority population. All could recall at least one instance when they had felt ostracised or blamed for their childlessness and/or pressurised to have (more! 23 and/or male) children. Specific themes mentioned were the exacerbation of personal suffering by an adverse social context, intense feelings of isolation, having to cope with stressful interactions around childlessness on a regular basis, the existing taboo around male infertility and how this results in directing the blame of infertility towards women, as well as the pressure put on men to leave their wives when the couple is not able to conceive. The study results advance current knowledge by showing that the women in this study also showed a critical attitude towards these socio-cultural pressures, emphasizing that it was not acceptable for women to be blamed for infertility and criticizing members of their communities for defining women's lives and value too narrowly in terms of marriage and children. Several women were assertive in expressing a need for further education within their communities, which, they argued, should focus both on gender equality and women's rights in general, and, more specifically, on the causes and treatments of infertility. They were assertive about the need to involve men in such initiatives and to tackle the taboo around male factor infertility, and suggested that a possible productive way to do so could be by engaging with religious leaders. These findings suggest that women do not passively accept their communities' views, but are active agents in negotiating their reproductive desires and co-constructing social meanings of infertility with their families and communities. Previous research has shown that women are more likely to experience infertility distress when they internalise the need to become mothers (McQuillan et al., 2012); therefore these women's conviction that one can be happy with or without children, may be contributing to their apparent resilience. Such conviction has also been found to be conducive to better psychosocial adjustment in people who did not manage to conceive with fertility treatment (Gameiro and Finnigan, 2017).! 24 None of the women in our study felt they had been subjected to discrimination in the NHS system. Indeed, women perceived their fertility care experiences to be more positive than negative and expressed a balanced view between what they know to be the pressures and demands put on the NHS and what they could reasonably expect from the professionals they interact with. However, some of the care experiences reported, for instance a perceived lack of empathy for seeking treatment to have a second child, suggest that institutionalised racism and/or stratified reproduction may condition women's access to optimal care (Ginsburg and Rapp, 1995), as observed in previous studies with minority groups (Blell, 2017;Gürtin-Broadbent, 2009). Consistent with these experiences, women expressed the need to receive more culturally competent care. Research shows that fertility staff struggle with communicating with patients from different socio-cultural backgrounds or beliefs, for instance, when a patient's religious beliefs conflict with the clinic's policies or when one of the partners is unwilling to cooperate with treatment (Boivin et al., 2017). In sum, both our participants and fertility staff agree that there is a need for staff training on these issues (Boivin et al., 2017) in order to ensure optimal care and prevent stressful patient-staff interactions, which are known to be detrimental to both parties. Another care need participants expressed is one all infertile patients report (Dancet et al., 2010): better interpersonal and communication skills from staff. Putting their own agenda forward, women explicitly expressed a desire to know more about infertility and its biological causes. A lack of (in)fertility education has been reported in previous research with minority groups, regarding infertility itself (Culley and Hudson, 2009;Culley et al., 2004;Inhorn, 1996), its treatments, and the way specific aspects of treatment (e.g., gametes storage) are handled by clinics (Simpson et al., 2014). Some research suggests that Muslim communities may be suspicious regarding (in)fertility information! 25 because it enables couples to better decide if, when and how they want to have children and to fully understand how their reproductive system works (Simpson et al., 2014). It should be noted, however, that multiple surveys have shown that (in)fertility knowledge is modest in the general population too (Bunting et al., 2013), which makes it hard to determine whether or not it is a particular problem in ethnic minority groups. The important issue to note is that women desire to be informed and feel such knowledge would empower them to better address their fertility problems. (Harper et al., 2017) (Harper et al., 2017) Another novel finding referred to how women differentiated between their sociocultural context and their religious faith, experiencing aspects of the former as stifling and harmful, and the latter mainly as comforting. For these women, their faith was an essential part of what we know to be effective religion-based coping with infertility, for instance, social support, positive reappraisal coping or (re)engagement with other fulfilling life goals (Roudsari et al., 2007). Nonetheless, it is important to say that multiple studies have shown that religious beliefs do influence reproductive and fertility help-seeking attitudes and behaviour in multiple and complex ways (Greil et al., 2010a). The DrawingOut method was successful in engaging this group of minority ethnic and religious women with varied levels of English proficiency, ranging from native-and near-native to very limited skills only. This is evidenced by the amount and richness of the data collected, although only a comparative study would have allowed us to ascertain whether DrawingOut is able to produce more or richer data compared to other qualitative techniques (e.g., interviews, focus groups). Nonetheless, it is fair to say that DrawingOut was very successful in engaging participants in personal disclosure. Participants were very positive about DrawingOut (to access the full data on participants' evaluation of DrawingOut see Gameiro et al., 2018)), in particular, they found drawing very appealing and enjoyable,! 26 stating that it made it easier for them to talk about such a distressing topic. Another obvious advantage of DrawingOut concerns the opportunity to use participants' drawings to coproduce outputs that are appealing to multiple audiences, such as the booklet produced. In addition, many of the graphic elements and visual metaphors in the booklet explicitly capture the participants' socio-cultural and religious background (e.g., drawing of the Quran and prayer mat to represent the comfort brought by religion), facilitating identification by other women from similar backgrounds facing similar challenges. DrawingOut has since been used to run three additional workshops (one exploring experiences of endometriosis and two exploring fear of infertility). Data suggests DrawingOut has benefits for workshop participants, namely in facilitating the normalization of experiences and empowerment, promoting social support and connectedness in illness, and providing education (Gameiro et al., 2018). Although DrawingOut was developed as a research method, it has been adapted into an online support tool for people affected with socially invisible diseases, where, like in infertility, symptoms are not immediately recognizable to others (see www.drawingout.org). Infertility researchers, clinics, charities and other entities can use DrawingOut to support infertile people, both in a group setting or, if patients struggle to meet (e.g., many women with endometriosis experience too much pain to travel), in an individual (online) setting. They can also use DrawingOut to conduct patient consultation activities or to co-produce tailored information and awareness raising materials. Our study examined the infertility experiences of a heterogeneous sample of women from different minority ethnic or religious background with links to nine nations, reflecting some of the diversity of the UK (Barnard and Turner 2011). While we focused on capturing commonalities in the participants' experiences of infertility, we recognise the danger of homogenising what are clearly diverse experiences (Hudson et al., 2016). Nonetheless, we! 27 are confident that we managed to communicate those messages that our participants wanted to share with their health carers and the general public (as they confirmed in the follow-up feedback session), a precondition for the deliverance of patient-centred care, whose ethos is precisely to ensure that patients' views and preferences are taken into account (Dancet et al., 2010). However, we recognise that our results are unable to adequately represent the full scope of some of the emergent themes (e.g., how religious beliefs shape infertility experiences, how infertility experiences may change as a function of participants' immigration status or generation, or according to the family and community ties they established in the UK) and that these would benefit from more in-depth exploration. Another limitation resulted from our recruitment strategy. Our decision to work with Women Connect First to recruit participants meant that our sample was composed of women who were well integrated and active members of their communities, which may have contributed both to their resilience and to their skilled analysis of the social and systemic issues affecting their infertility experience. This may have resulted in a too optimistic characterisation of general infertility experiences and low criticism of Western/Welsh cultures. Criticism may also have been dampened by the fact that the four researchers are white, secular women. Finally, although the DrawingOut method allows participants without language proficiency to express their views through drawing, they still have to explain their drawings verbally. Although we took this into consideration when determining the prevalence of themes across participants, some views may have been voiced more frequently and eloquently than others. Findings from this study and others highlight the need to increase awareness about the infertility experiences of minority ethnic and religious groups. The booklet Thorns and Flowers (www.cardiff.ac.uk/psychology/about-us/engagement/thorns-and-flowers) is available online and can be used by people experiencing infertility, fertility clinics and other! 28 stakeholders to introduce conversations and discussions on this topic. In addition, fertility staff might benefit from having evidence-based guidelines on culturally competent fertility care and accessing skills training on this topic. At the community level, educational initiatives are needed and may be better accepted if they engage with religious (or other community) leaders. Finally, the integration of fertility education into the academic curriculum, as advocated by many (Harper et al., 2017), would ensure that all young women and men, regardless of their socio-cultural background, are able to access relevant knowledge and information. --- Authors' Role --- Conflict of Interest The authors do not have any competing interests,! 29

Study question: What are the views, experiences and healthcare needs of infertile women from a minority ethnic or religious background living in Wales? Summary answer: Women from ethnic and religious minority backgrounds consider that their communities have highly pronatalistic attitudes and stigmatize infertility, and express the need for more infertility education (for themselves and their communities), as well as more socio-culturally and interpersonally sensitive fertility care. What is already known: Some people from minority ethnic or religious groups perceive pressure to conceive from their communities, experience social costs when they are unable to have children, and stressful interactions with the fertility healthcare system while attempting to conceive. Study design, size, duration: This study was based on a one-day drawing workshop to collect visual (artwork produced by participants) and textual (all conversations and discussions during the workshop) data about the participants' views and experiences of infertility and their fertility care needs. Participants/materials, setting and method: Participants were nine adult women with a minority ethnic or religious status living in Wales, UK, who were experiencing or had experienced infertility in the past. The workshop comprised five activities: 1) small and large group discussion of infertility-related drawings, 2) Slide-based lecture consisting of an introduction to the basics of drawing objects and people and 3) thoughts and feelings, 4) free drawing session, and 5) group sharing. Audio recordings of the workshop were transcribed verbatim. Textual data was analysed with thematic analysis. Risk for bias was addressed via individual coding by two authors followed by joint presentation and discussion of results with the research team and participants. Main results and the role of chance: Forty-one themes were identified and grouped into 8 distinct higher order themes. These themes described the emotional, relational and social burden of infertility experienced by women, which they perceived to result from their communities' highly pronatalistic attitudes and stigmatization of infertility. Themes also captured women's adaptive coping strategies and critical attitude towards pronatalist ideologies. Lastly, themes captured their overall positive evaluation of their fertility health care, their desire for more infertility education (for themselves and their communities), and for culturally competent and interpersonally sensitive care. Limitations, reasons for caution: Our participants were a small, non-random sample recruited in collaboration with a local charity, which may mean that all participants were well integrated in their communities. Analysis focused on capturing commonalities in participants' experiences and this may sometimes result in homogenising diverse experiences. Wider implications of the findings: More education about the infertility experiences of minority ethnic and religious groups at the community and healthcare delivery level may translate into lessened negative attitudes towards infertility and more culturally competent care, which can be beneficial for women.

appropriate care is universally large [3], it is particularly true for children and adolescents growing up in conflict affected low-and middle income countries (LMICs) [4]. Prevalence rates of psychiatric disorders are estimated to be two to three times higher among conflict-affected populations compared to those in the general population [5]. These elevated levels of psychiatric disorders have not only been attributed to the exposure to traumatic events. Post-conflict daily stressors such as increased poverty rates, loss of family members and caregiver mental health have also been associated with increased levels of psychiatric disorders in children [6]. Furthermore, traumatic experiences from one generation may be transmitted to the next [7]. In Sri Lanka, the context of this study, the adverse impact of the civil war on the mental health of children and adults, family structures and community dynamics has been well documented [8,9]. A study reported that nearly one in five children aged 13-18 years had experienced a mental health condition [10]. Another study of adults five years after the conflict showed a steady increase in symptoms of depression and anxiety depending on the level of exposure to past conflict [11]. Despite improvements in available decentralised mental health services in Sri Lanka [12], there is a major mental health treatment gap [13]. The most common barriers to seeking help for mental health problems include: a lack of awareness about symptoms or available services; myths about mental health; widespread social stigma; and negative beliefs about help-seeking [12]. It can be especially challenging among children and adolescents, who often rely on others to access care, to distinguish between symptomatic and normal behaviour [14]. Time and financial resources associated with existing methods to detect mental health problems are major deterrents to the feasibility of implementation in most LMICs [15]. Systematic universal screening, for example, often requires assessing all children in a classroom, community or primary health centre. Furthermore, it may exclude most vulnerable children who are out of school or who do not visit a health centre regularly. A proposed alternative method to overcome these demand side barriers is proactive community-level case detection by trusted and respected community members [15][16][17]. This approach entails the proactive process of identifying, or locating, children in need of mental healthcare from the larger population for the purpose of help-seeking promotion. Instead of screening the entire community, proactive detection relies on informal observations from trusted community members. The Community Informant Detection Tool (CIDT) was developed to support proactive detection of mental health problems [15]. It uses paragraph-long illustrated vignettes of the most common manifestations of mental health conditions, using culturally acceptable and nonstigmatising language. Trusted and respected lay community members are trained to use the tool in their daily routine. This allows them to proactively detect people in need of mental healthcare and to encourage help-seeking. The evaluation of the effectiveness of this approach among adults in Nepal demonstrated 46.9% greater helpseeking for mental health problems in areas randomized to using the CIDT compared to the control arm [18]. Building on these positive findings among adults, a child-focused Community Case Detection Tool (CCDT) was developed and evaluated in schools in Palestine. Using the CCDT, teachers accurately detected children in need of mental healthcare in three out of four cases (positive predictive value [PPV] = 0.77) [19]. Drawing on these promising findings, we applied the same tool and procedures to community settings as part of the current study. While teachers are likely to have more relevant training and more frequent interactions with children, trusted and respected community members are likely to have more informal encounters and closer relationships with families. Since all gatekeepers are selected based on the same criteria of having frequent interactions with children, and for being a trusted and respected member in the community, we hypothesized a comparable PPV in community settings. Furthermore, given the vital impact of family functioning on the mental health of children [9], an additional vignette was developed and evaluated that focused on family-level problems. Our hypothesis was that the CCDT could also be used to proactively detect families in need of mental healthcare. --- Methods --- Setting Sri Lanka is a lower-middle income country in South Asia with a multi-ethnic and multi-religious population of 21.3 million. Thirty nine per cent of the population is under the age of 24 and 80% resides in rural areas [20,21]. The Tsunami in 2004 and three-decades of civil war which ended in 2009, resulted in over 100,000 lives lost and left 300,000 civilians internally displaced [11,21]. This study was carried out in three divisions in the Eastern Province, with a total population of 25,591 children aged 5-19 years [22]. Despite Sri Lanka's overall economic growth, poverty rates in the Eastern and Northern Province, where most of the armed conflict was concentrated, are far above the national average [21]. There is no available data on the prevalence of mental health problems among children and adolescents in the Eastern Province. A 2011 study conducted in the Northern and Eastern Province showed that 92% of the children experienced life-threatening events such as bombings, attacks van den Broek et al. Child Adolesc Psychiatry Ment Health (2021) 15:57 on homes and loss of family members during the conflict [23]. Furthermore, a qualitative study in the Eastern Province reported that adolescents perceived disrupted family relationships, separation and migration of parents, violence at home and sexual abuse as the main factors affecting their mental and physical well-being [24]. --- Design This study assessed the accuracy of the CCDT. The purpose of the CCDT is to support proactive community-level detection of children and adolescents aged 6-18 years and families in need of mental healthcare to encourage help-seeking. This study therefore focused on the accuracy of CCDT probable positive cases (i.e., those detected by community members using the CCDT as probably in need of mental healthcare). A small proportion of CCDT probable negative cases (i.e., those detected by community members using the CCDT as probably not in need of mental healthcare) were included to avoid confirmation bias. In addition, concurrent validity of the CCDT positives was assessed against a widely used alternative instrument to detect mental health problems among children and adolescents. --- Instruments --- Community Case Detection Tool The CCDT is a tool for trusted and respected community members, who do not have any professional mental health background ('community gatekeepers'). It uses an adapted version of the 'prototype-matching approach' which is originally developed to simplify and standardize diagnosis. Following this approach, the tool presents three context-sensitive prototypes (i.e., case vignettes) of 150-200 words each (see Additional file 1). Each vignette presents a coherent pattern of child mental health problems or family-related problems. The vignettes are paired with six illustrations to support recognition in daily life [25]. At the bottom of the tool a simple decision tree algorithm is presented to determine the follow-up action based on the severity and functional impact of the symptoms identified. The tool is meant to be used as reference material onto which trained community gatekeepers can match children and families they encounter in their daily routine. If there is a match with one of the vignettes, and the symptoms are thought to be impacting daily functioning, the gatekeeper is advised to support the child and family to seek help from available services. In this study, we evaluated three Tamil vignettes focusing on internalising problems, externalising problems and family-related problems. A positive match with one of the three vignettes was scored as 'CCDT probable positive'. --- Ten Question Screen for Childhood Disability An abbreviated four-item version of the Ten Questions Screen for Childhood Disability (TQS) was used to assess hearing, speaking, or severe cognitive disabilities prior to participation in the study. As a screener tool, the ten item version previously showed overall acceptable psychometrics in Bangladesh, Jamaica and Pakistan (sensitivity from 0.53 to 0.84, specificity from 0.85 to 0.92) [26]. The research methods were insufficiently adapted and the research team was not equipped to administer the clinical interview to these children. Data from children who scored positive on one of the four items were therefore excluded from the sample, but were offered the same services if needed. --- Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) The Indian Tamil MINI-KID 6.0 was used to evaluate the mental health of children and adolescents the gatekeepers had detected. The MINI-KID is a short structured clinical interview to assess the presence of current DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) and ICD-10 (International Classification of Diseases) disorders in children and adolescents aged 6-17 years. In previous studies, the test retest and interrater reliabilities have been shown to be good (0.64 to 1), sensitivity ranged from 0.61 to 1 and specificity from 0.73 to 1 for the individual disorders [27]. Each diagnostic module starts with a screener followed by more detailed symptom, severity and functionality questions. The MINI-KID has been used with children in Sri Lanka before [28]. Relevant modules were selected by a child psychologist (MJ), supervising psychiatrist from Sri Lanka (PJRJ) and Indian child and adolescent psychiatrist and master trainer (JVSK). The selected modules were depression, suicidality, dysthymia, panic disorder, separation anxiety disorder, obsessive compulsive disorder, post-traumatic stress disorder, alcohol and substance dependence, attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, generalized anxiety disorder and adjustment disorder. The module on suicide was only administered for children aged 10 years and older and the modules on alcohol and substance dependence only for children aged 13 years and older. These modules were deemed culturally inappropriate for younger children based on feedback from the senior counsellors during the training. Standard relevant scoring and instructions were used for functional impairment caused by the symptoms and the time frame (i.e., current, past 6 or 12 months). van --- Family functioning We used an adapted version of the Safe Environment for Every Kid-Parent Questionnaire-R (SEEK PQ-R) to assess family problems and child protection needs [29]. Relevant items of the SEEK PQ-R were selected based on the construct captured in the family vignette. The questionnaire was further adapted and translated through a systematic process in which the items were first translated into Tamil. The research team provided feedback to ensure separate items and translations were culturally appropriate, followed by a blind back-translation. The final questionnaire consisted of 14 items that addressed harsh punishment, child neglect, parental stress, intimate partner violence and substance abuse. --- Indication for treatment At the end of the interview, the senior counsellor administering the MINI-KID and SEEK PQ-R answered a concluding dichotomous question regarding the need for any psychological treatment from a mental health counsellor or psychiatrist or child protection service. The indication for treatment was scored (i.e., yes/no) based on the counsellors' judgement following the information provided in the structured clinical interview and the family assessment. --- The Strengths and Difficulties Questionnaire The Sri Lankan Tamil parent version of the Strengths and Difficulties Questionnaire (SDQ) was used to assess the concurrent validity of the CCDT positives. This widely used 25-item behavioural screening questionnaire for 3-16 year old children, covers emotional symptoms, conduct problems, hyperactivity/inattention, peer relationships problems and prosocial behaviour. In previous studies, the parent version has shown interrater reliabilities between 0.37 and 0.62 for the different subscales. The Tamil self-report version showed acceptable internal consistency of the subscales (Cronbach's alphas between 0.67 and 0.78), sensitivity of 0.69 and specificity of 0.92 [30,31]. A three point Likert scale allows the respondent to indicate how each item applies to the participating child [30]. All items, except those related to prosocial behaviour, generate a total difficulty score classified as SDQ 'normal' (i.e., a score between 0 and 13) or SDQ 'borderline' and 'abnormal' (i.e., a score between 14 and 40). --- Training and supervision This study was carried out through an existing partnership between War Child Holland (WCH), an international non-governmental organisation (NGO) and the Eastern Self-reliant Community Awakening Organisation (ESCO), a local NGO. Community gatekeepers with regular interaction with children and families participated in a two-day training by the research coordinator (RC; PP). The training covered a basic introduction to child and adolescent mental health, the use of the CCDT and ethical considerations related to proactive case detection such as confidentiality, stigma and child safeguarding. A master trainer and child and adolescent psychiatrist (JVSK) with extensive experience in conducting the MINI-KID trained a supervising psychiatrist (PJRJ) and back-up psychiatrist for three days. The supervising psychiatrist subsequently trained five senior community counsellors (four female, and one male) for five days to administer the MINI-KID and the SEEK PQ-R. Supervision meetings were held with the counsellors for quality control and to support with referrals. Ten research assistants (RA) were trained for six days in research basics, ethics, informed consent and assent procedures, the SDQ, and data management. All research team members were trained in an adverse events reporting mechanism and the supervising psychiatrist followed up on children and families in need of immediate assistance. --- Participants and procedures Community gatekeepers in this study were all female and older than 18 years. They included youth club leaders (n = 11), women society group members (n = 22) and community health volunteers (n = 12). Youth club leaders organise recreational and awareness-raising activities in their village. Women society group members mobilise women to improve their social and economic conditions. Health volunteers assist midwives and medical health officers to organise monthly health clinics and conduct home visits. They used the CCDT for six months during their daily routine activities and detected a total of 238 children aged 6-18 years. After obtaining informed consent and assent, a study ID was created, the TQS was administered and an appointment with the counsellor was arranged by the RA. Within two weeks of identification, the counsellor met with the family at their home or another convenient location to conduct the clinical interview and the family assessment. Children aged 13-18 years were interviewed individually and younger children in the presence of their caregiver. The RA followed up within two days after the counsellors' visit to administer the SDQ with the same caregiver. Direct contact between the counsellors and gatekeepers was limited to reduce potential confirmation bias. In addition, gatekeepers were asked to identify a small proportion CCDT probable negatives throughout the study period. Counsellors were informed that both positive and negative cases would be referred to them, but not how many or who they were. The CCDT probable negatives were invited to participate in the study following similar procedures, but were only included to minimize confirmation bias. For the purpose of this study, a referral tracking sheet was developed for community gatekeepers. They were asked to note down the vignette that was used for the identification and their knowledge about the need of mental healthcare for the detected case prior to using the CCDT. Children and families that were known to the gatekeeper as needing mental healthcare prior to the introduction of the CCDT were excluded from the analyses. --- Ethics Ethical approval was obtained through the Ethics Review Committee of the Faculty of Health-Care Sciences at the Eastern University in Batticaloa. Divisional and district level approval was obtained before the start of this study. Prior to official informed consent and assent procedures, the gatekeepers asked the caregiver whether they were interested in participating in a research study. The referral tracking sheet was only completed for those families that were willing to participate. All children and families were informed about available and free of charge support, regardless of their participation in the study. Helpseeking was only encouraged, never imposed. --- Analysis The results of the CCDT, MINI-KID, SEEK PQ-R and SDQ were analysed using the Statistical Package for Social Sciences (SPSS version 19.0). The interrater reliability (IRR) of the MINI-KID among the five counsellors was assessed using Krippendorff's alpha for dichotomous variables [32]. The IRR was calculated for a selection of the screener, diagnostic, indication for treatment items, and total of these items. The accuracy of the CCDT was assessed through the Positive Predictive Value (PPV), which is calculated as the percent of children and families detected using the CCDT (i.e., probable positives) who are in need of mental healthcare based on the clinical interview. The primary reference criterion was the indication for treatment. The secondary reference criterion was a diagnosis of a psychiatric disorder. The primary outcome of this study was the PPV for all CCDT positives, regardless of the vignette used, assessed against the indication for treatment. The secondary outcome was the PPV for the subsample of CCDT internalising or externalising positives against diagnostic criteria. CCDT positives detected using the family vignette or cases detected with multiple vignettes were excluded from this subsample because diagnosis of a mental disorder is not applicable to these cases. Exploratory analyses were done to assess the differences in PPV for each individual vignette (i.e., internalising, externalising and family vignette), for each gatekeeper group separately (i.e., youth club leaders, women society group members and community health volunteers), for different age groups and gender against the indication for treatment. CCDT internalising positive cases were also compared against selected MINI-KID modules representing anxiety, depressive and somatic symptoms and the CCDT externalising positive cases with modules related to impulsive, disruptive conduct, and substance use symptoms. For the small proportion of CCDT probable negatives, we also assessed the Negative Predictive Value (NPV). This was calculated as the proportion of CCDT probable negative cases that were not in need of mental healthcare, against both reference criteria. Since our study focused on CCDT positives, we could not establish the concurrent validity with a correlation coefficient. It was therefore assessed as the proportion of agreement between the CCDT positives and the SDQ positives, i.e., borderline and abnormal scores. As with other studies in Sri Lanka, we used the internationally applicable original three-band cut-off scores for the SDQ [31]. Additionally, the PPVs of the CCDT were compared to the PPV of the SDQ against the indication for treatment criterion. --- Results A total of 207 CCDT positive children were detected, of whom 27 were excluded because of not providing consent, meeting exclusion criteria based on the TQS or were lost to follow up. Another 23 were excluded from the analysis because the gatekeeper knew about the need for mental healthcare prior to the introduction of the CCDT, which may have influenced the detection (see Fig. 1). Our final sample therefore consisted of N = 157 CCDT positives. In addition, 31 CCDT negative cases were detected to avoid confirmation bias by the counsellors, of which two were excluded because of consent. The average age of our sample was 12.3 years (SD = 3.3), with an equal distribution of girls and boys. The specification and frequency of vignettes used and gender distribution are presented in Table 1. The IRR using Krippendorff's alpha was <unk> = 0.88 (95% CI; 0.82-0.92) for the total of the selected screener, diagnostic, and indication for treatment items (32 items). For the 12 screener items <unk> = 0.75 (95% CI; 0.62-0.86), for the 13 diagnostic box items, <unk> = 0.94 (95% CI; 0.88-0.98), and for the seven treatment items <unk> = 1. Of the 157 CCDT probable positives, 109 were indicated for mental health treatment (PPV = 0.694). Analysis against the secondary criterion of psychiatric diagnosis showed that 42 of the 92 CCDT internalising van den Broek et al. Child Adolesc Psychiatry Ment Health (2021) 15:57 or externalising positive cases were diagnosed with a psychiatric disorder (PPV = 0.457). Exploratory analyses with separate subsamples against the primary criterion showed that detections based on the family vignette returned the least false positives (PPV = 0.755), followed by the internalising problem vignette (PPV = 0.707) and the externalising problem vignette (PPV = 0.618). Further assessment of the PPV against specific diagnostic criteria showed that 21 of the 58 CCDT internalising positives met the diagnostic criteria of any of the relevant modules related to internalizing disorders (PPV = 0.362) and 7 of the 34 CCDT externalising positives (PPV = 0.206) met the diagnostic criteria of any of the externalizing disorder modules. The measures of concurrent validity showed that 46.7% of the 92 CCDT internalising or externalising positives returned 'borderline' or 'abnormal' SDQ total difficulty scores. When compared against the same reference standard, there is little difference between the PPVs of the SDQ and the CCDT: of the 67 SDQ 'borderline' or 'abnormal' cases, 50 were indicated for mental health treatment (PPV = 0.746 vs. PPV = 0.674 with the CCDT). Exploratory PPV analyses for each gatekeeper group and vignette separately and by gender are summarized in Table 2. Of the 29 CCDT negative cases, 21 did not require mental healthcare (NPV = 0.724) and 24 did not meet any diagnostic criteria (NPV = 0.828). --- Discussion Efforts to bridge the treatment gap between children and adolescents in need of mental healthcare need to focus on supply (i.e., availability of services) and demand side factors (i.e., detection and uptake). In this study, we assessed the accuracy of a new method to overcome some of the demand side barriers by supporting community-level proactive detection of children, adolescents and families in need of mental healthcare in Sri Lanka. --- Purpose and performance of the CCDT The CCDT is developed to proactively detect children and families in need of mental healthcare to encourage help-seeking. This may include children experiencing a mental disorder, as well as children not meeting formal diagnostic criteria but in need of mental healthcare. This study demonstrated that just over two-thirds of all children and families detected using the CCDT were correctly detected as in need of mental health treatment based on a clinical interview. This is line with the results of proactive case detection among adults in Nepal and children in Palestine and can be regarded as a moderate to high PPV since the CCDT was used among the general population [15,19]. The CCDT vignettes focusing on children and adolescents represent generic distress domains (i.e., internalising and externalising problems) as potential indicators of mental health needs. The diagnostic criteria, which are more categorical in nature and do not include children in need of mental healthcare with subclinical levels of symptoms, were therefore used as secondary criteria. As anticipated, the predictive value of the CCDT to detect a diagnosis was lower compared to the indication for treatment. This confirms that the use of the CCDT should be limited to the detection of mental healthcare needs and not for diagnostic purposes. The performance of the CCDT is comparable to the SDQ with regards to detecting need for mental healthcare, which indicates that the CCDT could be used as a low-cost alternative to the SDQ. Even though the CCDT is not meant to detect negative cases and the sample of CCDT negatives was too small to draw conclusions, the NPV of 0.72 shows that the CCDT resulted in a relatively small percentage of false negatives. Interpretation of these results should take the potential burden of a false positive CCDT detection in each context into account as it could cause distress among children and caregivers and may pose unnecessary pressure on a service system. Although similar burden is expected with alternative methods, proactive case detection using the CCDT is only recommended and applicable in places where services of sufficient quality are available and accessible. Furthermore, to reduce the potential burden on children and caregivers detected, it is recommended to integrate the CCDT into an existing system (e.g., training teachers in schools or community health workers engaged in home visits), and to connect caregivers with free of charge services at a convenient location. --- Constructs and performance of the CCDT The best performing vignette, in terms of accuracy and the most cases detected, was the family vignette. The close bonds and cohesiveness in Tamil nuclear and extended families [9] may have facilitated the accurate detection of family-related problems compared to symptoms of internalising or externalising problems among children. This finding is particularly relevant given the strong emphasis on the family unit as a central pillar of life in Sri Lanka, the impact of family functioning on mental health outcomes of individuals in the family [9,33,34] and the rise in reported family-related issues in Sri Lanka in the past years [35]. These findings suggest that the CCDT could play an important role in proactively identifying a broad range of family-related problems at the community level. It also highlights the need for validated more in-depth family functioning assessment tools to be used after detection and designated interventions which target the family system. The majority of instruments that are currently available were developed in high income countries. Additionally, most instruments only focus on one specific element of family functioning, like parenting or communication [33]. Using the CCDT to detect family-related problems may introduce specific sensitivities compared to the detection of child mental healthcare needs. The safety of gatekeepers and the potential risks for individual family members should therefore be prioritized in any future implementation and training. The accuracy of cases detected with the internalising vignette was slightly better compared to the externalising cases. This could be explained by cultural norms with regards to social behaviour and self-presentation. While public behaviours of self-control, obedience, and emotional restraint are important traits in Sri Lanka, behaviours that are more in line with the construct covered by the externalizing vignette such as overt extensive expression of emotions and children directly confronting an older person, are more often discouraged [36]. The differences between detecting internalising and externalising problems seem to be in conflict with dominant conceptualisations in other contexts (e.g., from Europe or North America). Here, externalising problems are often perceived as being easier to observe by an outsider and are therefore more likely to be detected and receive treatment compared to internalising problems [37]. This externalising problem vignette performed slightly better than version evaluated in Nepal [15]. --- Gatekeepers and performance of the CCDT The proactive approach relies on informal observations from individuals with strong community engagement. The type of community gatekeepers that are best placed to use the CCDT is therefore dependent on each context. The role of the gatekeepers in their community is an important general selection criteria. They should be trusted and respected individuals with easy access to families and children. In our previous study in Palestine teachers and staff working at community centres were recommended. In Sri Lanka youth club leaders, community health volunteers and active women group members were recommended by community members as users of the CCDT. Only female gatekeepers were selected as they were considered to be best placed to engage with children, adolescents and families in an effective way, conforming social norms in their community. Although this was seen as most appropriate, this meant we did not select male gatekeepers. We are therefore not able to evaluate gender differences in the results. This is something that should be explored in future research. In this study, most cases were detected by community health volunteers. They were also best placed to engage with families in a comfortable way because of their regular home visits. Similar to the findings in Nepal, active women group members slightly outperformed community health volunteers [15]. A likely explanation for this is their more informal contacts within their daily routine and familiarity with families in their village. In our previous study in Palestine, in which teachers used the CCDT, the results were slightly better (PPV = 0.769) [19]. This may be because of teachers' relevant educational background and training, and shows the importance of the selection of suitable gatekeepers in each new context. --- Limitations Due to the proactive use of the CCDT to detect children and families in need of mental healthcare, the main sample included CCDT positives only. The ratio of CCDT positives and negatives (N = 157 vs. n = 29) was therefore not an accurate representation of reality. The relevant and possible accuracy metrics were therefore also limited to PPV and only a limited version of the concurrent validity could be assessed. In addition, analyses were done without prevalence rates and caution should be taken when generalising the results to other settings. We opted for using instruments that were already available in Tamil and previously used in Sri Lanka. This introduced a couple of limitations that may have influenced the results obtained. We used an older version of the MINI-KID that was based on the DSM-IV classifications instead of the newest DSM-V. Furthermore, our sample included adolescents somewhat older than the intended age group for the SDQ (i.e., 2-17 years). Although the Tamil MINI-KID and SDQ parent version have been used in previous studies in Sri Lanka, both instruments have not been validated in Sri Lanka [28,31]. In addition, due to a lack of available instruments that assess the global family functioning in Sri Lanka we used an instrument that had never been used in Sri Lanka. The PPV of cases detected by the family vignette was only assessed against the indication of treatment criterion. Using locally validated instruments and adjusted cut-off scores would most likely have influenced the results. Gatekeepers first asked permission to introduce a research team member and the referral tracking sheet was only completed with their permission. This selfselection might be based on caregivers' accurate estimation that there was no need for any mental healthcare and therefore may have inflated the results. In real-world application of the tool this potential accurate self-selection will limit the unnecessary burden on the services as help-seeking will only be encouraged. Caregivers or adolescents themselves will make the ultimate decision to seek help or not. --- Conclusions This study demonstrates that community members using the CCDT, can accurately detect two out of three children and families in need of mental healthcare. The performance of the CCDT was comparable with the SDQ. This provides further evidence of the potential of the CCDT as an alternative scalable method to universal screening to promote help-seeking for mental health problems. Furthermore, the approach and tool could optimize the van • 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: --- van den Broek et al. Child Adolesc Psychiatry Ment Health (2021) 15 :57 use of limited number of specialized mental health professionals by improving the match between those seeking services and the availability of care. Overcoming under-detection is only the first step in the process of seeking help. Additional strategies are needed to tackle intersecting demand side barriers to effectively encourage help-seeking behaviour. Future research will therefore focus on the development and evaluation of an additional component of the CCDT: a help-seeking encouragement strategy. --- Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s13034-021-00405-2. Additional file 1. The Community Case Detection Tool -English Version developed for Sri Lanka. --- Authors' contributions The authors confirm contribution to the paper as follows: study conception and design: MvdB, MJ, BAK; data collection: PP, PJRJ, JVSK; analysis and interpretation of results: GG, MJ, BAK, MvdB, PP, JVSK; draft manuscript preparation: MvdB, MJ, GG, PP, JVSK, PJRJ, BAK. All authors read and approved the final manuscript. --- Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on request. --- Declarations Ethics approval and consent to participate Ethical approval for this study was obtained through the Ethics Review Committee of the Faculty of Health-Care Sciences at the Eastern University in Batticaloa. --- 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: Most children and adolescents in need of mental healthcare remain untreated even when services are available. This study evaluates the accuracy of a new tool, the Community Case Detection Tool (CCDT). The CCDT uses illustrated vignettes, two questions and a simple decision algorithm to support proactive community-level detection of children, adolescents and families in need of mental healthcare to improve help-seeking. Methods: Trusted and respected community members in the Eastern Province of Sri Lanka used the CCDT in their daily routine. Children and families detected as potentially in need of mental healthcare based on utilizing the CCDT (N = 157, aged 6-18 years) were invited for a clinical interview by a mental health counsellor using the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The CCDT results were compared against the results of the clinical interview. The concurrent validity and performance of the CCDT were also evaluated by comparing the CCDT outcomes against the Strengths and Difficulties Questionnaire (SDQ). Results: 7 out of 10 children and families detected by community members using the CCDT were confirmed to be in need for treatment (positive predictive value [PPV] = 0.69; 0.75 when compared to the SDQ). Detections based on the family problem vignette were most accurate (PPV = 0.76), followed by the internalising problem vignette (PPV = 0.71) and the externalising problem vignette (PPV = 0.62).The CCDT is a promising low-cost solution to overcome under-detection of children and families in need of mental healthcare. Future research should focus on evaluating the effectiveness, as well as additional strategies to improve help-seeking.

Introduction As defined by the Oxford English Dictionary, a selfie is a self-portrait photograph of one's own self (which may or may not be taken with others) captured using a camera or a camera phone. Although the selfie phenomenon was evident in an era where Polaroid cameras and, more recently, digital cameras were in vogue, in more recent times selfies have become ubiquitous as a consequence of the phenomenal uptake of the smartphone and, more generally, the widespread adoption and use of social media (Kedzior et al., 2015;Mascheroni et al., 2015). Self-presentation or a "selfie" is part of a social ritual of "impression management" which involves learning to deal with others' responses and maintaining emotional control by putting on a face (Mascheroni et al., 2015). As such, the supposition that the "selfie" is not just a social media-based fad, but rather has multifarious expressions due to situational and contextual interpretations, is evidenced in prominent news stories. For example, a British Labour Party leader was suspended for posing for a "selfie" photograph at the scene of the Tunisian beach slaughter (Awford, 2015). Another example is the Lebanese Miss Universe's "selfie" pose with her Israeli counterpart, which created controversy and criticism (https://storify.com/cmgnationalnews/miss-universe-selfie-sparks-uproar). Selfies have increasingly become a significant facet of social life. They permeate many aspects of contemporary lives and cause marketing managers to reappraise and recalibrate marketing activities (Ma et al., 2017;Lim, 2016). Recent research on selfies has examined the influence of demography (Dhir et al., 2016;Williams and Marquez, 2015), creation and maintenance of meaningful relationships between individuals and communities (Tiidenberg, 2015), individuals' personality and psychology (Qiu et al., 2015) apropos consumers' intentions along with the selfies' role in self-presentation. While selfies are often regarded as a reflection of an individual's desire for attention, validation and recognition (Chua and Chang, 2016) on social media, the selfie phenomenon, nonetheless, should also be understood in wider socio-cultural contexts (Cruz and Thornham, 2015;Nemer and Freeman, 2015). Marketing strategists have not been slow in realising the potential of selfies and have utilised the phenomenon as part of a product placement strategy for large multinationals such as Samsung (Vranica, 2014). Marketing managers have exploited selfies as a prominent dimension of a branding strategy for so-called "micro-celebrities" (Kozinets and Cereno, 2014). The popularity of the selfie phenomenon and its myriad interpretations and uses reinforces the notion that human beings are not malleable to a technological application (Williams and Edge, 1996;MacKay and Gillespie, 1992), as they can choose to reject and redefine technologies during their use (Dey et al., 2013). As such, technology design, use, interpretation and impact can be deemed to be socially constructed (Avgerou, 2013;Walsham, 2010) and technology use goes through recursive and iterative interaction between a technology and its users within a given social context (Orlikowski, 1992;Jones et al., 2004). Furthermore, the iterative interaction between users' situated capabilities and technological application leads to the appropriation of technology, which also denotes how technology becomes integrated into users' day-to-day lives (Ylipulli et al., 2014;Dey et al., 2011;Carroll et al., 2003;DeSanctis and Poole, 1994). The current literature provides empirical and theoretical scaffolding for the appropriation of mobile telephones (Carroll et al., 2003;Bar et al., 2007). The Adaptive Structuration Theory (AST: DeSanctis and Poole, 1994), developed following Giddens' structuration theory, for instance, is a widely cited framework for assessing the appropriation process and helps to investigate the influence of organisational systems and structures on individuals' technology use. However, the inter-relation between individuals and social and cultural institutions and their impact on the appropriation of technology have not been detailed within the current AST and other appropriation literature. Aricat (2015) explains how migrant workers' acculturation strategies and their socio-occupational challenges within a host society are reflected in their perceptions and use of mobile telephones, indicating technology appropriation's potential link with acculturation and cultural appropriation. However, Aricat's work is largely context specific and provides limited scope for generalisation. Furthermore, for all its utility, it makes little contribution with regard to migrant communities' cultural identity. --- 483 --- Selfie appropriation Cultural dispositions and expressions are also appropriated by individuals, as they creatively find and make opportunities for presenting themselves in a multicultural environment through adoption and adaption (Weinberger, 2015). Recent scholarship on acculturation has stressed the importance of social media led interactions within and across communities (Forbush and Faucault-Welles, 2016;Jafari and Goulding, 2013). However, the aforementioned studies consider social media as a platform and do not capture the reciprocal relationship between social media led self-presentation and individuals' actual selves. The missing link between cultural appropriation and technological appropriation does not allow a thorough comprehension of the dynamic inter-relationship between the offline and the online world. Further investigation into people's online self-expression, such as the selfie phenomenon's role in expressing cultural identity in social media, will not only contribute to technology appropriation literature, but will also advance identity and acculturation scholarship. Our study addresses the above research gap by analysing the appropriation of selfies by young British South Asian adults. This research aims to analyse the selfie phenomenon and its appropriation by examining how individuals' roles and identities within a given cultural environment is reified through the use of technology. In so doing, it examines how and why ethnic minorities' dual cultural identities are expressed through the adoption and adaptation of cultural dispositions in a multicultural society and analyses how the inter-relationship between individuals and their society impacts on the appropriation process. Hence, this study explores an under-explored area: the inter-relationship between cultural appropriation and technology appropriation. --- Literature review This study aspires to advance our understanding of the selfie as a technological application vis-à-vis how its appropriation exhibits the cultural identity of young British South Asian adults. The research is distinctive by virtue of its utilisation of two major streams of scholarship: cultural identity and acculturation and technology appropriation. Accordingly, the review of the literature takes cognisance of the aforementioned canons. --- Cultural identity and acculturation Cultural identity is defined as the feeling of belonging to a group defined by certain bonds/linkage such as nationality, ethnicity, religion, generation, etc. (Ennaji, 2005). As consumers are exposed to the interaction between various co-existing cultural attributes, they are likely to exhibit complex and multifarious identities (Cleveland and Laroche, 2007). Socio-historic and political background and their influence on the extent of religiosity and consequent liberalism among various religious groups in Lebanon (Cleveland et al., 2013), the conflict between global and local cultural dispositions faced by Danish youth (Kjeldgaard and Askegaard, 2006) and the influence of normative political ideologies on African American's shopping behaviour (Crockett and Wallendorf, 2004), for instance, explain how modern consumers are entangled within complex cultural dynamics. In a multicultural environment such as the UK, the identity of ethnic consumers is often examined through their level of acculturation. The seminal work of Berry (1980) explains four major acculturation strategies: assimilation, integration, separation and marginalisation, which define the bipolar continuum of acculturation. His subsequent works (Berry, 1997(Berry,, 2009) ) adhere to the initial model and a more positivist approach to analysing acculturation strategies. However, in multicultural contexts, wholesale acceptance and/or rejection of the host or ancestral culture is overly simplistic, as complex co-existence of ancestral and host cultures' attributes among migrants can be found (Oswald, 1999;Jamal and Chapman, 2000;Weinreich, 2009), calling into question the validity of the bipolar acculturation continuum. In consumer studies, Pe<unk>aloza (1994) suggests four outcomes of the acculturation process in the form of assimilation, resistance, maintenance and segregation. According to Schwartz et al. (2010), young Latin American migrants in the USA can at the same time be fluent in both Spanish and English and can demonstrate both individualistic and collective values in different contexts. Their practice, values and identifications can simultaneously manifest Latin, US and/or global consumer culture. Hence, ethnic communities are more likely to have dual or multiple cultural identities. Askegaard et al. (2005) emphasise the bicultural identities of ethnic minorities by identifying a new acculturation outcome, termed "pendulism", which refers to the oscillation between acculturation and maintenance. Weinberger (2015) has identified "appropriation strategy" for ethno-religious minorities' (e.g. Jews and Muslims) approaches to celebrating Christmas in the USA. She has defined appropriation strategy as ethnic consumers' deliberate effort to engage with the mainstream without losing their ancestral identity. This classification is not complete, as it does not explain the various reasons and motivations behind such duality. However, it provides a strong indication that individuals as independent agents try to negotiate the differences between their host and ancestral cultures and consciously or sub-consciously make adjustments. Hence, their cultural disposition is a dialectic outcome of the interaction and friction between the cultural differences. While the above mentioned dualism and dialectic interrelationships have scopes for further analysis, it would be also interesting to analyse the link between cultural appropriation and technology appropriation. Information systems and consumer research scholarship can be enriched with empirical evidence and conceptual understanding of how individuals' dual cultural identity is manifested and reified through the use and appropriation of technology. As such, this paper analyses how the appropriation of selfie as a technological application reflects and reifies cultural dualism. The following section looks into the current scholarship on technology appropriation with a view to developing stronger theoretical scaffolding and exploring scopes for future advancement. --- Technology appropriation Technology appropriation is defined as how technology is adopted, adapted and incorporated in daily lives, which involves making use of technology for purposes beyond the original intention of the designers (Dourish, 2003;Salovaara and Tamminen, 2009). The idea that appropriation involves non-linear interactions between users' situated capabilities and technological applications is built on the structuration theory. Giddens'(1979, 1984) sociological theory of structuration suggests that social interaction produces and reproduces social structures via the action of social agents. Human agency and structure are inextricably linked with each other. The concept has been widely used in information systems literature to examine the use of technology in organisational contexts. AST (DeSanctis and Poole, 1994) applies structuration theory in a techno-centric manner. The AST literature (Gopal et al., 1992;Chin et al., 1997), mostly driven by positivist philosophy, considers technology as a deterministic tool and assumes that faithful appropriation (use of technology in designers' intended way) has a more positive impact on the performance/outcome. However, AST is criticised for being too rigid to explain user-end adaptation and the reciprocity of influence between collective and individual capabilities, norms and practices (Isika et al., 2015;Majchrzak et al., 2000). Hence, the dual and reciprocal interaction between technology and users' situated capabilities are not fully captured by the AST model. Peer influence shapes and reshapes individuals' capabilities for selfie use and subsequent interaction on social media (Chua and Chang, 2016), and hence the AST model falls short of explaining the appropriation of selfies. Orlikowski's (1992) duality of technology explains the reciprocal influence between technology, society and human capabilities. Orlikowski also identifies technologies' interpretive 485 Selfie appropriation flexibility, which denotes the physical and social construction of a technology during its development and use. In her subsequent work, she argues that technology does not have a stable structure and is subject to perpetual changes (Orlikowski, 2000), calling into question Giddens' (1979) and AST's assumption that technology should be equated with persistent and stable rules and resources. Similar analysis can be noticed in other IS literature that is theoretically motivated by Giddens' works. Lindgren et al. (2004), for example, argue that an organisation's structure of core competence (e.g. human resources, learning, routine), individualisitic agency (e.g. individuals' competence) and the competence management system have mutual reciprocal influence, which eventually influences the design of future technological intervention. More recent academic works have expanded on Orlikowski's (1992Orlikowski's (, 2000) ) arguments and presented conceptual frameworks for technology appropriation (Dey et al., 2011;Carroll et al., 2003). The dynamic nature of the adoption, use, adaptation and rejection of and resistance to technology has been captured in those frameworks. However, those models do not explain the influence of individuals' interaction with socio-cultural and/or occupational structures and how this interaction influences appropriation and/or is reflected through the appropriation process. Carroll et al. (2003), for instance, consider social management as a criterion for appropriation, while Dey et al. (2011) do not reflect on how social practices give rise to the appropriation of technology. Ylipulli et al. (2014) advance Carroll et al.'s model for technology appropriation in urban settings. However, their empirical work mostly emphasises on the physical environment and its influence on communal use of technology, rather than beliefs, values and emic aspects of cultural dispositions. The concept of disappropriation discussed by Dey et al. (2011) and Carroll et al. (2003) also needs to be revisited. Technology use is neither a monolithic nor a mono-dimensional phenomenon. It involves both appropriation and disappropriation. This issue has also been highlighted in consumer studies: Mick and Fouriner (1998) coined the term "paradoxes of technology", which essentially denotes the notion that people's perceptions and use of technology may not have linear outcomes, as people may have ambivalences regarding the use of technology. Domestication theory (Silverstone et al., 1992) has also been used to explain appropriation at a more household and familial level. For instance, when a certain piece of technology is introduced into a household, technology appropriation extends the physical boundaries of the household into the outside world (Lim, 2016;Yoon, 2016). Consequently, the individuals within the household take possession of this technology, give meanings to that technology, thus symbolising the values of the owners and users (Lim, 2016). For example, the need for constant and mediated communication between family members may lead to extensive appropriation of ICTs such as smartphones and their apps (Yoon, 2016). As technology spans different communities, cultures and societies, they may not have a stable and fixed form of use, interpretation and value system, indicating that socio-cultural appropriation is central to the adoption of the diffusion process (Lindtner et al., 2012). However, the current literature lacks theoretical scaffolding in conceptualising technology appropriation as an outcome of individuals' interaction with their socio-cultural surroundings. British South Asian young adults' expression of cultural identity through selfies can offer empirical findings to address the research gap and conceptual deficiency. The following table summarises some of the key scholarly works on appropriation, their theoretical foundations and their scope for further advancement (Table I). From the literature review, it can be understood that both acculturation and cultural identity and appropriation scholarship have further scope for advancement. The extant acculturation literature does not fully explicate the reasons for and the nature of biculturalism and dual cultural identity. While appropriation of culture partly explains the dynamics, further research on this area would be beneficial. The appropriation literature does not fully explain how individual agents interact with socio-cultural institutions and how that interaction is reflected in the appropriation processes and outcomes. Hence, establishing links between the appropriation of culture and of technology could be a key to developing a more holistic understanding of individuals' interaction within a given socio-cultural context, their cultural identity and their appropriation of technology. --- 487 --- Selfie appropriation --- Methodology The research strategy was designed with a view to gain a thorough understanding of young British South Asian adults' appropriation of the selfie on social media and how that reflects their cultural identity. Recourse was made to an interpretivist methodology, which affords the opportunity to identify and analyse "why" and "how" young British South Asian adults define themselves via their use and appropriation of the selfie phenomenon. Hence, the study relies on qualitative data. For this investigation, the primary modes of qualitative data collection included in-depth interviews and netnographic observations. The research was conducted from April 2014 to May 2016. In-depth interviews were done first ( for ten months), followed by netnography. The precepts of triangulation were applied as a means to ensure robustness with regard to opinions and perceptions of selfie usage among the target group and, more generally, their engagement with social media in the context of their socio-cultural backgrounds. --- In-depth interviews In all, 33 respondents were selected using maximum variation purposive sampling (Bryman, 2012;Denzin and Lincoln, 2000) so that various linguistic (e.g. Punjabi, Bengali, Gujarati), religious (Muslim, Hindu, Sikh) and demographic groups (in terms of gender, occupation and income) were covered. Both first-generation migrants and British-born South Asians were included in the sample, as education, upbringing and lifestyle are likely to be different for the two groups ( Jaspal, 2015). Furthermore, acculturation literature suggests that second generation migrants are more likely to demonstrate cultural duality than the first-generation migrants (Schwartz et al. 2010). As such, a good mix of first and second generation migrants can offer different approaches and perspectives to cultural dualism. In the main, this population is more likely to be found within Great Britain's metropolitan areas, particularly English cities. The large South Asian population and their cultural heritage in some of these cities (e.g. London, Leeds and Manchester) have received research attention (Eade, 2014;Kalra, 2014). For instance, the Bangla Town in East London and Rushhome in Manchester not only exhibit the richness of British curry industry, but also demonstrate the development of ethnic habitat, businesses and socio-religious institutions that are often argued to have influence over ethic communities' cultural identities (Pe<unk>aloza, 1994). Furthermore, the large cities have bigger ethnic population than smaller ones and/or semi-urban areas (Demangeot et al. 2015). Hence, the South Asian population of the big cities were selected for this research. Our sampling selection takes the following information into consideration (Table II). Mindful of the above, 33 respondents were selected from the six major metropolitan areas of Great Britain that have large South Asian populations (London and surroundings: 16 respondents; Leeds and Yorkshire: six respondents; Birmingham and the greater Midlands: four respondents; Manchester and the North West: two respondents; Newcastle and the North East: three respondents. Additionally, we also included two respondents from Glasgow. Interview respondents were identified by making initial contact with targeted places of worship (churches, mosques, and temples), community organisations and universities. A list of respondents along with their demographic and ethnic profiles is provided in Table AI. The first author (who is fluent in spoken English, Bengali, Hindi and Urdu) conducted the in-depth interviews. Interviews took places in different locations based on the convenience of the respondents. While most of the interviews were conducted in the respondents' houses, there were also occasions when interviews took place in places of worship and university campuses. --- Netnography Netnography is a pragmatic interactionist research approach which views the online environment as a social world. As such, online data is viewed as a social act demonstrated by online users (Giannelloni and Vernette, 2012;Kozinets, 2010). Kozinets (2010) has defined netnography as a qualitative research methodology that adapts ethnographic research techniques to the study of cultures and communities emerging through computer-mediated communications. This method is found to be a non-obtrusive, less costly and less time-consuming way to comprehend the behaviours of online users (Langer and Beckman, 2005). It allows the researcher to immerse himself or herself into an online community's culture: that is, its values, norms, language and rituals (Kozinets, 2010). This method focusses primarily on issues surrounding the consumer and emphasises revealing complex patterns of consumer behaviour in an online world (Misopoulos et al., 2014). As Kozinets (2002) suggests, netnographic investigation starts with identifying appropriate online forums for the study. In this study, the interview respondents were followed on social media (Facebook) to observe their interaction and engagement with friends and family members. In total, 23 interview respondents gave permission to follow them on Facebook, as mentioned in Table AI. The purpose was to observe their selfies on social media and resulting interaction with their friends and family members. This would complement their interview response. In his brief netnography, Kozinets decoded the language, observed the consumption desire and analysed online communities' perceptions of brands. In our research, we have defined the scope of the investigation on the basis of research objectives. The respondents' Facebook interactions and their selfie posts were assessed on the basis of the content (which selfies/posts were shared, who was in those selfies), contexts (locations and events) and convergence (how they related to or differed from the real lives of the particular individuals, whom we came to know through the interviews). Furthermore, the interactions resulting from the posts/selfies were investigated by observing the "likes" and "comments". The researchers followed the procedure adopted by Kozinets et al. (2010) to investigate online bloggers. The investigation was not guided by positivist or a priori coding, but it rather undertook an interpretivist and qualitative approach. Observation of respondents' posts and selfies took place over a one-year period so as to provide longitudinal data. In addition, the respondents' posts from the last two years were monitored and a research diary was kept to record noteworthy posts and selfies. With the permission of the respondents, their posts and comments were copied into Nvivo for further analyses. A strict confidentiality protocol was adhered to so as to maintain the anonymity of respondents. --- Analysis and interpretation All interviews were transcribed. Four interviews were conducted in Hindi/Bengali for the convenience of the respondents. Five other interviews involved English-Hindi/Urdu or English-Bengali switching. All of the interviews were translated and transcribed in English. Two of the co-authors have proficiency in Hindi and Urdu and one is a native Bengali speaker. --- 489 --- Selfie appropriation Translation in qualitative research can be a challenge. There are certain words which have rich meaning in South Asian countries. For instance, Wilayat (Urdu), Vilayat (Hindi) and Bilat (Bengali) mean "foreign country" according to the dictionary. However, the word in its use particularly refers to Britain. It comes from the colonial past, when the word was used to denote Britain as a more civilised and better place. Likewise the word Apna (Hindi/Urdu) means "very own". British Asians normally use this word to refer to their own way of doing something. For instance, they use the word to explain authentic Indian/Pakistani food/recipes. Being mindful of this fact, the translation was checked amongst the co-authors, who foreignized the translation, as suggested by Dion et al. (2014). We tried to keep the tone of the statements the same and used some of the Hindi/Bengali words (e.g. deshi/desi), as was the case in some other similar research (e.g. Dey et al., 2013;Dion et al., 2014). The interview transcripts and netnographic data were coded using the NVivo software package. Template analysis (King, 2004) was applied for data management. Template analysis is the system of thematically organising and analysing data. In this research, four broader thematic areas were identified and applied: acculturation, selfie image, use of social media and appropriation. As suggested by Waring and Wainright (2008), the codes that emerged from the data were classified under each of the broader thematic categories and then corroborated with a view to developing conceptual scaffolding. Against each theme, there were two sets of codes. Two researchers were involved in the analysis and coding. Investigator triangulation was conducted by involving one more researcher to check the codes so that manual errors and biases could be minimised (Lewis-Beck et al., 2004;Haring, 2008). While some of the codes were theory driven, others were data driven, as suggested and practiced in previous scholarly works (Chen et al., 2011;Fereday and Muir-Cochrane, 2006) (Table AII provides a list of codes and their origins). Once the information related to the research objectives had been identified, data were analysed using a constant comparative method (Rocca et al., 2014). --- Findings and analysis As previously enumerated, we consider the selfie phenomenon as a technological application and seek to identify and analyse the process and outcome of its appropriation by British South Asian young adults. Appropriation involves adoption, adaptation and how people give meanings to the use of a technology while integrating it in their day-to-day lives. As such, we start with assessing users' perceptions of a technological application that encourages or discourages their initial adoption. Then, we look at the actual use, user-end alterations and disappropriation (as discussed in the literature review). Finally, we analyse how the appropriation of the selfie phenomenon is linked with the acculturation and appropriation of culture. The appropriation of the selfie General perceptions and adoption. In terms of the respondents' general perceptions of selfies, it appears that the selfie phenomenon is an integral part of smartphone and social media use. One respondent was very quick to identify the selfie as the most exciting part of using a smartphone: Question: Tell me about an exciting part of using a smartphone. Respondent 23: "Ermm.. selfie" (with a big smile). (Both the researcher and the respondent keep laughing about it). Question: Do you think it is just a social media based fad like 'ice bucket challenge'? Respondent 23: Absolutely not. I had my first selfie with my camera long before I started using smartphones. It was about 7 years ago. My wife and I were visiting Germany. We were in a park and we did not find anyone around to take a photo for us and we tried a selfie and it worked. We gradually got the habit. Instead of disturbing others, we prefer to have our selfie. Smartphones, however, have made it easier and social media has certainly made it more exciting. It is like I am putting a caption, checking in a place and capturing a selfie all at the same time, and most importantly, sharing it with all my friends. These all kind of complement each other and together it is a complete package. Generally the respondents hold positive perceptions of the selfie phenomenon. Like many other technological applications, the adoption of the selfie is also influenced by functional and social benefits. It has been noted that the convenience of capturing a significant moment and expressing one's own self and one's involvement with an event are regarded as major functional benefits of selfies. The adoption of the selfie phenomenon is also influenced by social relationships and subjective norms. The facility for instantly sharing the same on social media and subsequent interaction with friends and family members provide encouragement and motivation for selfies. Netnographic observation of her Facebook posts supports her claim: "She got 20 selfie posts on Facebook in the last 4 months. A selfie with her husband received a lot of appreciation from friends and family members. That particular photo has more 'likes' and comments than her other post. She replied to all the comments and appeared to have enjoyed the interaction"researcher's diary note. Of the 23 respondents who were followed on Facebook, 19 had posted selfies during the observed period. The use of selfies was more frequent among the female respondents. It has also been noted that the individuals who have more regular interactions on social media tend to post selfies more than the relatively irregular ones. The four individuals who did not have any selfies posted on their own Facebook timelines were tagged/part of selfies taken and posted by others. One of them provided a hint on this during his interview: Question: Have you ever taken selfies? Respondent 4: No, my wife does it regularly; it is not my cup of tea. Question: Why? Respondent 4: I think it is rather an expression of narcissism and social media addiction. I do not use social media much and selfies do not interest me. Hence, while some people consider selfies as a social media led fad, others adopt this practice as an integral part of their interaction on social media. The difference in perceptions of selfies further highlights the fact that their adoption and use can have multifarious dimensions and may lead to varied expressions and outcomes. Selfie use and user-end adaptation expand on this notion. Selfie use, impacts and paradoxes. From the interviews and netnographic observation, it is evident that people share selfies and other posts including photos on various social media platforms and consciously or sub-consciously expect appreciation from their friends. On social media, the appreciation is interpreted in terms of "likes" and complimenting comments. It has been noticed that "selfie" photos on Facebook receive more "likes" and "comments" than other photos. The following excerpt elaborates on that point: Question: Do you enjoy receiving 'likes' and 'comments' on selfies? Respondent 13: Yesif someone likes my selfies or leaves positive comments, it is always refreshing and often rewarding. Question: Do you like/comment on your friends' selfies? Respondent 13: Yes I do as well. I regularly engage with my friends on social media. If I like a particular dress, make-up, jewellery or just the location, I do not hesitate to appreciate it. --- 491 --- Selfie appropriation A British-born respondent considers that selfies become more meaningful to her when they capture her very own self: Respondent 8: I love taking selfies rather like American-Armenian Kim Kardashian. I do understand, however, that you can make yourself look slimmer and prettier with all the filtering apps so it can deceive people when they see the real you in person, as people cannot distinguish you from the flattering selfies which are put out there on social media. While for some people, selfies may project their real selves, for others there can be a tendency to use selfies to create a more appealing and attractive impression. However, the appropriation of selfies involves their continued use, which leads to reciprocal influence between individuals' own selves and what is being projected on the social media. The next section sheds light on this issue by examining British South Asian young adults' bicultural identity and how that is represented by selfies. As one respondent mentions: Respondent 30: I do not take selfies with everyone or everywhere. I take selfies with the people who are very special to mefor instance, my family members, close friends, favourite colleagues, or some celebrities. Selfie to me is not only just fun: it also projects what I am and whom and where I belong to. It is also important to mention that selfie use involves paradoxes and dichotomies, as we have gathered evidence of disappropriation. Respondent 16, for instance, thinks that selfie photos make her face look too big, as they are taken from a very short distance, and she has thus stopped using selfies after short trial. This is evidence of disappropriation as discussed in the current literature (Carroll et al., 2003;Dey et al., 2011). As such, selfie adoption and use is not a linear and monolithic process. Users choose to use and interpret selfies in various ways while appropriating them in their daily lives. While we broadly concur with the existing literature on the above points, we also emphasise that a holistic understanding of the appropriation of a technology requires further examination of its relationship with and outcome on users' socio-cultural lives. The following section sheds light on this issue as it looks into how selfies reflect bicultural identity. --- British South Asian young adults' acculturation and the selfie phenomenon Understandably, due to their education and upbringing, British-born South Asians are more attached to British culture. In contrast to first-generation migrants, they find it easier to integrate with mainstream British society. As one respondent explains: Respondent 3: I was born in Newcastle. My parents came from Sylhet in Bangladesh. I visited Bangladesh when I was very young and do not have much memories. UK is my country, my home. Most of my friends in the university are of white English origin. As well as their engagement and interaction with their own community, some of the British-born respondents also speak their native language at home. For instance, respondent 19 (a British-born Indian) speaks Punjabi with his family members. Respondent 27 is a third-generation British Pakistani who speaks three languages: English, Punjabi and Urdu. British-born respondents, nevertheless generally have preference for South Asian foods and a taste for Hindi/Bollywood movies and music, although none of them visit their ancestral country frequently. As respondent 27 explains: On the other hand, first-generation migrants have strong attachment to their home countries. They migrate to the UK for work/study or for a better future. However, they also endeavour to explore and learn British culture. As respondent 16 explains: Respondent 16: [...] After completing my degree, I decided to stay in this country. I like London and life in the UK. Although I miss my country, and my relatives back home, I consider this to be my new home. Hence cultural dualism is evident in both first-generation and British-born respondents although they have different nature and orientations. Contrary to the seminal articles in acculturation scholarship such as Pe<unk>aloza (1994) and Berry (1997Berry (, 2009)), our data do not offer evidence of absolute assimilation or absolute separation. We have found strong evidence to suggest that in a multicultural country such as UK, ethnic community members exhibit cultural duality as part of their acculturation strategies, as they adopt certain traits from the host country and also retain traits of their ancestral countries. Based on these findings, four factors motivating acculturation strategies can be identified: consonances, contexts, conveniences and constraints. These factors determine British South Asian communities' cultural duality and have been identified and terme

Purpose -The purpose of this paper is to examine how young British South Asian adults' dual cultural identity is exhibited and reaffirmed through the appropriation of selfies. Design/methodology/approach -The research adopts a qualitative perspective and utilises a combination of in-depth interviews and netnographic data. Findings -The appropriation of the selfie phenomenon by young British South Asian adults reifies, endorses and reinforces their dual cultural identity. As such, their dual cultural identity is influenced by four factors: consonance between host and ancestral cultures, situational constraints, contextual requirements and convenience. Research limitations/implications -In terms of the selfie phenomenon, the study makes two major contributions: first, it analyses young British South Asian adults' cultural dualism. Second, it explicates how their acculturation and their dual cultural identity are expressed through the appropriation of the selfie phenomenon. Practical implications -Since young British South Asians represent a significant, and distinct, market, organisations serving this market can marshal insights from this research. As such, managers who apprise themselves of the selfie phenomenon of this group are better placed to meet their consumer needs. Account, therefore, should be taken of their twofold cultural identity and dual British/Asian identification. In particular, consideration should be given to their distinct and demonstrable traits apropos religiosity and social, communal, and familial bonding. The characteristics were clearly evident via their interactions within social media. Consequently, senior marketing managers can utilise the aforementioned in positioning their organisations, their brands and their products and services. Originality/value -The study details a new quadripartite framework for analysing young British South Asian adults' acculturation that leads to the formation of their dual cultural identity and presents a dynamic model that explicates how cultural identity is expressed through the use and appropriation of technology.

or for a better future. However, they also endeavour to explore and learn British culture. As respondent 16 explains: Respondent 16: [...] After completing my degree, I decided to stay in this country. I like London and life in the UK. Although I miss my country, and my relatives back home, I consider this to be my new home. Hence cultural dualism is evident in both first-generation and British-born respondents although they have different nature and orientations. Contrary to the seminal articles in acculturation scholarship such as Pe<unk>aloza (1994) and Berry (1997Berry (, 2009)), our data do not offer evidence of absolute assimilation or absolute separation. We have found strong evidence to suggest that in a multicultural country such as UK, ethnic community members exhibit cultural duality as part of their acculturation strategies, as they adopt certain traits from the host country and also retain traits of their ancestral countries. Based on these findings, four factors motivating acculturation strategies can be identified: consonances, contexts, conveniences and constraints. These factors determine British South Asian communities' cultural duality and have been identified and termed on the basis of the data gathered in this research (as mentioned in Table AII). Acculturation by consonances. In this category, the researchers classified respondents who assimilate (or intend to do so) with the mainstream British culture, but at the same time retain ancestral cultural identities on the basis of consonances. We have taken the dictionary meaning of the word "consonance" that refers to agreement and compatibility. The motivation for acculturation strategy is influenced by the agreement and compatibility between the host and ancestral cultures. British South Asians often retain the parts of their ancestral cultural identities which are consonant with British mainstream culture. They also feel more comfortable with parts of the host culture that are consistent with what they experienced and practiced back home. Hence, there is strong evidence of cultural reflexivity, as defined by Askegaard et al. (2009), as British South Asians identify and explore their cultural roots and links during their acculturation process. Cricket, a quintessential English sport, despite having lost its glamour in the UK in recent times (Dobell. 2014), has become more popular in the Indian sub-continent over the years. Eventually cricket secured a strong base among British South Asians, who celebrate the sport as a hybrid identity of their ancestral and international culture. Furthermore, the passion for cricket among some of the Indian and Pakistani respondents is also influenced by Indo-Pak political and cricketing rivalry, highlighting cricket as a significant component of their perceived national identity. One respondent says: Like cricket, there is wide appreciation for Bollywood movies among the South Asian communities. Both interviews and netnographic observations can identify the respondents' interest in Bollywood culture. British-born and first-generation migrants both offered similar responses in this regard. There is increasing interest in Bollywood dance (particularly bhangra) and music among the wider British population. Most of the respondents in this research follow famous Bollywood stars on Facebook. One of the respondents (respondent 10) took a selfie with famous Bollywood star Raima Sen during her recent trip to Delhi. She tagged her friends (on the Facebook photo) who are fans of the actress. --- 493 --- Selfie appropriation There is a sense of pride and passion for Bollywood and cricket, particularly when South Asians know that both are accepted amongst the wider British population, as shown in the following excerpt: Respondent 20: Yes, I am very much into Bollywood culture. Coming to the UK, I can still watch Bollywood movies in theatres. I have been to some Bollywood events organised in local pubs and found bhangra music played in night clubs. People from all communities enjoy them. I was pleasantly surprised to see that a colleague of mine knows some of the Bollywood stars. Selfies and acculturation by consonance. Respondents' acculturation strategy chooses to retain the attributes, which are consonant with wider British culture. Selfies with famous cricket and Bollywood stars, at cricket grounds and in cricketing clothing endorse, reinforce and reify this identity. Here, selfies are used to express their engagement with the particular ancestral or host country cultural attributes that have mutual acceptance and consonance. Acculturation by contexts. Acculturation by contexts is noticed mostly at the behavioural level. Oxford dictionary defines context as the circumstances that form the setting of an event and idea. We apply this definition in our research as well. Respondents motivated by this factor, exhibit behaviours in different contexts due to circumstantial requirements. As one respondent says: A third-generation Indian respondent (respondent 30) who demonstrates strong assimilation in terms of language and lifestyle also celebrates her ancestral origin. Researchers did not have permission to access her Facebook profile. However, her interview response shows her passion for traditional South Asian dresses. Her opinion in this case explains her appreciation for traditional dresses: Respondent 30: I do take selfies before going to parties and post them on Facebook. Question: Do you prefer to take selfies when you are in traditional Indian dress? Respondent 30: Yes, I do. Because, I do not have many opportunities to wear 'desi' dresses. Normally, during Diwali or wedding parties I wear salwar kameez or sarees. Yes I wear Western dresses when I go out with my British colleagues. This is common among quite a number of respondents who exhibit different cultural attributes in different contexts. They celebrate Diwali, but also go to Christmas parties, and their clothing, appearance and behavioural expressions meet contextual requirements. These varied behavioural expressions are also demonstrated through their selfies posted on social media. Selfies and acculturation by contexts. Selfies in different dresses (Western and Eastern), different locations (nightclubs and temples), with different individuals (colleagues/friends from the wider community, friends/family members from their own community) and their sharing on social media, followed by "comments" and interactions, reify and endorse the multiple identities. Acculturation by constraints. Some of the respondents in this research appear to integrate in their occupational lives despite keeping their social life restricted to their own community people. We have termed this factor as "constraint" as in limitation or restriction. Immigrants' motivation for selfies often comes from their intention towards separation from the mainstream culture. Some evidence of separation among the first-generation migrants can be found in the following excerpt: Respondent 10: I am an avid social media user. I am living far away from most of my friends and family members, and social media is a bridge for me to remain connected with them. When I go out, visit some nice places or perhaps do nothing and chill at home, I want to share the moments with them. That is a reason behind my addiction to selfies and Facebook. Respondent 10 in the above statement explains her strong desire to remain connected with friends and family members back home: her use of selfies lends itself to that motivation. All her selfies on Facebook are with members of her own community. However, as an accountant, she is unable to separate herself entirely from the mainstream community. Likewise, respondent 16 is a college teacher, a first-generation immigrant who interacts and integrates with the wider community for her work. Despite separation in their social lives, both of them integrate in their occupational lives. Their interaction on social media nevertheless exhibits their strong desire to adhere to their own communities. The following excerpt provides us with further evidence of forced integration: The respondent does not seem to be very comfortable in integrating with his colleagues/ neighbours. Netnographic observation shows that he had not posted any selfies on his Facebook in the past year; however, his other photographs and interactions were only with fellow Indians and other South Asians. This is a form of forced integration, where the respondents are required to integrate for occupational/locational (living in the same neighbourhood) reasons. Selfies and acculturation by constraints. Respondent 16, for instance, took selfies only with South Asian friends, and her social media-based interaction is limited to her own community members, although she has friends and colleagues from other communities. The selfie phenomenon, and its use on social media, reifies and reinforces her strong desire to remain connected with her own community, although in the real world she interacts with wider communities due to situational constraints. Acculturation by convenience. Integration can also be demonstrated on the basis of convenience. Here, the integration with wider cultural traits is not by force or in a contingent or consistent manner, but rather is driven by convenience. Cultural attributes ( from either side) that are convenient are adopted/retained. As a result, integration may lead to duality of identity, which may exhibit paradoxical behaviour. It is a form of selective integration driven by the principles of convenience. We choose to define the word as per the dictionary: "being useful, easy and suitable to someone" (according to the Oxford Dictionary). Hence, acculturation by convenience happens when people choose options that are easy and suitable to their likings, although those may be contradictory and inconsistent with their religious/social/cultural beliefs. The researchers found differences in religiosity among the respondents, despite the fact that the majority can be identified as moderately to highly religious. As respondent 23 and 17 explain their religiosity: Respondent 23: I am a proud Sikh. I go to Gurdwara (Sikh Temple) every Sunday [...]. Yes, I know Punjabi and I speak this language at home and at the Gurdwara. Our scripture is written in a language which is similar to Punjabi. The above respondents' Facebook pages also demonstrate their religiosity and attempt to express the way they would want fellow community members to see them. Regular religious posts are very common among these respondents. Another respondent's (respondent 16) (Muslim) husband drinks alcohol. However, she is very careful not to post any photos/comments/posts on her or her husband's Facebook account that might give her friends and relatives the impression that her husband drinks. She does not normally take photographs or selfies in pubs or bars. Respondent 28 wears the Hizab to comply with the stricter version of Islam, but does not mind selfies or photographs. When she was asked about whether or not selfies clash with her religious belief, she said: [...] taking photos itself is not very Islamic in a very strict sense. However, I don't maintain that stricter version. Culturally, I don't think there's a clash, as it's just another global trend that has become part of our daily lives. Hence, I wouldn't be too worried about selfies or any kind of photography. We have classified this dichotomous acculturation strategy as "acculturation by convenience". Integration with wider cultural traits is not by force or in a contingent manner, but rather is driven by convenience. Selfie and acculturation by convenience. As selfies reflect and reify individuals' identities, the respondents are careful in considering the time, place and persons for selfies. In that respect, one may find the acculturation by convenience being applied to individuals' decisions to take selfies and/or to post them on social media. --- Discussion Figure 1 provides a theoretical framework for selfie appropriation in relation to cultural dualism. The appropriation of culture exhibiting dual cultural identity is an outcome of individuals' constant and dialectic interaction with their ancestral and host cultures. Hence, we have three components of this theoretical framework: formation of cultural identity, appropriation of selfies and the inter-linkage between cultural appropriation and technology appropriation. --- Formation of dual cultural identity through cultural appropriation Based on the findings, we have identified four motivating factors of acculturation strategies that lead to cultural duality: consonances, contexts, conveniences and constraints. The British-born respondents show their appreciation and interest in host cultures and they feel more comfortable with cultural attributes that have agreement and compatibility with the wider British community. This also happens for some of the first-generation migrants who choose to integrate with the wider society. As such, some respondents in this research express their pride in Bollywood culture that is recognised in wider British society (as discussed in the findings section). "Acculturation by constraints" refers to the situation when migrants integrate with wider communities for locational, occupational and educational reasons. Unlike "pendulism" (Askegaard et al., 2005), which refers to more volitional and elective decisions to move between the host and the ancestral culture, this group of migrants integrate due to situational "constraints". This classification adds a different dimension in explaining acculturation strategies. The migrants acculturating by constraints are not "separated" from the mainstream in the way Berry (1980) explains. Although they show some kind of "resistance", as defined by Pe<unk>aloza (1994), their resistance does not lead to complete segregation. "Convenience" explains some of the ambiguities and paradoxes surrounding biculturalism and dual or multiple identities. Here we find consumers acting like pragmatic and often opportunist agents who conveniently choose cultural attributes that suit their living in multicultural environments. They can manage to keep the influence of both the host and the ancestral culture to a limited level. However, they show less desire to integrate and assimilate compared to those who show different cultural traits in different "contexts"our fourth category. This is closer to "pendulism", although our classification implies a more assertive intent than Askegaard et al. (2005) found among their respondents. Furthermore, their interaction in the multicultural environment is not driven by oscillation, but rather by contextually defined expectations. This quadripartite classification provides further insights into cultural dualism and appropriation of culture as described by Weinberger (2015). The factors of acculturation strategies identified in this research explain cultural dualism and appropriation of culture. The next section investigates how this appropriation of culture relates to the appropriation of technology. --- Selfie appropriation The findings suggest that respondents adopt selfies for hedonic, social and psychological reasons. However, the focus of this study is on how the appropriation of selfies relates to their cultural identity. The complex and often contradictory expression of cultural dispositions, as the findings suggest, are expressed on the social media marketplace through selfies. We argue that the extended "self" of an individual in the virtual world is reified through the selfie. Furthermore, due to the fact that on social media, the selfie comes as a "complete package" with explicit and implicit expression of other tangible features and --- 497 Selfie appropriation physical evidence, it is a reflection of self-identity that is much closer to one's "actual self". For instance, when we see that all the selfies posted by some respondents (acculturation due to constraints) only include their own community members, it appears that their day-to-day engagement with other community members in the offline world may often be enforced by situational/locational reasons. In effect, they desire to adhere to their own community members. Hence, a comparison between their virtual and real-life interactions reveals their acculturation by constraints. At the same time, selfies on social media exhibit their actual intent to belong to a particular community, which they are unable to do in the real world. Overall, we concur with Orlikowski (1992Orlikowski (, 2000) ) apropos the selfie as a technology that replaces previous social practice. Through the repetitive reproduction of this practice by a large number of the population, the selfie is gradually becoming an integral part of daily lives. This is consistent with socio-cultural theories in which appropriation is seen as the transformative process a technology undergoes, whereby introduction of technology initiates changes in social practice. Again, the use of technology (selfies) itself is supported by other social practices (use of social media) and reifies changes in human and social interactions. As such, the selfie phenomenon is one of those technological applications that become embedded in our virtual and real lives and demonstrate the iterative and spiralling interaction between the two spheres (virtual and real life). Here we concur with the current appropriation literature (Dey et al., 2011;Carroll et al., 2003) in terms of the appropriation process. However, we argue that appropriation and disappropriation are neither binary nor mutually exclusive. Users may appropriate a technological application in a particular context, while disappropriating the same in other situations. When a respondent decides not to have a selfie inside a pub, she disappropriates, but the same respondent exhibits use of selfies in other contexts. It is not only about where and with whom selfies can be taken: it is also important to study the situations and individuals that would be included/avoided when taking selfies. --- Link between technology appropriation and cultural appropriation We extend the concept of appropriation by identifying and analysing how individuals' appropriation in socio-cultural behaviour influences and determines technology appropriation processes and outcomes. Selfies reify cultural identity. We argue that social media is increasingly narrowing the gap between virtual and real life by portraying more tangible aspects of our real life not only in terms of clothes and fashions but also through their appearance, locational settings and other physical evidence. The popularity of selfie practices inside cars, trains and aeroplanes was noted, as people wanted to share the pleasure of certain special journeys or travelling experiences. Hence, the selfie can work as a tangible expression of a situation, moment, emotion or experience. Selfies endorse and reinforce cultural identity. The dual cultural identity discussed earlier in this section is constructed in the real world and is often endorsed and reinforced through selfies in the social media. There is iteration between the selfie phenomenon and cultural identity. It was noticed that respondents preferred selfies with cricket stars and Bollywood stars: the selfie creates the identity, and through its sharing in social media and the resulting interaction with friends and family members, individuals' identity is endorsed and reinforced. While the current literature (Ma et al., 2017;Chua and Chang, 2016) also argues that selfies reify consumers' (un)willingness to express the physical environments, our research also brings in the emic aspects of cultural dispositions. --- Theoretical contributions The nature of and motivation for acculturation strategies discussed in this paper explain why and how cultural appropriation occurs and influences cultural identity, particularly in a multicultural environment, and thereby advance current scholarship in acculturation. Although this research speaks for a specific context of British South Asians' appropriation of selfies in a multicultural environment, the findings and contributions can be generalised. Cultural appropriation can happen even in a more homogenous country where people negotiate between local culture and global culture (Cleveland et al., 2013). It can happen in any situation where people are exposed to multiple cultural attributes and seek to adopt, adapt and adjust cultural dispositions. People's behaviour may be constrained by situational factors, may be in response to contextual requirements, may be driven by the principles of convenience or may be a result of volitional choiceas identified in this paper. Hence, this paper addresses the current knowledge gap by explaining the dualism and paradoxes that constitute cultural appropriation, and in turn shape cultural identity. While our research focusses on social and ethnic culture, similar dichotomies may exist for organisational cultures. Nevertheless, the major theoretical contribution of this paper comes with the furthering of technology appropriation theory as it integrates cultural appropriation into its dynamics. The current technology appropriation literature (Dey et al., 2011;Carroll et al., 2003;Lindtner et al., 2012) does not fully explain the role of individuals' interaction with socio-cultural institutions in shaping and determining appropriation processes and outcomes. We argue that the appropriation of culture has reciprocal influence on technology appropriation and they reify each other. Hence, the appropriation goes through a spiralling and iterative process of mutual shaping of culture and technology use that leads to the expression of cultural identity in a given context. This is a new dimension added to both consumer studies and appropriation literature. Aricat (2015) and Bar et al. (2007) also emphasise cultural expression through technology appropriationbut do not explain the dialectical adoption and evolution of culture through technology use. This paper also argues that appropriation and disappropriation are not binary or mutually exclusive phenomena, but rather depend much on contexts and applications. People may appropriate a technology in a certain situation, but disappropriate the same in other contexts. --- Conclusion Our research has analysed how selfies reify, endorse and reinforce cultural identity in virtual world. However, scholarly debate and discussion on the inter-relationship between offline and online world is far from over. Future research can examine how and to what extent selfies or other forms of social media-based self-expression reflect acculturation towards global consumer culture and/or promote or inhibit cross-cultural interaction. The selfie phenomenon being a global social media-based phenomenon can explain how technology use and appropriation transcend geographic and cultural borders. Future research can also delve into acculturation in social media marketplace. --- Practical implications First of all, this paper offers useful means for segmenting ethnic customers. The concept of acculturation by consonances would be useful for South Asian brands such as Patak's, Cobra and Kingfisher that have acceptability amongst the wider British population. Their brand identities, South Asian origin and presence in British society would resonate with the dual cultural identity of British South Asians. Acculturation by contexts can be used by the fashion industry. Ethnic clothing and jewellery brands such as Khadi can highlight the contextually appropriate use of their products. International airlines companies, hotels and tourism industry may also benefit from this particular pattern as ethnic consumers falling in this category are not rigid to any particular cultural disposition. Acculturation by constraints can provide a useful understanding for Government and not-government organisations that promote cross-cultural interaction to combat social exclusion, ethnic 499 Selfie appropriation segregation and religious extremism. People may suffer from segregation and separation even if they live and work with wider communities. Finally, religious brands and products (such as sweets in Diwali, juice during Ramadhan) can target the acculturation by convenience. Businesses can also try different approaches for their different product categories. BBC Asian Network have different sets of programmestheir Bhangra fusion and Bollywood music normally target both first and second generation migrants, while their classic Hindi/Urdu songs attract first-generation migrants. Furthermore, our research suggests selfies reflect the cultural duality and thereby can be used for both customer segmentation and communication/engagement. Customers' selfies on Facebook/Instagram hence can be used to analyse their cultural identity. As such, managers who apprise themselves of the selfie phenomenon of the ethnic group are better placed to meet their consumer needs. Account, therefore, should be taken of their bicultural identity that is shaped by demonstrable traits apropos religiosity and social, communal, and familial bonding. Selfie practice can bolster the co-creation of brand identity and provide opportunities to identify synergy between brands' and their target consumers' images. It is also important for companies to be aware of the paradoxes and dichotomies. Selfies in certain places (e.g. pubs and nightclubs) may not be appreciated by certain quarters of South Asian communities. --- Limitation The research did not engage with the most vulnerable and marginalised members of British South Asian communities, and hence this paper is unable to explain their cultural identities. It does not cover minors or senior citizens either. Future research could investigate how the selfie phenomenon exhibits the cultural identity of the host community and/or other ethnic minority communities in Great Britain. It would be fascinating to see whether or not the host community demonstrates dual and multiple cultural identities due to their regular interactions with a number of migrant communities. Research could also be conducted on the South Asian diaspora in other countries such as the USA and Australia to examine how their cultural identity in the social media marketplace is exhibited. --- For instructions on how to order reprints of this article, please visit our website: www.emeraldgrouppublishing.com/licensing/reprints.htm Or contact us for further details: [email protected]

Purpose -The purpose of this paper is to examine how young British South Asian adults' dual cultural identity is exhibited and reaffirmed through the appropriation of selfies. Design/methodology/approach -The research adopts a qualitative perspective and utilises a combination of in-depth interviews and netnographic data. Findings -The appropriation of the selfie phenomenon by young British South Asian adults reifies, endorses and reinforces their dual cultural identity. As such, their dual cultural identity is influenced by four factors: consonance between host and ancestral cultures, situational constraints, contextual requirements and convenience. Research limitations/implications -In terms of the selfie phenomenon, the study makes two major contributions: first, it analyses young British South Asian adults' cultural dualism. Second, it explicates how their acculturation and their dual cultural identity are expressed through the appropriation of the selfie phenomenon. Practical implications -Since young British South Asians represent a significant, and distinct, market, organisations serving this market can marshal insights from this research. As such, managers who apprise themselves of the selfie phenomenon of this group are better placed to meet their consumer needs. Account, therefore, should be taken of their twofold cultural identity and dual British/Asian identification. In particular, consideration should be given to their distinct and demonstrable traits apropos religiosity and social, communal, and familial bonding. The characteristics were clearly evident via their interactions within social media. Consequently, senior marketing managers can utilise the aforementioned in positioning their organisations, their brands and their products and services. Originality/value -The study details a new quadripartite framework for analysing young British South Asian adults' acculturation that leads to the formation of their dual cultural identity and presents a dynamic model that explicates how cultural identity is expressed through the use and appropriation of technology.

initiatives designed to prevent or reduce drug-related morbidity and mortality among PWUD [1][2][3]. These programs were designed to modify the social, physical, economic, and political factors that interact to create a risk environment for PWUD [4,5]. There has been a growing acknowledgement across drug policy and harm reduction research about the role risk environments play in perpetuating social and structural marginalization for PWUD and the need for interventions to operate at micro, meso, or macro levels [6] to reduce these harms [5,6]. Spotting, a remote method of supervising drug consumption, represents a community driven intervention that allows for overdose response in environments where supervision of drug use is not available [7]. The practice of spotting is not new; for years some PWUD have contacted someone they trust to monitor their use of drugs using remote methods (by telephone, or more recently, using online video conferencing services) and intervene (either in person or by summoning emergency services) in case an overdose occurs. This remote method of supervision has become more salient during the lockdowns, stay at home orders, physical distancing requirements, service restrictions/closures and self-isolation orders during the COVID-19 pandemic. Indeed, formalized spotting services have begun to be implemented across Canada in the form of a call-centre and mobile apps [8,9]. Access to supervision of consumption in person or by remote methods is important given the increases in overdose mortality observed since the beginning of the COVID-19 pandemic. Reports from the Government of Canada document that there were over 3,000 overdose related deaths across Canada from April to September 2020 as a result of the onset of the COVID-19 pandemic, which represented a 74% increase from the months of October 2019 to March 2020 [10]. Most overdose deaths are currently being driven by unregulated fentanyl and fentanyl analogues in the street-based opioid supply, with recent data indicating that fentanyl was a direct contributor to mortality in 87% of opioid-related deaths occurring during the COVID-19 pandemic in Ontario [11]. Similar reports have been documented by the Centre for Disease Control and Prevention, which state that over 80,000 overdose related deaths occurred across the United States from May 2019 to May 2020, with a substantial increase documented between the months of March and May 2020 as a result of the COVID-19 pandemic [12]. Additionally, unregulated benzodiazepines such as etizolam & flurazepam are being increasingly detected in fentanyl samples by drug-checking programs and during post-mortem toxicology, highlighting the volatility of the unregulated drug supply [13]. The increased rate of overdose deaths during COVID-19 follows several years of rapidly increasing overdose rates in Canada [10]. For example, Health Canada reported over 19,000 opioid-related deaths between January 2016 and September 2020 [10]. Canadian reports also indicate that 94% of overdose-related deaths were accidental and 80% of deaths involved fentanyl or fentanyl analogues in 2019 [14]. While harm reduction interventions such as SCS, OPS, NSP, and even a safe supply of drugs have expanded in number, PWUD continue to face access barriers (i.e., geographic accessibility, drugrelated stigma, discrimination, or gender-related concerns such as violence and gendered stigmatization) [15][16][17][18]. Although the expansion of these harm reduction services have occurred in some provinces across Canada such as in Ontario, many others such as Newfoundland or Prince Edward Island, do not have or fund SCS or OPS spaces for these lifesaving services. Even within provinces which have implemented harm reduction services, there remains limited access to such services in urban, rural, and remote regions [19][20][21]. Lack of access has resulted in many PWUD using drugs alone in their private residences, increasing risk of overdose and drug-related morbidities [22][23][24]. For example, reports from Ontario, Canada indicate that three out of four overdose-related deaths which occurred during the COVID-19 pandemic took place when "no one was present to intervene" [11]. Literature from British Columbia, Canada document that PWUD engage with substance use alone as it improves convenience, comfort, and reduces experiences of stigma and discrimination [25]. Using data from an exploratory community-based research project, we aim to explore the ways in which spotting has been implemented by and for PWUD in two Canadian provinces-Nova Scotia and Ontario-during the COVID-19 pandemic and describe spotting motivations, processes, strengths, and limitations. Questions that were explored in this study and manuscript include how spotting practices operate, what the perceived benefits, challenges, and risks of spotting are, and for whom, and what the impact of spotting practices are for PWUD. --- Methods For this exploratory qualitative study we recruited PWUD who had provided informal spotting services (spotters) and those who used informal spotting services (spottees). The study was approved by the University of Toronto Human Subjects Review Committee. --- Participant recruitment and sampling Eligibility criteria for the study included: 1) having spotted and/or been spotted informally in the past 6 months; 2) being able to conduct the interview in English; 3) having access to a telephone or computer/internet; and 4) being willing to provide contact information (i.e., email address, full name, or postal address) to receive the honoraria by e-transfer, money gram, online gift card or by mail. Participants were recruited using personal and professional networks of study team members with lived/ living expertise of drug use and through snowball sampling techniques. All members of the team have extensive experience in conducting harm reduction research and/or have lived/living experience of substance use and were consulted in the design of the study and study material. Given our recruitment strategy, certain participants had existing relationships with one of the interviewers. All participants were asked if they were comfortable with this prior to engaging with the study. Each potential participant was given the study phone number and email address. People who contacted the study team were screened for eligibility and were provided with an overview of the study objectives. We emailed a consent form to those who were interested and obtained verbal consent prior to participation. We recruited those who reported engaging in both formal (e.g., toll-free line operated by a harm reduction organization; n = 10) and informal (n = 20) spotting but this manuscript focuses exclusively on the latter group. The sample size for this study was determined a priori based on a recommended sample size [26]. We did indeed reach saturation of key themes (i.e., benefits, limitations, challenges) with this sample. --- Data collection methods Interpretive descriptive [26] qualitative methods were used to conduct this study. All participants were asked to complete a brief socio-demographic questionnaire and semi-structured interview using a telephone. Participants were asked questions about: 1) how they learned about spotting -as a spotter and/or spottee and how spotting 'works'; 2) what attracted them to use spotting either as a spotter or spottee; 3) by whom, where, and how often they engaged with spotting; 4) what platforms (e.g., telephone, FaceTime, and/or Zoom) were used to spot and how well these worked; and 5) what the perceived benefits (e.g., overdose, STBBI's prevention, and/or COVID-19 prevention), challenges, and risks of spotting are for both spotters and spottees. If participants identified as both a spotter and spottee, they had the choice of what interview type (spotter vs spottee) they would like to complete. Each interview was conducted by two team members (MP, NK, CS, and/or GK), including one with lived experience of drug use, audio recorded, and uploaded onto an encrypted cloud. The interview guide was pilot tested with three participants and adapted according to their feedback. Interviews lasted between 30-60 min and were conducted between 08/2020-11/2020. All but one of the participants received a $30 honorarium by e-transfer, with the one individual preferring to receive it in cash. --- Data management and analyses Once completed, interviews were professionally transcribed, corrected for accuracy, and managed using NVivo 12. Interpretive descriptive analytic methods were used to analyze the data; these methods are designed to excavate, illuminate, and articulate patterns and commonalities in qualitative data and to generate knowledge that is practical [26]. To develop the codebook, MP, CS, NK, and MB reviewed multiple transcripts and discussed appropriate codes. This preliminary codebook and themes which emerged from data analysis were shared with the larger team for feedback and adapted accordingly. Coding was completed in an iterative manner by two team members (MP, CS, NK, and/or MB) with discrepancies being discussed and resolved by a third team member. Demographic data were entered into RedCap and analyzed using descriptive statistics with Excel. Some quotations were modified to ensure confidentiality. --- Results --- Socio-demographic data We recruited 20 PWUDs who provided or used informal spotting, of whom 10 identified themselves as spotters and 10 identified themselves as spottees. On average, participants described having people spot for them 12 days in the past month and having been a spotter for 4 days in the past month. The average age of participants was 37 years, 35% selfidentified as cisgender men (n = 7), 60% as cisgender women (n = 12) and 5% as transgender or gender-diverse (n = 1). The majority (75%) of the sample resided in southern Ontario (N = 15) and the remainder from Halifax & Cape Breton (N = 5) on the east coast of Canada. When asked about their ethnicity and racial background, 25% identified as Indigenous (n = 5), 10% as African, Black, or Caribbean (n = 2) and/or 90% as Caucasian (n = 18). Spotters and spottees described similar informal spotting processes (e.g., how and why spotting is done), benefits (e.g., improved safety), limitations (e.g., locality), and recommendations on improving spotting practices (e.g., developing spotting guidelines). Each of these themes are outlined below. --- Informal spotting processes Spotting was described as a long-standing community practice. Participants explained that the community previously referred to spotting as informal witnessing, but the name spotting caught on during the COVID-19 pandemic. When asked about the technology used for spotting, most participants reported using phones, text messaging, or video calls and being at home while spotting or while being spotted. Participants described informal spotting processes as starting with reaching out to a friend, family member, colleague, or another person with lived/living expertise of drug use by text, phone, or video call and asking them to'spot'. One participant described spotting with someone in this way: So it would just involve me calling somebody. You know, they pick up, let them know that I'm going to be using at that time. And then, yeah, and then I would use and then stay on the phone with them for five minutes, and yeah, and I would give them the explicit instructions that if I don't respond or if my response is essentially nothing, then, it's probably a good idea to go ahead and call an ambulance. (Spottee 28) Spotting calls most often included discussion of an overdose plan before the spottee used drugs. Issues such as whom to call, when to call, and what the spottee might do to reduce harm should they overdose were discussed on the majority of calls. For example, a spotter told us: So, what I did was, I called the girl over FaceTime. We came up with a plan; so she didn't want me to call 911 because she was a parent. So, she said if she would overdose, to let her mom know and to guide her mom and how to use the naloxone and what to do, in that moment, should it happen. (Spotter 1) When asked, many spottees said that they preferred that a partner, family member, neighbour or other person in close proximity to them be called in the event of an overdose. Many did not want the spotter to call emergency services because of fears of police accompanying paramedics on overdose calls, or fears of arrest. As one spotter expressed: --- And I know a lot [spottees] are scared to even call anyone for help, because they're scared of being criminalized; they might have a warrant; they've had a bad experience with the police. A lot of men that I deal with are Indigenous, and they're very criminalized. And they trust me not to call the cops. (Spotter 12) Some spotters also mentioned that they recommended putting extra drugs out of sight, pets in a safe place and unlocking the door. Once ready to use, spotters noted that they often chatted while the spottee used to'monitor' what was going on and stayed on the line for 5-15 min after they had used drugs to ensure safety. Fear of overdose -stated succinctly by one participant who explained 'Ah, cause I don't want to die. " (Spottee 9) and/or a desire to have someone to talk to while using were reasons for spotting. All participants had concerns surrounding the high rates of drugrelated overdoses and the unsafe drug supply. Spotting was offered a way to reduce social isolation and overdose risk elevated when COVID restrictions led harm reduction facilities to reduce the availability of services. Participant's echoed narratives from previous research [27] surrounding fear of stigma, criminalization, and policing surrounding in person harm reduction services, which also facilitated their engagement with spotting. They used spotting as a strategy to try and stay safe during these multi public health emergencies. Spotting frequently occurred from home, as it offered spottees the privacy they needed to feel safe from stigmatization, discrimination, the fear of criminalization of drug use and for some women and gender-diverse people, harassment and violence they experienced at some harm reduction programs. As a spottee explained: [Spotting] is something that's easily accessible to people for when they're using alone, because they're likely to use alone anyway. And at least if I know that, like, people I care about are using alone, I can be, like, 'Call me.'You know, like, there's at least, like, an alternative safety net that offers some kind of support, that's more so than just if you have nothing in place. (Spottee 11) Spotting on the go from places such as public parks or in cars, which did not lend itself to the same quality of privacy or safety, was also mentioned. Spotters continued to spot in non-ideal circumstances because they cared about the person who was reaching out to them for support. Some spottees also explained that they used spotting because they wanted the safety of supervision but either did not have access to an SCS or did not feel comfortable using their drug of choice within those spaces. As one spottee explained: I like the ability to, like, it feels safe, and I get to use in a place that's comfortable for me. So, like, an overdose prevention site, is not somewhere safe for me to use, if I'm using a substance that causes psychosis in me. Which I rarely, don't use those, like, I don't use ah, stimulants for that reason. But, I wouldn't be able to use a stimulant in an overdose prevention site, because I would go into psychosis, and it would feel very uncomfortable and I would be embarrassed, versus being in the comfort of my own home, where I feel like I have some privacy. (Spottee 3) --- Benefits of spotting Participants described the benefits of spotting as providing access to overdose response whenever and wherever they needed it. This was particularly beneficial for people who smoked drugs, as supervised inhalation and smoking facilities are extremely limited in Canada, with most sites only allowing injection of drugs [28][29][30][31]. One spottee explained: Well, you can't smoke, drugs in an overdose prevention site. So that's not even an option. So, the type of, the method in which I use my drugs doesn't work in the current model of how consumption and treatment sites are regulated in Ontario (Spottee 3) Many participants explained that spotting helped to fill in a gap in service availability. One spottee expressed their hesitations in using SCS: A lot of people just don't feel comfortable, either it's far removed from their communities, and it's just not, like, the scene they're used to being in, or it's just like, so unusual for them to use in such a like, formal medical setting, or even in front of people at all. --- Some people aren't close to a site. Some people use during hours that sites aren't open. Some people use only when they're with people, and some people, I don't know, just like, feel intimidated by sites in general. And some places don't even have site, so, yeah (Spottee 11) Participants also highlighted the role of spotting in providing a sense of connection with members of their community. During the COVID-19 pandemic, while trying to adhere to physical distancing expectations, this connection was extremely important for those who typically used and shared drugs together. For some participants, the opportunity to talk to someone during a spotting call and develop a connection afforded them an opportunity to open up about past traumas. The informal conversations during spotting calls helped both parties develop trust: --- I like spotting because spotting can save lives. Um, it's almost like a relationship. You get back from it what you put into it. So, if you build the trust with, like, a core group of people, inform them and you're like, open, and you're actually, like, honestly open with them, about, like, trying to let them understand why you tick the way you do, you know what I mean? Cause then, they can understand like, why you're doing what you're doing. So, they can counteract in term of help, in the right way. (Spottee 5) Spotters described benefits of spotting both for spottees and for themselves in explaining how spotting improved their sense of pride and accomplishment. One spotter expressed: I think the benefits of spotting are that people are safe. And that's mainly for the person who's using. The spotters, I think they can, I think, they, like, there's something to be said for feeling like you're accomplishing something, and feeling like you're helping someone. And I think that's what the spotters can take away from it. (Spotter 1) --- Limits of spotting: fear of delays, police, and the neighbours When asked about the limitations of informal spotting, many said that because spotting was done remotely/ virtually and often at a geographic distance, they worried about the consequences of delayed responses to an overdose event. Both spottees and spotters were anxious about any delays in reaching a person should they experience an overdose. One spotter shared their anxiety: --- I've experienced anxiety -I, I get, like, I get anxiety. I worry about the person. Like, I worry if what I can do is going to, if what I'm doing is actually going to help save them in time. Like, I worry that because I'm looking for all these signs, and I have to make a phone call, and then I have to wait -like I worry that the overdoses won't be attended to in time. And, I worry about negative impacts of overdose, like, later on for them. But it's just like the anxiety of having to be hyper aware of someone else's situation. Yeah, that's the biggest one for me is anxiety. (Spotter 1) Participants also expressed concern about what might happen if emergency services (e.g., ambulance) were called and repercussions for spottees from the police who often attend ambulance calls, and also from neighbours: --- But I just think that police can do what they want. They can decide that a personal amount is an amount for trafficking. They can find other reasons to arrest people or they can just threaten you with arrest and be generally aggressive and make it an unpleasant situation, regardless. (Spottee 11) The fear of criminalization stemming from police response during an overdose call was uniformly expressed by all participants and has been documented in the literature. This issue was particularly salient for participants who experienced intersecting oppressions. For example, one spottee who identified as a trans person described the following: This fear of criminalization was also acknowledged by participants when describing their willingness to engage in formalized spotting services, which often did not provide spottees with an opportunity to choose response plans (i.e., automatically call emergency services). Among participants who were aware of formalized spotting services, many described this policy as incredibly limiting and that it would deter them from wanting to use these services or from working within them. --- Emotional burden of the overdose crisis Despite priding themselves on spotting, and the sense of community it created, spotters explained how spotting had a significant toll on their mental health and well-being. Many described experiencing trauma related to the constant fear and multiple losses as a result of the ongoing overdose crisis in Canada. This emotional burden limited how often they were willing to spot for others: Because I think the problem is that right now, everybody is so burned out, that like, you almost feel like you're overburdening another person who already has so much on their plate, right? And so I think that, I mean, like, I think that this is exactly the issue, is that we're all so tired of this. (Spotter 7) Spotting offered a reprieve from the trauma they rexperienced as a result of overdoses amongst friends, family, and community members. Spotters explained that calling others to help instead of physically responding themselves to an overdose helped minimize the trauma of intervening: To be honest, the thing I like about spotting the most is that I can help someone, but I don't have to be the one to respond physically to the overdose. I can like whoever, like, say the parent of the person or I can call 911 for them, whatever they want me to do. --- But I don't actually have to be the one going through the trauma and the actions of saving someone's life. (Spotter 1) --- Recommendations for improving spotting A recognition of the emotional burden that can accompany spotting underlies a recommendation to ensure spotters have access to supports -including debriefing supports -when necessary: For people who are doing it informally, it would be nice if there was, like an awareness about a way to get support about, like, best practices or who to talk to about debriefing if something goes wrong. Cause like, nobody else knew that I was spotting in the scenario. So if he did, like, die for example, how do I go about talking about that, with other people [...] So even just the place to for advice or debrief, and then, I could see how if one was offering that as part of like, a program, organized program, hopefully, those supports would be there, to some degree or another but offering it informally, I don't even know where I would necessarily, like, turn. (Spotter 30) Other recommendations included compensation for spotters, guidelines for proper spotting practices, and improving accessibility, and awareness of spotting services among community members. As one spotter explained: Like, so if there was funds available for these services, for people to have paid roles in this, so that we could not formalize something, cause I hate that word. [...]But, I do like the sound of having funding for people to be paid for this service, so that it can be readily available when the user needs it, and um, so that it's not reliant on people just volunteering their time or you know, cause like, what if somebody needs me and I'm at my sister's wedding and nobody could pick up that time? (Spotter 6) --- Discussion This study explored how informal spotting operated in the context of the COVID-19 pandemic and identified key benefits, concerns, and recommendations for the improvement of spotting. This is the first study to report on spotting in the literature and to address this issue during the COVID-19 pandemic. PWUD use spotting as a method to ensure that overdose response will be available if needed. They also highlighted that barriers to accessing appropriate harm reduction services including NSP/ SCS and STBBI's prevention services, as well as fears of criminalization made spotting an appealing'safety net' in the context of a continuing overdose crisis. Among those who did not inject drugs, spotting provided access to overdose prevention which was otherwise inaccessible. Spotting has the potential to mitigate risk environments which are prevalent for PWUD and during the COVID-19 pandemic, has created opportunity for PWUD to connect with someone improving overdose prevention and physical distancing. Spotting's role in facilitating overdose prevention during the pandemic is critical given closures and reduced capacity of in person harm reduction care [11,24]. Even though spotting provides access in times and places where SCS are not available, the criminalization of drug use continues to act as a barrier to accessing this overdose prevention practice. As we document, spotting provided a perceived reprieve from the risk of criminalization faced when engaging with in person harm reduction services and when using in spaces other than one's home. However, many feared arrest if 911 were called. This fear has been documented by others. Kolla and Strike [32] document fear of police amongst people operating SCS in their homes. Latimore and Bergstein [33] reported a similar concern in a study of PWUD in Baltimore, Maryland. The majority of participants feared arrest after calling emergency services for an overdose event. Many were not aware of the Good Samaritan Law which was designed to extend "immunity from low-level charges and/or parole violations to overdose victims or bystanders who call 911, or otherwise seek medical attention" [33, p. 3, 34]. Evans and colleagues [35] further substantiated these findings as they reported that among 198 people who used non-medical prescription opioids only 45.5% were aware of the Good Samaritan Law enacted in Rhode Island. Changes to the Good Samaritan Law, policing practices, and emergency response policies are needed to ensure that PWUD can access services designed for them without fear of repercussion. Moallef and Hayashi [36] outline how knowledge of Good Samaritan Laws among police officers and emergency service responders is generally low across North America. Limited knowledge of this law amongst first responders facilitates negative experiences associated with overdose events for PWUD. Improving knowledge among these groups may therefore play a role in increasing the effectiveness of Good Samaritan Laws [36,37]. Jakubowski and colleagues [38] reiterate this point by advocating for incorporating Good Samaritan Law knowledge within overdose prevention training programs and services which has the potential to improve the effectiveness of Good Samaritan Laws. However, increasing opportunities for knowledge dissemination surrounding Good Samaritan Laws do not address longstanding mistreatment of PWUD by the police. Scholars have recently called for the implementation of police non-attendance policies to overdose events [33,36,39]. Such policies have been implemented in Vancouver, Canada where Police Department members do not attend overdose events unless requested by emergency services [36,39,40]. The lack of attendance of police officers will minimize risk of harm experienced by PWUD and may improve the effectiveness of Good Samaritan Laws. While better training and changes in policies may alleviate some of the harms of criminalization, decriminalization of simple possession is what is needed [41]. These changes will be important in general and also in relation to other forms of spotting that exist in Canada including apps [8], peer witnessing [42], and several formal spotting telephone lines [9,43]. Informal or formal spotting are tools for PWUD in this longstanding overdose crisis to reduce the number of people who use alone. Some research suggests that mobile app based technology in British Columbia may be beneficial in not only overdose prevention but in preventing co-occurring issues such as gender-based violence [44]. While our participants agreed that improved access to overdose response was crucial for their survival, they expressed hesitation to use these services if calling 911 was the policy in the event of an overdose. In addition, mobile apps come with distinct limitations such as accessibility concerns and general technology barriers [45]. Our study shares the limitations common to other qualitative studies related to size of the sample and transferability of findings. However, our exploratory community-based study benefited from the knowledge and connections of community members to rapidly recruit PWUD who may be difficult to recruit in general and in particular during a pandemic. As well, Damon et al. [46] outline the importance of using community based research approaches to minimize experiences of exploitation and stigma among PWUD. --- Conclusion Spotting is a novel addition to, but not replacement for, existing harm reduction services. Spotting is useful in any setting but may be particularly useful in contexts without access to SCS and other harm reduction services. While formal overdose lines, apps, and SCS provide important options to reduce overdose risks, our participants expressed a desire to continue to connect informally to their friends and family for spotting. To improve spotting, guidelines which provide information on how to effectively spot (i.e., what questions to ask when spotting) and include safety information for spotters and spottees should be developed in partnership with community members engaging in spotting and PWUD [47]. More research is needed comparing informal, formal, and mobile app based spotting and each methods relative benefits and limitations as well as how spotting practices can improve response times in overdose event situations. Increasing awareness of spotting and support for those who engage with spotting holds potential for providing an additional safety net for PWUD during the overdose crisis. • 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 Data sharing is not applicable to this article. --- Authors' contributions MP wrote the original draft of the manuscript, completed revisions, participated in the conceptualization of the manuscript content, participated in data collection and analysis and managed the development of the manuscript. NK completed revisions on the manuscript, participated in the conceptualization of the manuscript content, and participated in data collection and analysis. MB completed revisions on the manuscript, participated in the conceptualization of the manuscript content, and participated in data analysis. GK completed revisions on the manuscript, participated in the conceptualization of the manuscript content, and participated in data collection. AG completed revisions on the manuscript and participated in the conceptualization of the manuscript content. AB completed revisions on the manuscript. LC completed revisions on the manuscript. MG completed revisions on the manuscript. NT completed revisions on the manuscript. PM completed revisions on the manuscript. CS completed revisions on the manuscript, assisted in the conceptualization of manuscript content, participated in data collection and analysis, and provided overall supervision and guidance for the manuscript and study. All authors approved of the final manuscript draft. --- Declarations Ethics approval and consent to participate Ethics approval was obtained by the University of Toronto Human Subjects Review Committee. --- Consent for publication All participants provided verbal consent. --- Competing interests No competing interests to declare. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Spotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI's) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees.Research assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used.We interviewed 20 individuals between 08/2020-11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings.Spotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI's prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

Background --- Family support as a social determinant of sleep Families play an integral role in supporting the health and wellbeing of individuals, and several studies have shown that a lack of family support in the general population has been linked to poor sleep outcomes [1][2][3]. A US-based study involving 175 adults found that the presence of unsupportive parents was associated with a decrease in sleep quality as measured by the Pittsburgh Sleep Quality Index [2]. In another US study (n = 2871), having a supportive family relationship reduced the likelihood of monthly sleep problems by 18% and weekly sleep problems by 24% [4]. Moreover, in a 2018 meta-analysis of social support and sleep [1], the authors noted the lack of longitudinal evidence to understand the long-term impacts of family support on sleep. The importance of family support on sleep may be even greater for LGB individuals compared to the general population. A longitudinal study found that family support was the only source of social support (among family, friend, and partner support) uniquely associated with LGB mental health [5]. However, while cross-sectional association between family support and sleep has been established in the general population in the studies cited above, we are unclear of the strength of its influence on the LGB population and whether it has long-lasting impacts. Prior research has provided evidence that being socially excluded from one's family is linked to negative health outcomes for LGB individuals due to the increased allostatic load, emotion dysregulation, and cognitive processes that confer risk of poor mental health outcomes [6][7][8][9]. LGB-related discrimination and social exclusion can increase proximal stressors in the form of poor selfimage, internalized homophobia, fear of rejection, and concealing one's sexual orientation according to Hatzenbuehler's psychological mediation framework [10,11]. Previous studies among youth also provide evidence that family support has a critical role in shaping early LGB identity development [12,13] with sustained effects on mental wellbeing throughout one's adulthood [5]. These studies highlight the importance of family as a locus of LGB minority stress, which in turn can impact LGB sleep outcomes [14]. In Meyer's landmark paper on LGB minority stress [6], the author makes a similar argument that family exclusion, which he argues to be an important source of minority stress, has led to traumatizing effects on LGB individuals, leading to experiences of nightmares, sleep disturbances, diarrhea, and restlessness. Given that sleep problems are associated with cardiovascular disease [15], anxiety and depression [16], type-2 diabetes [17], and all-cause mortality [17], investigating the effects of family support on LGB sleep problems may help us better understand the determinants of persistent mental and physical health disparities across sexual orientations [18,19]. --- Lack of family support among LGB individuals Compared to heterosexuals, LGB individuals are more likely to be rejected by their families and experience a lack of family support [20,21]. In a US-based study (n = 224), two-thirds of sexual minority individuals reported experiencing family rejection because of their orientation [13]. LGB youth from the Longitudinal Study of Australian Children reported lower levels of family support compared to heterosexuals (0.43 standard deviations (SD) lower than the mean support of heterosexuals) [22]. In a study of Western Europe including 754 LGBT individuals, 51% reported discrimination and/or a lack of support from their families [23]. In a recent UK survey of 5375 LGBT individuals, only 46% reported that they were able to be open about their sexual orientation to their family [24]. A lack of family support for LGB individuals has been linked to a range of detrimental health outcomes, including higher risk of mood disorders [13,21], lower levels of psychological well-being [25], increased risks of suicide-related behaviours [13,26,27], a higher likelihood of experiencing internalized homophobia [28], and depression [13,21]. On the other hand, the contribution of family rejection/lack of family support to sleep problems among LGB individuals is not well understood. --- Disparities in sleep problems across sexual orientations Disparities in sleep problems between the LGB and general population have been documented in prior studies [25,[29][30][31]. LGB individuals are more likely to report short sleep duration and other sleep problems, including snoring, sleep latency, and low sleep quality, compared to the general population [17,32,33]. A population-based study examining 169,392 adults found that a greater number of sexual minorities reported less than 5 h of sleep compared to heterosexual individuals (17.3% vs 12.2%) [10]. In a US population-based study, gay men had 32% higher (adjusted) prevalence of trouble falling asleep and a 22% higher prevalence of waking up feeling unrested compared to heterosexual men, whereas bisexual women had a 43% higher prevalence of trouble falling asleep compared to heterosexual women [29]. A recent literature review noted that while sleep disparities for LGB individuals are well documented, there is a dearth of research investigating possible social determinants of sleep disparities across sexual orientations [34]. The authors found a possible relationship between stress and sleep problems for LGB individuals, where one study explored a pathway identifying family rejection as a possible determinant of LGB sleep problems [35]. The study found that sexual minority men have increased sleep difficulties which were mediated by poor relationships with their fathers: sexual minority men had 0.09 SD lower paternal relationship quality compared to heterosexual men (p <unk> 0.001), where each SD decrease in paternal relationship quality was associated with 0.04 SD (p <unk> 0.05) increase in sleep difficulties. However, the authors noted the limitations of their cross-sectional study and the need for longitudinal studies to justify causal inferences. The purpose of this study is to build on the prior literature by: 1) investigating prolonged impact of family support on LGB sleep problems, and 2) understanding the role of family support in the larger context of LGBspecific social support systems. More specifically, many LGB individuals who come out to their families of origin (e.g., biological or legal family) may encounter some form of rejection or negative reaction, which can lead to a greater reliance on extrafamilial relationships for support (e.g., advice, guidance, resources) [36][37][38][39]. These extensive friendship networks, also known as one's chosen family, have been found to buffer the negative effects of homophobia and rejection [40] by substituting support from one's family of origin. While family rejection can have an immediate effect on LGB sleep problems (captured in the prior cross-sectional study [25]), the association is unknown in the medium term (e.g. after 2+ years), as LGB people may adjust to family rejection by relying more on their chosen family for support. A number of qualitative studies show that sexual minorities consider chosen family members to be the most prominent sources of support in their lives [41][42][43]. However, a recent study of 175 LGBTQ+ individuals found that support from one's family of origin was associated with psychological wellbeing, and the effects of the chosen family were fully attenuated in adjusted models [39]. Research on the chosen family as a social determinant of LGB health is scant, and none have been linked to LGB sleep problems. Further research is needed to understand the interplay of support from family of origin and chosen family in the development of LGB sleep problems over the life-course. Our study uniquely contributes to the literature by 1) further clarifying the role of family support as a determinant of LGB sleep problems, and 2) investigating whether there is evidence that the chosen family can mitigate the effects of low family support on sleep among LGB individuals. Unlike prior studies that have largely focused on the short-term or cross-sectional associations of family support and sleep, we take advantage of a longitudinal design to investigate its prolonged impact (after 24 months). We ask the following research questions: 1) does family support have a prolonged effect on sleep problems for sexual minorities after adjusting for individual-and environmental-level confounders? 2) If so, can the friendship networks of LGB individuals (i.e., their chosen family) help mitigate the negative effects of family rejection on sleep? --- Methods The United Kingdom Household Longitudinal Survey (UKHLS) is a nationally representative longitudinal household panel study which began in 2009. The study included a random stratified sample of approximately 40,000 households in the first wave and has been surveying individuals aged 16 or older every 1-2 years. Further information on recruitment, locations, relevant dates, and follow-up can be found on the UKHLS website. Our sample included 1703 sexual minority individuals of the UKHLS who participated in the sleep questionnaires of UKHLS. Sexual orientation was captured by asking participants to identify which of the following best describes their sexual orientation: "heterosexual or straight", "gay or lesbian", "bisexual", "other", or "prefer not to say". Previous LGB studies have used this measure of sexual orientation as a valid instrument against multi-item instruments with high agreement (kappa statistic of 0.89) [44]. Participants with other sexual orientations (e.g. asexual, pansexual) may have self-identified as "other". Furthermore, the survey did not include a question on whether participants were transgender. A key advantage of longitudinal study is the opportunity to link prospectively measured exposure variables to subsequent individual-level health outcomes; therefore, the key exposure and control variables are captured at waves 2 and 5, and they are used to estimate sleep outcomes at waves 4 and 7 respectively. The use of time-lagged dependent variables is a common strategy to investigate long-term and lasting impacts of key exposures on a health outcome in longitudinal research [45]. The original survey was approved by the Ethics Committee of the University of Essex. The exemption for ethical approval was granted by the Brock University Research Ethics Board. --- Exposure measures To measure social support, we drew on the UKHLS family and friend support instruments, which have been previously validated and found to have high internal consistency (<unk> = 0.84) and predictive validity for general mental health and psychiatric distress as measured by General Health Questionnaire-12 [5]. Since the chosen family has been defined as one's extensive friendship network, rather than relationships established through blood and legal ties [36], we used the friend support questionnaire to measure it. The family and friend support instruments were administered in waves 2 and 5, and were constructed from six questions (i.e. understands the way you feel, can rely on them, can talk about worries, criticizes you, lets you down, gets on your nerves). Each question was rated from 1 (not at all) to 4 (a lot). Scores were summed for each participant at each time point and standardized. --- Outcome measure Sleep problems were measured in waves 4 and 7, which allowed us to examine the impact of family support 24 months after exposure. This study has 3 outcomes (sleep problems) that were based on the Pittsburgh Sleep Quality Index (PSQI), all of which were self-reported based on participant experience in the past month: the presence of sleep dysfunction, short sleep duration, and poor sleep quality. The PSQI has shown to have high validity and reliability with adult respondents (<unk> = 0.86) [16,46]. Based on a previous study [30] the participant was considered to have a sleep dysfunction if they indicated 'yes' to any of the following more than three times a week: a) unable to sleep within 30 min (sleep latency), b) cough or snore loudly, c) waking up mid-sleep or too early, d) trouble staying awake during the day. Short sleep duration was defined as sleeping less than 6 hours on average in the past month [31], and is associated with increased risk of obesity, cardiovascular disease, stroke, and depression [47]. Sleep quality was rated on a 4-point scale from very bad to very good and responses were dichotomized into good or bad quality sleep. --- Control variables We controlled for social factors that have been shown to influence LGB sleep problems at the neighbourhood-level based on prior literature, which included perceptions of neighbourhood safety [30]. To account for differences at the neighbourhood level, we used Buckner's Neighbourhood Cohesion index, which includes questions on neighbourhood safety, sense of belonging, trust in neighbours, and attraction to neighbourhood. The questions were rated on a scale of 1 (strongly agree) to 5 (strongly disagree). These responses were totaled and derived to reflect a final cohesion score of 1 for lowest cohesion to 5 for highest cohesion. Cronbach's alpha for waves 2 and 5 were 0.86 and 0.88, which demonstrates a high level of internal consistency. Prior studies have shown that the index is predictive of mental health in LGB individuals [11] and minority populations [48]. Regional differences have also been found to impact LGB sleep problems: a prior study found that state-level differences in support for same-sex marriage were associated with poor sleep among lesbian women [49]. Therefore, we controlled for regional-level fixed effects (i.e., London, North East, North West, East Midlands, West Midlands, East of England, South East, South West, Yorkshire and the Humber, Wales, Scotland, and Northern Ireland) to adjust for difference in level of LGB acceptance and availability of resources. Furthermore, we controlled for LGB density at the regional-level, which was derived using the Annual Population Survey [50]. The following individual-level characteristics were included as potential confounders: net individual income in the last month (£), highest level of education attained (no education, GSCE/A-Level, degree/higher degree, or other), ethnicity (British white, other European white, and non-white), physical health (measured using Short Form-12 physical component score, PCS-12), adverse health condition (presence of a diagnosed mental or physical chronic condition in the last 12 months), current smoker and/or heavy drinker (defined as 26 units for men, 18 for women, in a single sitting at least once in the past month) [51], frequent use of sleep aid medication (more than once a week), year fixed-effect, sexual orientation, natural log of age, and gender (man/woman). Since the UKHLS only included a single item question for sex (with the only available choices being male or female), sex was used as a proxy for gender in our study. --- Statistical analysis Mixed-effect logistic regressions were used to estimate the longitudinal associations between the main exposures (family and friend support) and a time-lagged dependent variable (sleep outcomes) using a maximum likelihood algorithm while controlling for all potential confounders described above. Three fully adjusted models are presented in this paper, with model 1 for sleep dysfunction, model 2 for short sleep duration, and model 3 for poor sleep quality (see Supplementary Tables 1 and2 for unadjusted associations between family support/friend support and sleep outcomes). For all models, serial autocorrelation is dealt with through individual-level random intercepts. Survey weights were included to minimize bias from selection of participants and non-responses. We tested for interaction between our 2 main exposure variables, family and friend support, in all models. Models were estimated using the PGLM (panel generalized linear models) package in RStudio version 1.2.5001. For all results, we followed a standardized method of converting odds ratios to relative risk [52]. To deal with missing data, we analyzed the full, incomplete dataset using maximum likelihood estimation (MLE). This method does not impute any data, instead it uses each case's available data to compute MLE based on the distributional properties of the statistical model. The likelihood is computed separately for those cases with missing data and those with complete data on all variables. These two likelihoods are maximized together to find the estimates. Prior studies provided evidence that MLE performed similarly to multiple imputation in its ability to provide unbiased parameter estimates and standard errors in empirical and simulation studies with missing data [53,54]. --- Results In our study sample (n = 1703), 43.1% had sleep dysfunction, 16.4% had short sleep duration, and 20.0% had poor sleep quality. The average lag time between the measure of the main exposures (family and friend support) and sleep outcomes is 24 months (SD = 1.5 months). Family and friend support had high internal consistency, with Cronbach alpha of these measures at <unk> = 0.88 and <unk> = 0.89 respectively. Baseline characteristics of the study sample are displayed in Table 1. In unadjusted analyses, 1 and2). We found evidence that family support was independently associated with all three of the tested sleep problems after 24-months in LGB individuals. In fullyadjusted regression models (see Table 2), each standard deviation increase in family support was associated was associated with a 0.94 times lower risk of sleep problems (95% C.I = 0.90-0.98), a 0.88 times lower risk of short sleep duration(95% C.I = 0.81-0.95), and a 0.92 times lower risk of sleep quality (95% C.I = 0.93-0.98), with results from models 1, 2, and 3, respectively. Friend support was not independently associated with any sleep problems in fully adjusted models. In separate models, we tested for effect modification of friend support by family support, but we did not find evidence that the effect of friend support on sleep was different for those at different levels of family support. In addition, bisexual women were independently associated with a 1.15 times greater risk of experiencing sleep --- Discussion The importance of family support on sleep problems Our study provides evidence that family support (i.e., support from one's family of origin) has a prolonged effect on the sleep problems of sexual minorities, where higher levels of family support were associated with reductions in the risk of sleep dysfunction, short sleep duration, and poor sleep quality. In contrast, support from the chosen family did not have prolonged effects on the sleep problems with sexual minorities, and we did not find evidence that the chosen family was able to mitigate the negative effects of family rejection on sleep problems. While the effects of family support in our study may seem modest in size (e.g., 12% reduction in risk of short sleep duration with 1 SD increase in support), the effects are consistent across the 3 sleep outcomes we tested. Moreover, the salience of low family support among sexual minorities means that even modest effect sizes add up to a significant LGB health issue: approximately half of LGB individuals (based on Western European studies) experience low family support and rejection [28,29], and up to two-third of LGB individuals in the US reported family rejection based on their sexual orientation [13]. The lack of family support in LGB individuals has been examined for its impact on a range of health outcomes [13,21,26,55], but this is the first study to investigate its effects on sleep problems, and more importantly, establish the persistent nature of the problem. While prior cross-sectional studies have investigated the association between low family support and sleep problems [1][2][3], and our results are consistent a prior cross-sectional study that found that LGB sleep difficulties are mediated by parental relationships [35], the lack of longitudinal studies (in the general or LGB population) has prevented researchers and clinicians from understanding the prognosis of sleep problems as a result of low family support. By establishing that the association between sleep problems and low family support persists over 24 months, we provide evidence that LGB sleep problems resulting from low family support are likely not going to "go away on their own" through psychological adjustment or adaptation. Historically, advocacy organizations including PFLAG [56] (Parents, Family and Friends of Lesbians and Gays) in the US (1973), and FFLAG [57] (Families and Friends of Lesbians and Gays) in the UK (1956) were established to address the abuse (e.g. verbal, physical, property crimes) and rejection experienced by sexual minorities perpetrated by their family of origin. Despite advancements in LGB human rights such as marriage equality and anti-discrimination laws [58], there are still persistent health disparities across sexual orientations, many of which may be the result of family rejection [13]. Our study results (covering the period of 2012-2017) highlights the harms (with regards to sleep problems) as a result of widespread unsupportive families among sexual minorities that continues today, and the ongoing need to improve the capacity of these organizations to improve LGB family support through sustained funding from local and national governments. In addition, our findings emphasize the need for evidence-based family oriented interventions for sexual minorities such as the Family Acceptance Project [55], which help families accept and support their LGBT children. The Family Acceptance Project has developed a screening tool that helps identify and measure family and caregiver behaviours that are predictive of negative health and mental health outcomes for LGBT youths. --- The influence of the chosen family on sleep problems Our study is also the first to provide evidence that support from one's chosen family (i.e. friend support) did not reduce sleep problems among sexual minorities. Furthermore, there is no evidence that support from one's chosen family can replace family support (i.e. the effect of friend support on sleep was not significant at any level of family support). Our results are consistent with a prior longitudinal study association between friend support and general mental health that was fully attenuated after adjusting for family support [5], and a qualitative study that chosen family is more likely to complement rather than replace the support of biological families [43]. Therefore, support from one's chosen family alone may not be enough to completely overcome the sleep problems associated with having an unsupportive family of origin. However, these findings are nonetheless notable, given the myriad qualitative studies that emphasize the integral role that chosen family can play in an LGB individual's life, whether the chosen family is additive or completely substitutes the support of their family of origin [41][42][43]. Additionally, when the chosen family is complementary to their family of origin, sexual minorities tend to place more value in approval received from their friends over that of their family, and feel generally more supported by friends [42]. --- The protective effect of neighbourhood cohesion Our findings also suggest that neighbourhood cohesion has a protective effect against sleep problems in sexual minorities, which is consistent with prior studies that identified the same protective effect among Native [59] and Latino [60] populations in the US. While there is currently no evidence of the effect of neighbourhood cohesion on sleep among sexual minorities, a prior study has found that neighbourhood cohesion has a positive influence on the mental health of LGB individuals [11]. As neighbourhood cohesion is the social connections shared with one's neighbours, the sense of belonging that develops through these relationships may be of added value for sexual minorities as LGB individuals tend to face social rejection from other areas of their lives [23,43]. Future studies should investigate how interventions to increase neighbourhood cohesion (e.g. promoting safe spaces for LGB individuals and LGB-friendly community events) may reduce sleep problems among sexual minorities, in order to understand how to design neighbourhoods that promote sexual minority health. --- Strengths and limitations Although it is well-documented that sexual minorities have worse sleep outcomes compared to the general population, there are few studies examining possible social determinants of LGB sleep problems [35,61]. While a previous study suggested the possible influence of family support on LGB sleep problems [35], a causal relationship could not be established from its cross-sectional design (i.e. it is possible that sleep problems may have exacerbated family support issues). Our study uses a repeated measures analysis with time-lagged dependent variables (24-months lag) to establish temporal ordering of the family support exposure and sleep outcomes, which provides stronger evidence that family support should be considered a social determinant of sleep for LGB individuals. While a number of studies have demonstrated that a lack of family support is linked to a range of health outcomes in LGB individuals (i.e. higher rates of mood disorders, suicide-related behaviours [27], risky sexual behaviours, and illicit substance usage [13], our study provides further evidence that it can also contribute to sleep problems. There are a few study limitations that would affect the generalizability of our results: 1) A single item question was used to capture the sexual orientation each participant identified with, but did not include questions on sexual attraction and behaviours. This may lead to respondents selecting a sexual orientation that does not truly represent the complex nature of their sexuality, which can then lead to misclassification. The availability of the "other" category may have helped reduce misclassification: since it is available to participants who did not feel they belonged to the categories of heterosexual, homosexual, or bisexual. 2) The UKHLS survey does not include any information on the participant's disclosure of their sexual orientation to their family members, which could be considered a potential confounder. 3) The UKHLS survey does not ask about gender identity (i.e. does not include transgender and non-binary as valid choices), which limits the generalizability of our results and they may not be applicable to transgender individuals. 4) Sleep problems were based on participant self-reports which may affect the reliability of this measure; however, the PSQI is a well validated instrument used in prior studies to identify sleep problems. 5) There was approximately 14% missing data for family and friend support which may have led to selection bias, however our statistical models used MLE to account for the missing data which has been shown to be comparable to using multiple imputation [53]. 6) Another source of selection bias could be that self-identification of LGB on the UKHLS survey may be influenced by potential family rejection, resulting in some individuals misidentifying instead as heterosexual or preferring not to say. It is important to note that sexual orientation concealment (e.g. not disclosing one's sexual orientation for the fear of social and family rejection) has been linked to reduced physical and mental health in prior studies [62,63], and increases the risk of experiencing sleep disturbances [6]. Moreover, these individuals with concealed sexual identities have been found to have lower levels of family support [64]. Therefore, by excluding this group, our findings may have been biased towards the null. 7) While there were no evidence from our study that the effect of family support on sleep problems differed by sexual orientation (e.g. homosexual vs. bisexual), we cannot rule out this possibility given the small cell sizes in some categories, which could have resulted in a Type-II error. Future studies that are sufficiently powered to investigate the effect modification by gender and sexual orientation groups are required to rule out the possibility of effect heterogeneity of family support across these categories. --- Implications for practice Findings from our study support the development of routine protocols for screening of sleep problems in LGB patients in primary care settings. For clinicians working with LGB people who experience sleep problems, they can investigate the patient's level of family support as a potential cause of these issues, which can then inform further clinical or social interventions. For example, psycho-social supports which aim to improve sexuality support within the family unit such as through family counselling or culturally-informed psychotherapy, can target the root issue of rejection and lack of support that drives the sleep disparity among sexual minorities. --- Availability of data and materials Waves 1-9 of UKHLS data are available via registration with the UK Data Service (beta. ukdat aserv ice. ac. uk/datacatalogue/series/series?id = 2000053). This dataset is open to the public. --- Abbreviations LGB: Lesbian, gay, bisexual; UKHLS: United Kingdom Household Longitudinal Survey; PSQI: Pittsburgh Sleep Quality Index; PGLM: Panel generalized linear model; MLE: Maximum likelihood estimation. --- Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12889-021-12308-0. --- Additional file 1. Authors' contributions AC, AN, CT conceived the study and drafted the first versions of the manuscript, AN and CT performed the data management, and CT performed the statistical analyses. Funding was provided by AC for the study. All authors contributed to the design of the study and the interpretation of data, contributed important intellectual content to the manuscript and have approved the final version to be published. --- Declarations Ethics approval and consent to participate The University of Essex Ethics Committee has approved all data collection on Understanding Society main study and innovation panel waves, including asking for verbal consent for all data linkages except to health records. The exemption for ethical approval was granted by the Brock University Research Ethics Board. --- Consent for publication Not applicable. --- Competing interests On behalf of all authors, the corresponding author states that there is no conflict of interest. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: There is growing evidence that lesbian, gay, and bisexual (LGB) adults experience more sleep problems than the general population. As LGB individuals experience a significantly greater risk of family rejection and low family support, our study investigates the role of family support as a potential determinant of LGB sleep problems over a prolonged period, and whether friend support (i.e. chosen family) can mitigate the effect of low family support. Given the importance of sleep on mental and physical health, study results may help shed light on persistent health disparities across sexual orientations.LGB individuals from the UK Household Longitudinal Study (UKHLS). Mixed-effect logistic regressions were used to estimate the effect of family and friend support on the development of sleep problems after 24 months while controlling for potential confounders. A modified Pittsburgh Sleep Quality Index was used to measure 1) presence of any sleep problems, 2) short sleep duration, and 3) poor sleep quality. Results: Family support at baseline was independently associated with all sleep problems in our study after 24-months: 1 SD increase in family support was associated with a 0.94 times lower risk of sleep problems (95% C.I = 0.90-0.98), a 0.88 times lower risk of short sleep duration (95% C.I = 0.81-0.95), and a 0.92 times lower risk of sleep quality (95% C.I = 0.93-0.98). Support from one's chosen family (proxied by friend support) did not mitigate the effects of low family support on sleep problems.Our study found a consistent effect of family support across all sleep outcomes along with evidence of a persistent effect after 24 months. Our findings point to the importance of targeting family support in designing interventions aimed at reducing LGB sleep problems.

Introduction Opposition to same-sex marriage reflects the denial of opportunities to one group of people that are routinely afforded to another. For this reason, it is understood by many as inherently unjust and prejudiced [e.g., [1][2][3]. Empirically, research confirms this understanding, with positive associations observed between same-sex marriage opposition and both direct [4] and indirect [e.g., 5,6] measures of prejudice. In the current paper, however, opposition to samesex marriage, as well as support for it, are examined through a different conceptual and empirical lens. In particular, we do not assume from the outset that one group of people in this debate (e.g., supporters) is somehow rational and just, while the other (e.g., opponents) has a flawed psychology and a flawed sense of justice. Instead, we propose that political debate over samesex marriage is characterized, at least in part, by conflicting understandings about what constitutes prejudice itself. It is this intergroup conflict over subjective understandings of what is and is not prejudice that forms the empirical basis of the current paper. Below we present a brief review of social-psychological conceptualizations of prejudice, with a particular focus on the variability of these conceptualizations and their ultimate bases in social norms. From this, hypotheses are derived that are evaluated in an experiment measuring perceptions of prejudice, tolerance and truth in the context of the 2017 Australian national poll on support for, or opposition to, same-sex marriage [7]. --- Psychological conceptualizations of prejudice Social psychology has a long history examining prejudice [e.g., [8][9][10][11]. Most of this work has focused on the expression of negative intergroup attitudes, and has been highly successful in identifying the causes of these attitudes as well as various means of changing them [e.g., [12][13][14][15]. Recent analyses, however, have highlighted challenges inherent in the prejudice concept that make it a variable and changing target in terms of both theoretical understanding and prejudice-reduction efforts [16,17]. For example, although negative intergroup attitudes characterize most understandings of prejudice [16], not all negative intergroup attitudes are equally recognized as such. In fact, some negative intergroup attitudes are, at times, seen as just and accurate descriptions of reality (e.g., negative attitudes toward child molesters; [17,18]). At the same time, not all prejudice research has focused exclusively on the expression of negative attitudes. Indeed, Allport's [8] original analysis recognized that positive attitudes can also be understood as prejudiced (see also [19]). This variability in attitude valence is exposed in the tensions inherent in the identification and expression of "modern," "symbolic," and "benevolent" prejudice [20][21][22]. In contrast to more explicitly negative "traditional" or hostile forms of prejudice, modern/symbolic/ benevolent prejudiced attitudes are often congruent with other broadly accepted group norms and values (e.g., hard work, religious values). Unfortunately, this variability in understanding means that psychologists often end up examining not a single concept, but multiple ones, often with different underlying assumptions about the social and psychological processes underlying them [23]. What consensus there seems to be among both researchers and lay people alike is that prejudice is about groups and it is bad [e.g., 24]. Effectively, prejudice is understood as the expression of wrong or inappropriate attitudes about groups and group members [25,26]. Even conceptualizing prejudice as a form of pre-judgement, for example, assumes a more appropriate and correct form of judgement. This "enlightenment" perspective, thus, assumes that prejudice emerges because people do not have access to the full understanding of the true nature of groups and group members [27]. This is demonstrated in work that links lower cognitive abilities to prejudice [e.g., 28], implicitly suggesting that higher cognitive abilities would allow one to gain a more accurate understanding of the "facts." Similarly, an explicit purpose of intergroup contact to reduce prejudice is that of "learning about the outgroup" [29, p. 65]. Again, this perspective presupposes that prejudice is the consequence of inaccurate beliefs. And, of course, educational programs that directly attempt to teach non-prejudiced ways of understanding [30] once again presuppose that prejudice emerges from inaccurate beliefs. Another way of characterizing this perspective is by recognizing that it assumes prejudice emerges when attitudes and beliefs diverge from normative standards of accuracy and correctness [17]. Critically, however, such normative standards have their own bases in the social psychology of group life [e.g., 31,32]. Indeed, social psychologists have long acknowledged that divergent understandings of the same reality can be (and often are) determined by people's group memberships and the nature of the intergroup relations [e.g., [33][34][35]. In the context of the current analysis, when group members do not agree upon what the facts are, or how to determine facts in the first place, then they are not likely to agree on what attitudes are or are not prejudiced as well [36]. This is seen very clearly in political debates over same-sex marriage [37,38]. Each side of the debate harnesses facts to support its position, and neither considers itself to be prejudiced (a process that extends to prejudice debates beyond the same-sex-marriage; [18,39]). When admission of prejudice is at least hinted at, it is often done with the disclaimer that "I'm not prejudiced, but..." [40,41]. The use of such disclaimers reveals speakers' awareness that their attitudes may be perceived as prejudiced, and that work is needed to avoid incurring the prejudice label [42]. The need for this work emerges because the prejudice label itself is seen as pejorative by implying irrationality and non-normative behaviour [43,44]. Indeed, being simply labelled as prejudiced has the potential to evoke feelings of offense and anger [45], so that people actively seek to avoid this label across a variety of intergroup contexts [e.g., 46,47]. Opponents to same-sex marriage, for example, are actually "sensitive to the possibility of being labelled homophobic" [38, p. 11]. --- The current research Currently, we propose that the identification of attitudes as prejudiced or not is always, and necessarily, done with reference to perceived norms and values of one's salient group membership, situated within a particular intergroup context [e.g., 17,48]. In this way, people will view attitudes they share with a salient in-group to be rational, veridical and unprejudiced. In contrast, non-normative attitudes will be seen as irrational, untrue and, in the case of intergroup attitudes, prejudiced. Note that the absolute valence of the attitudes is irrelevant in this analysis, as are independent assessments of veracity. Of course, as scientists, we do not deny an independently verifiable reality. However, our assumption is that the means by which people confirm this reality is tied to their salient group memberships (just as ours is tied to science). In this manner, different people's understandings of truth and prejudice will be tied to their group memberships. To the degree that there is variability in group memberships, then there will also be variability in understandings of prejudice, as noted above. In the case of attitudes toward same-sex marriage, this leads us to predict that (H1a): Supporters of same-sex marriage will judge expression of support for same-sex marriage as unprejudiced and tolerant, and opposition as prejudiced and intolerant. In some ways, H1a is unremarkable, as it is congruent with our opening observation. However, we also predict that (H1b): Opponents of same-sex marriage will judge expression of opposition to same-sex marriage as unprejudiced and tolerant, and support as prejudiced and intolerant. Moreover, we predict that (H2): Members of each (supporting or opposing) opinion-based group will see their own views as both veridical and normative of the broader society, while the other group's views will be seen as false and non-normative. We tested these hypotheses in a sample of Australians and, as such, this "broader society" was operationalized as Australians. --- Method --- Participants and design Participants were sampled using Qualtrics Australia panel service. Data supplied by this service included an initial sample of 460 participants who satisfied several inclusionary criteria, including: (1) correctly responding to an experimental manipulation check (described below), (2) correctly responding to all three included conscientious responder items [49], and (3) indicating that they had well-informed views about the same-sex marriage debate. Moreover, a relatively balanced male-female gender ratio was sought, as was a basic age stratification. Of these, 44 participants asked that their data not be included in the final analyses (an ethical requirement imposed upon the current study). Finally, one participant under the age of 18 years was excluded from analyses (an ethical requirement and a requirement of the study design, as the minimum Australian voting age is 18 years). Participants were sampled on 5 November, 2017-8 November, 2017. These were the final days during which the Australian government held a non-binding, national Postal Survey of all eligible voters' support for, or opposition toward, same-sex marriage. Postal Surveys were distributed to Australians from 12 September, 2017 and were required to be received by the government no later than 7 November, 2017. As such, at the time the current study was conducted, considerable public debate about the Postal Survey had already occurred [e.g., 50,51]. Participation rate in the Postal Survey was 79.5% of eligible voters (all Australians over the age of 18 are required by law to register to vote; [7]). Of the final sample, 199 identified as male and 216 identified as female. Ages ranged from 18-89 years (median = 50). Two-hundred, twenty participants identified as "White"/"Caucasian"/"Anglo" or simply "Australian;" of course, someone who identifies as "Australian" could also be of, for example, Aboriginal, Asian or African descent, making it difficult to present accurate frequencies of the remainder of the ethnic composition. One-hundred, sixty-three participants had completed some level of university education, while 126 completed tertiary vocational education or apprenticeships. Three-hundred, seventy-four participants indicated that English was their first language. Of particular relevance to the current research on same-sex marriage, a total of 254 people were or had been married (189 people reported being currently married, 10 separated but not divorced, 43 divorced, and 12 widowed); a further 48 people reported being in de-facto relationships. In terms of sexual orientation, 335 people indicated that they were "only attracted to members of the opposite sex;" twenty-seven indicated being "only attracted to members of the same sex," 32 people indicated being attracted to members of the same sex, opposite sex and transgender persons, 10 indicated not "really that attracted to other people," six indicated that their "preferences are more complicated than the options provided," and five preferred not to say. Finally, 252 participants (60.7% of the sample) identified as supporters of same-sex marriage while 163 participants (39.3% of the sample) identified as opponents of same-sex marriage. These numbers compare quite well with the final distribution of supporters (61.6%) and opponents (38.4%) in the broader population based on the Postal Survey. Each participant was randomly assigned to one of two between-participants conditions in which they were presented with a statement either supporting or opposing same-sex marriage (described below). The research design was, thus, a 2 (measured participant support for or opposition toward same-sex marriage) x 2 (manipulated stimulus statement supporting or opposing same-sex marriage) between-participants factorial. --- Materials and procedure Participants first read a Statement of Informed Consent. Upon agreeing to continue, they read a brief introduction reminding them about the same-sex marriage Postal Survey, stating "...there are a lot of different views on the matter. In the current survey, we're interested in what average Australians think about this matter and what they think about some of the opinions people have been expressing." This was followed by a statement informing participants that they would be presented with "...one randomly selected opinion on the matter. Please read the opinion and consider what the author has said. We will then ask you about your own opinions about what the author said." The subsequent screen then informed participants that "a statement is now being randomly chosen," which was followed by one of two statements representing the experimental manipulations. Each statement began with "Marriage has been around for centuries. What makes a marriage though is a life-long romantic commitment between...." The statement in support of same-sex marriage continued with "....two people, whoever they may be. That is why I'm voting YES in the survey." In contrast, the statement in opposition to same-sex marriage continued with "...a man and a woman, whoever they may be. That is why I'm voting NO in the survey." These two stimulus statements were constructed to be relatively pallid in nature, simply reaffirming support for, or opposition toward, same-sex marriage. We intentionally did not provide explicitly negative statements. Indeed, even the oppositional statement was affirmative about a particular understanding about human relationships. Moreover, the statement in support of same-sex marriage is, at least on the surface, explicitly and intentionally devoid of attributes that would allow it to be categorized as prejudice by most conceptual accounts (e.g., negative intergroup attitudes or feelings; [16,17]). Both statements also include an attribute that, with deeper reflection, participants could have easily recognized as a falsehood: that there is a centuries' long tradition of marriage involving life-long romantic commitments. This explicitly ignores, for example, arranged and forced marriages in which romance and commitment may play little to no part. Our goal in constructing the stimulus statements in this nature was not simply to reaffirm negative intergroup statements as prejudice. Instead, our goal was to identify conditions under which statements that would not otherwise be formally categorized as prejudice would be judged as such by lay perceivers. Despite our pursuit of experimental control in the design of our stimuli, we recognize that the public discourse on this issue at the time of the national survey was often more emotionally charged and even hostile than our more staid manipulations; participants may well have encountered this hostility outside the context of this study, either directly or indirectly (e.g., traditional media, social media). We reflect on this briefly in our Discussion. A single multiple-choice manipulation check question followed the presentation of the statement, stating, "Just to make sure you understand a bit about the statement...the author of the above statement is going to vote...." Response options available to participants were simply "yes", "no", and "did not say." Only data from participants who correctly answered this question were provided by Qualtrics panel service. To encourage participants to reflect on the statement, they were then given a free-response opportunity to write their thoughts in response to the statement, "My own views about the statement above are..." (the data measured here will form the basis of a separate publication). At this point, the primary dependent variables were presented. Participants were asked to "use the rating scales below to record your thoughts about the statement... 'I think the statement is....'" A series of 40 items comprising six conceptual scales were randomly presented to each participant. The items, the scales they comprised, and Cronbach's alpha for each scale are presented in Table 1. As can be seen, the scales measured perceptions of prejudice, tolerance, truth, Australianness (i.e., normativeness within the broader society), individual liberty, and sinfulness. The individual liberty and sinfulness scales were not related to our hypotheses, and were included for exploratory purposes. Individual liberty was included because arguments in favour of same-sex marriage often rely on this concept. Similarly, arguments against same-sex PLOS ONE marriage often rely on the concept of sinfulness. Although all of the scales were uniquely developed for this study, similar methods have been used in other research [e.g., 48,52]. All responses were measured on seven-point Likert scales (1 = strongly disagree, 7 = strongly agree). Participants were then presented with a new set of 12 randomly-presented evaluative items [e.g., 53] and were asked to provide judgements of "yes voters" and "no voters" (counter-balanced) in general (i.e., not of the stimulus statement, as above). The items were "aggressive" (reverse coded), "competent," "friendly," "honest," "intelligent," "intolerant" (reverse coded), "pleasant," "sincere," "skilful," "threatening" (reverse coded), "trustworthy," and "warm." All responses were measured on a six-point scale (1 = not at all; 6 = extremely). These items allowed us to measure directly in-group favouritism in the current intergroup context. Finally, participants answered additional questions, including demographics. The additional questions included scales measuring social dominance orientation, right-wing authoritarianism, religiosity, and endorsement of political correctness attitudes; these will form the basis of a separate paper. Including these four scales as covariates did not alter the pattern of currently reported results. In the demographic section, participants were presented with a single item measuring the extent of their social identification with their opinion-based group, "I identify with YES [NO] voters" (1 = fully disagree, 7 = fully agree; [54]). The experiment ended with a complete written debriefing, including an explanation of the fictitious nature of the attitude statement presented. --- Results A single missing value was identified and replaced with an estimate derived from the expectation maximization procedure. In an attempt to control for personal self-interest, each of the following analyses was re-conducted with a reduced sample excluding participants who could potentially benefit personally from the institution of a same-sex marriage law (i.e., participants who expressed same-sex attraction). The pattern of results in all cases was identical to what we currently present. --- Social identification A 2 (measured participant support for or opposition toward same-sex marriage) x 2 (manipulated stimulus statement supporting or opposing same-sex marriage) between participants analysis of variance (ANOVA) on participants' levels of social identification with their in-group revealed no statistically significant main or interaction effects. Importantly, there was no significant difference in levels of social identification between supporters (M = 6.43, SEM =.08) and opponents (M = 6.21, SEM =.10), F(1,411) = 2.93, p =.09. Participants' overall levels of social identification with their supporting or opposing in-group was extremely high (M = 6.34, SEM =.06). A full 85.32% of supporters and 80.98% of opponents reported social identification levels of either 6 or 7 on the seven-point scale. Because of the highly skewed nature of this measure, we did not employ it further as a potential moderator in the primary analyses. --- Primary analyses Independent 2 x 2 ANOVAs were conducted on each of the six evaluative scales described in Table 1. More relevant to the hypotheses, participants' responses on each of the six dependent variables entered into highly significant disordinal interactions. The F-statistics are presented in Table 2, and the interactions are presented in each of the panels of Fig 1. Consistent with our hypotheses, both supporters and opponents of same-sex marriage judged the in-group statement as being tolerant, truthful, and Australian, while the out-group statement was clearly perceived as relatively prejudiced. A similar pattern was also found in judgements of individual liberty. The only interaction that deviated from this symmetrical pattern was participants' judgements of sinfulness. Along this dimension, only same-sex marriage opponents perceived a difference between the statements, with a supporting statement being perceived as more sinful than an opposing statement. Simple effects comparisons within the supporter and opponent groups were all statistically significant (all ps <unk>.001) except for supporters' judgements of sinfulness (p =.39). The common pattern replicated across the panels of Fig 1 suggests that the six scales are likely to be correlated. Separate analyses confirms this (see Table 3). However, we chose to maintain the independent ANOVAs (rather than averaging across all items) precisely to reveal this common pattern emerging across conceptually different judgements. Concerns of enhanced Type 1 errors are mitigated against in light of the currently obtained high levels of statistical significance. We also chose to maintain our original conceptual scales rather than empirically deriving them because a separate principal-components analysis with varimax rotation yielded a solution in which multiple items loaded highly across several components. As such, the solution was suboptimal in identifying independent scales despite the varimax rotation. Although these common patterns exist (with strong disordinal interactions), it is also visually apparent that the magnitude of the pair-wise difference in ratings within same-sex marriage supporters is often different from that within same-sex marriage opponents. To examine these apparent differences, we recoded our data to allow us to conduct 2 (measured participant support for or opposition toward same-sex marriage) x 2 (judgement of an in-group statement or judgement of an out-group statement) between participants ANOVAs. In these new analyses, the interactions reported above will manifest as simply main effects for the judgement of ingroup vs. out-group statements. However, a significant interaction will now indicate that the magnitude of this main effect differs between supporters and opponents. These significant interactions were observed for three judgements only: prejudice [F(1,411) = 56.35, p <unk>.001, <unk> 2 partial =.12], tolerance [F(1,411) = 137.26, p <unk>.001, <unk> 2 partial =.25], and sinful [F(1,411) = 163.66, p <unk>.001, <unk> 2 partial =.29]. We consider the implications of these differences in our Discussion. --- In-group favouritism The 12 evaluative items used to measure in-group favouritism had high internal reliability for judgements made of same-sex marriage supporters (<unk> =.96) and same-sex marriage opponents (<unk> =.96). As such, means of the two sets of 12 items were calculated for each participant and analysed in a 2 x 2 x 2 mixed ANOVA, with the final factor being the within-participants judgements of each of the two groups. The only statistically significant effect to emerge was the two-way interaction between participants' own group and the group being evaluated, F(1,411) = 389.65, p <unk>.001, <unk> 2 partial =.49. Strong in-group favouritism was found: Supporters of samesex marriage judged fellow supporters more favourably (M = 4.77, SEM =.07, 95% CI [4.64, 4.90]) than opponents (M = 3.03, SEM =.07, 95% CI[2.90, 3.17]), while opponents of same-sex marriage judged fellow opponents more favourably (M = 4.69, SEM =.09, 95% CI [4.52, 4.86]) than supporters (M = 3.20, SEM =.08, 95% CI [3.04, 3.36]). --- Post-hoc analyses: Controlling for in-group favouritism We recognize that the observed interactions from the primary analyses presented in Fig 1 are similar to the in-group favouritism interaction also observed. It may, thus, be that the Fig 1 --- Post-hoc analysis: Examining mediation In our Introduction, we reasoned that group members are not likely to agree on what is and is not prejudice if they do not agree on what the facts are in the first instance. We explored this possibility by examining whether perceived truth mediated the relationship between the interaction of support/opposition toward same-sex marriage and the supporting/opposing stimulus statement on judgements of prejudice (including the measure of in-group favouritism as a covariate). Using Hayes' Process model, the index of moderated mediation was significant (IMM = -3.86; 95% CI [-4.45, -3.29]). The interaction process that we observed in the prediction of prejudice judgements is, indeed, mediated by judgements of truth. --- General discussion The current research examined group members' perceptions of what is and is not prejudice in the context of a political debate over legalizing same-sex marriage in Australia. Rather than assuming from the outset that one side of the debate was inherently just and correct while the other was inherently prejudiced, we asked the group members themselves to provide their own judgements of claims supporting or opposing same-sex marriage. Supporters of same-sex marriage saw opponents' views as prejudiced, intolerant and untruthful, while their own views where perceived as unprejudiced, tolerant and truthful. As noted, this finding is broadly unsurprising, as opposition to same-sex marriage denies a group of people opportunities that others are granted. What is more novel is that opponents of same-sex marriage did not share this view. In fact, they saw their own views, too, as unprejudiced, tolerant and truthful, while supporters' views were perceived as relatively prejudiced, intolerant and untruthful. Although these judgements have an element of in-group favouritism, the patterns remained even after statistically controlling for direct expressions of in-group favouritism. We propose that these are genuine views held by members of each group. The patterns were not simply about hurling the pejorative prejudice label against out-group members, but about grounding the in-group perspective in subjective understandings of truth and in-group normativeness. Group members on each side of the debate were essentially saying, "We see reality as it truly is, and our fellow Australians concur with us. They do not understand this reality and are, hence, relatively prejudiced and intolerant." This pattern has important implications for the enlightenment perspective of prejudice described in the Introduction. This perspective assumes that there are objectively prejudiced people and objectively enlightened people, and that enlightened people must educate the prejudiced if there is to be appropriate social change. The current data suggest, however, that all people see themselves as enlightened (at least on average). To this degree, each side may feel no need to receive further education and, moreover, may feel responsible to "educate" those on the other side. In this case, such education becomes a social influence attempt [55] to persuade out-group members to see the world as they (the educators) do themselves. These data thus pose clear conceptual and applied challenges. On the one hand, they compel researchers and social-change agents alike to reflect more deeply on the concept of prejudice itself, and articulate precisely the parameters around which the concept is understood and defined. As we observed, recent analyses have highlighted variable disciplinary definitions of prejudice that often invoke variable social and psychological processes. This, in itself, means that researchers' failures to come to a conclusive understanding of prejudice emerges from researchers' failures to come to a definitional consensus. The current data, however, clearly demonstrate that this lack of consensus is paralleled within the broader community. It is here where the heterogeneity of understandings poses a challenge to social change efforts. For example, same-sex marriage opponents are likely to be immune to (at best), if not actively push back against (at worst), efforts to change their attitudes, particularly if their own attitudes incurred the label of "prejudice" in the process. This would be, based on the current data, because opponents again see their own views as veridical, normative and tolerant. The perspective of same-sex marriage opponents warrants further reflection. The opening sentence of this paper identified same-sex marriage opposition as the denial of opportunities to some that are afforded to others. By this very description, then, how can opposition ever be seen as anything other than prejudice, even by opponents? In answering this, it may suit supporters to maintain claims that opponents are misinformed, uneducated and simply cognitively lazy. But the current data suggest other possible explanations. Same-sex marriage opponents see their own views as being veridical and in accord with individual liberties, while supporters' views are seen as sinful and, in fact, relatively prejudiced. Although the current research did not include independent measures of cognitive abilities, opponents do appear to be constructing a rational argument for their views as they understand them. Moreover, while supporters may see opponents as prejudiced against people seeking same-sex marriages, opponents may well see supporters as prejudiced against themselves (i.e., opponents). Indeed, previous research has clearly articulated how opponents frame their views within particular normative values (as we have currently argued; e.g., [56]). The legalization of same-sex marriage, then, may be perceived by opponents as denying them opportunities (e.g., individual liberty and freedom of religion) routinely afforded others (and, hence, is prejudiced). We do note, of course, that when expressing judgements of prejudice in particular, opponents' mean views of a supporting statement were around the midpoint of the current response scale. As such, it is not so much that supporting statements are seen as prejudiced, per se, but simply more prejudiced (or less unprejudiced) that opposing statements. In this manner, opponents' judgements may still be tempered, at least in part, by additional social norms within Australia regarding the nature of justice and fairness (the same applies for their judgements of tolerance). As previous authors have noted [57,58], justice rules are bounded within social categories. Regardless of opponents' views of the relative Australianness of the statements, when providing their judgements of prejudice (and tolerance), the broader selfcategorization as Australian may have been salient, thereby leading them to include supporters as well as opponents in the same moral community to which the justice rules applied. Clearly, this potential process is ripe for more detailed empirical examination. Ultimately, the current conceptual and empirical work highlights an alternative path to prejudice reduction to those that have routinely been employed by psychologists and social change agents. We propose that debates over prejudice are, at least in part, debates over truth. But rather than assuming a priori that one side has privileged access to this truth while the other does not, we should enter into the debate with the recognition those on each side share the same psychological processes despite not sharing the same attitudes. Here Ross and Ward's [59] analysis of na<unk>ve realism becomes particularly useful. These authors propose that people believe that they, themselves, "see entities and events as they are in objective reality, and that [their] social attitudes, beliefs, preferences, priorities...follow from a relatively dispassionate, unbiased...apprehension of the information..." (p. 110). Ross and Ward also propose that people believe other "rational social perceivers" (e.g., fellow in-group members) will see the world similarly, while those who do not are "lazy," "irrational," or "biased" (p. 111). The currently obtained patterns of data could not be more closely aligned with Ross and Ward's analysis. The primary difference is that Ross and Ward's analysis focuses more on idiosyncratic perceptions aligned with personal identities (i.e., "I see things as they are in reality."). Our work expands this to shared perceptions aligned with social identities (i.e., "We see things as they are in reality."), just as has been shown in independent research related to the Israeli-Palestinian conflict [60]. The post-hoc analysis of our data provide preliminary confirmation of the role that truth perceptions are likely to play in mediating the relationship between participants' own opinionbased group memberships (same-sex marriage support or opposition) and their prejudice judgements of supportive or oppositional statements. Clearly, when people fail to agree on what is and is not true, they are not likely to agree on what is and is not prejudice. An important conceptual and applied consideration of the collective na<unk>ve realism currently observed is that prejudice reduction efforts ought to focus not so much on the truth per se (which each side believe they have), but on the means by which the truth is determined. In this way, debates over prejudice can be reframed as debates over epistemologies. Once intergroup consensus and shared norms are obtained over how truth is determined, then consensus over what is and is not prejudice should follow. None of this is trivial in the context of same-sex marriage debates. As of writing this paper, same-sex marriage remains legally unavailable to people in 85% of the world's countries [61]. Millions of people are denied this simple but valued social relationship (a relationship that often brings with it other economic and social benefits). Efforts to change this state of affairs will be stifled if opponents are cast as irrational and uneducated. We can see this problem in other political domains, such as in the support for populist ideologies [62] and anti-vaccine attitudes [63]. Consensus needs first to be built over what the relevant facts are and how they are determined. This is no simple matter, as each side may turn to ideologically incompatible epistemologies (e.g., science and religion). But it is precisely here where the prejudice-reduction practices that social psychologists have developed become relevant and useful. The critical point, however, is to employ these not between, say, heterosexual and homosexual people, nor between religious and non-religious people, nor between (supposedly) educated and uneducated, and not even between prejudiced and non-prejudiced people. These practices need to be employed simply between supporters and opponents of same-sex marriage. Moreover, we suggest that it is not sufficient simply to build intergroup friendships to reduce or eliminate ingroup favouritism. Instead, the goal must be to develop a common shared social identity [14,64] that will form the basis for the requisite shared epistemology. Again, this is no simple task, as we are saying nothing less than prejudice reduction is needed. But the current research does provide guidance by proposing a mechanism through which we can pursue social change. Before we conclude, it may be worth reflecting on the broader context in which this work was conducted. As we noted above, the debate in Australia became, at times, emotionally charged and hostile. Members of the broader Australian LGBTIQ community, along with their parents, reported increased experiences of negative attitudes and behaviours directed toward them, leading them to feel anxious, fearful and depressed [65][66][67]. This broader negative discourse, of course, may have impacted upon how our participants understood the claims we presented. Indeed, it may well have contributed to the larger difference in judgements among the "yes" supporters than the "no" supporters. At the same time, we can not deny the strength of the disordinal interactions we observed; our effects were not driven solely by the judgements of "yes" supporters. The current findings thus align with other recent analyses on the partisan

The current research examined the proposition that debates over same-sex marriage are characterized, at least in part, by conflicting understandings about what is and is not prejudiced, normative and true. Toward this end, Australians' (N = 415) prejudice judgements of supportive and oppositional statements toward same-sex marriage were measured and analysed with analyses of variance. Unsurprisingly, same-sex marriage supporters perceived a supportive statement as unprejudiced, tolerant, truthful, in pursuit of individual liberty, and normative; oppositional statements were seen in precisely the opposite manner. Same-sex marriage opponents, however, disagreed, instead judging an oppositional statement as unprejudiced, tolerant, truthful, in pursuit of individual liberty, and normative; it was a supportive statement that was seen as relatively prejudiced. These effects remained even after controlling for independent expressions of in-group favouritism. The current data align with a collective naïve realism perspective, in which group members see their own views as veridical and those of disagreeing others as biased. We argue that prejudice-reduction efforts must be instantiated to facilitate a common in-group identity between supporters and opponents to enable consensus over facts and, ultimately, what is and is not prejudice. Without this consensus, each side of the political debate may simply hurl the pejorative label of "prejudice" against the other, with likely little opportunity for social influence and social change.

common shared social identity [14,64] that will form the basis for the requisite shared epistemology. Again, this is no simple task, as we are saying nothing less than prejudice reduction is needed. But the current research does provide guidance by proposing a mechanism through which we can pursue social change. Before we conclude, it may be worth reflecting on the broader context in which this work was conducted. As we noted above, the debate in Australia became, at times, emotionally charged and hostile. Members of the broader Australian LGBTIQ community, along with their parents, reported increased experiences of negative attitudes and behaviours directed toward them, leading them to feel anxious, fearful and depressed [65][66][67]. This broader negative discourse, of course, may have impacted upon how our participants understood the claims we presented. Indeed, it may well have contributed to the larger difference in judgements among the "yes" supporters than the "no" supporters. At the same time, we can not deny the strength of the disordinal interactions we observed; our effects were not driven solely by the judgements of "yes" supporters. The current findings thus align with other recent analyses on the partisan nature of truth-or, at least, subjective understandings of truth-that have been observed in the absence of intergroup hostility, among experimentally-created, randomly assigned groups [68]. --- Limitations and future research Despite clear strengths of the current research (e.g., a broad cross-section of the Australian population, sampling during a time when people were likely to have well-formed attitudes), we recognize that this work is not without limitations. First, by its very nature, our use of opinionbased groups means that relationships we observe are necessarily correlational. We have argued, for example, that people base their judgements of prejudice upon their understandings of truth. This assumes a causal order of self-categorization (into one group or another) that leads to truth determination that leads to prejudice determination. Clearly, there are other possible causal orderings. The most obvious alternative causal ordering is that truth and prejudice determinations are simply developed post facto to justify one's a priori negative intergroup attitudes in a motivated reasoning manner [69]. Indeed, we believe that, in some cases, this may well be the operative process. But the fact that directional motivated reasoning may guide some people's judgements does not negate the possibility of collective na<unk>ve realism as we suggested above. Separation of these processes will require experimental research, not simply surveys. Second, we recognize that our conceptual analysis has cast opponents of same-sex marriage in potentially a more favourable light than many readers would like. In this way, we may be seen as nothing more than apologists for prejudice (much as psychologists have been in other domains, as in the justification of prejudice against Aboriginal Australians; [70]). We acknowledge this, but disagree. Instead, as researchers, we are seeking to understand social and psychological processes that underlie what otherwise are labelled as prejudiced attitudes. Moreover, the current analysis seeks to understand how and why the same-sex marriage debate remains entrenched. If we simply cast dispersions against those with attitudes we do not share, we will, of course, be open ourselves to accusations of prejudice. Currently, we are, through the epistemology of science, attempting to understand and solve this social problem. Finally, it would be of value to clarify precisely the nature and targets of perceived prejudice in the judgements our participants currently made. As we suggested above, opponents' judgements of the relative prejudice of supporting statements may have been made with reference to themselves as the targets of this prejudice. Future work can focus the wording of the items used to measure specifically prejudice towards same-sex attracted people or, say, prejudice towards religious people. --- Conclusion This research has demonstrated how opposition to same-sex marriage is seen by those holding this oppositional view as tolerant, rational, normative, and even in pursuit of individual liberty despite such opposition denying rights to some that are afforded to others. In fact, participants on each side of this debate saw their own perspective as unprejudiced. Recognition of these patterns is important both for theoretical and practical reasons. Theoretically, the data (re)illuminate the traditional "enlightenment" approach to prejudice reduction, reframing supposed educational efforts more as simply social influence. In practice, given influence's basis in shared group membership [31], what is needed is not pejorative name-calling of opponents as "prejudiced," but active prejudice-reduction efforts between opponents and supporters to build a common identity [e.g., 71,72]. As has been detailed elsewhere, this common identity provides a basis for shared values [17], common understandings of fairness and justice [58], and ultimately prejudice reduction [14]. It should also form the basis within which to ground a shared epistemology that will facilitate consensus over facts, and allow for a common recognition of what are and are not prejudiced attitudes. Same-sex marriage supporters have a critical role in this process, as the common identity and shared epistemology could lead to an understanding that actually denies same-sex marriage. Again, we recognize that this is no small effort. But simply labelling opponents as "prejudiced" will most likely entrench the current intergroup divide even further. --- The data that support the findings of this paper are available at https:// osf.io/5dgkr/?view_only= 2741adb6d261442ea58908e1bb4570e0. --- Author Contributions Conceptualization: Michael J. Platow, Dirk Van Rooy, Martha Augoustinos, Daniel Bar-Tal, Russell Spears. Data curation: Michael J. Platow. Formal analysis: Michael J. Platow, Clinton G. Knight. Funding acquisition: Michael J. Platow, Dirk Van Rooy, Martha Augoustinos, Daniel Bar-Tal, Russell Spears. Investigation: Michael J. Platow. Methodology: Michael J. Platow, Clinton G. Knight, Dirk Van Rooy. Project administration: Michael J. Platow. Resources: Michael J. Platow. Supervision: Michael J. Platow. Writing -original draft: Michael J. Platow. Writing -review & editing: Michael J. Platow, Clinton G. Knight, Dirk Van Rooy, Martha Augoustinos, Daniel Bar-Tal, Russell Spears.

The current research examined the proposition that debates over same-sex marriage are characterized, at least in part, by conflicting understandings about what is and is not prejudiced, normative and true. Toward this end, Australians' (N = 415) prejudice judgements of supportive and oppositional statements toward same-sex marriage were measured and analysed with analyses of variance. Unsurprisingly, same-sex marriage supporters perceived a supportive statement as unprejudiced, tolerant, truthful, in pursuit of individual liberty, and normative; oppositional statements were seen in precisely the opposite manner. Same-sex marriage opponents, however, disagreed, instead judging an oppositional statement as unprejudiced, tolerant, truthful, in pursuit of individual liberty, and normative; it was a supportive statement that was seen as relatively prejudiced. These effects remained even after controlling for independent expressions of in-group favouritism. The current data align with a collective naïve realism perspective, in which group members see their own views as veridical and those of disagreeing others as biased. We argue that prejudice-reduction efforts must be instantiated to facilitate a common in-group identity between supporters and opponents to enable consensus over facts and, ultimately, what is and is not prejudice. Without this consensus, each side of the political debate may simply hurl the pejorative label of "prejudice" against the other, with likely little opportunity for social influence and social change.

Introduction Conspiracy theories-beliefs attributing agency over important world events to the secret plotting of powerful, malevolent groups-have been common in our population over a sustained period [1][2][3][4][5]. Conspiracy beliefs have the potential to cause harm both to the individual and the community. Conspiracy endorsement is associated with lowered intention to participate in social and political causes [6], unwillingness to follow authoritative medical advice, increased willingness to seek alternative medicine [7][8], and a tendency to reject important scientific findings [9][10]. There are a variety of attitudes individuals might have towards conspiracy theories. Many people passively endorse conspiracy theories, in the sense that they will assent to one or more conspiracy-related beliefs if asked. Conspiracy endorsement can be a relatively weak attitude, reflecting a general suspicion of the powerful [11]. Measurement of assent also appears to be strongly influenced by contextual and partisan cues [12]. A subset of individuals who endorse conspiracy theories also actively engage with conspiracy theories by, for example, discussing and spreading them online. Many researchers take people who endorse or engage with conspiracy theories to depart from the ordinary norms of belief formation. As such, there has been a search for psychological factors which explain why particular individuals find conspiracy theories attractive. The psychological literature offers two types of explanation. Cognitive explanations cite mental processes that are adaptive in some contexts (including evolutionary ones), but which go awry in contemporary political situations [13]. Such processes might include Bayesian [14] or abductive [15][16] inference about hidden causes, or over-enthusiastic pattern completion [17]. Such processes are in some sense universal, but exaggerated instances play an especially important role in explaining conspiracy endorsement in individuals. Trait explanations, by contrast, focus on factors which explain individual differences in endorsement of conspiracy theories. While both are important for understanding why people engage with conspiracy beliefs, trait explanations have received more attention: the wide variation in acceptance of conspiracy theories among individuals, combined with the negative consequences of that acceptance, is a natural explanatory target. An early and influential set of trait theories focused on the attraction of conspiracy theories to the powerless. Hofstadter wrote of the attraction of conspiracy theories to those who "...see only the consequences of power-and this through distorting lenses-and have no chance to observe its actual machinery" [18, p. 86]. More recent literature has focused on a positive relationship with measures of powerlessness and external locus of control [19], the relationship between feelings of powerlessness and cognitive factors such as illusory pattern perception [20], and the role of stressful life events [21]. These accounts are not always critical of conspiracy endorsement: some assign it an important role in institutional critique by the politically disadvantaged [22] or emphasize the role that conspiracy theorizing may play in masking more salient social tensions [23]. A general role for distrust of and defiance towards authority has also been posited [24]. Goetzel [3] identified lack of interpersonal trust as a key predictor of conspiratorial belief. Goetzel also noted a close relationship between endorsing conspiracy theories and being a member of a racial minority. The relevant conspiracy theories often resemble legitimate reasons for distrust by a minority community-for example, the theory that human immunodeficiency virus (HIV) was engineered to decimate African-American communities appears to be more popular among those aware of the Tuskegee Syphilis experiments and other historical medical abuses of African-Americans [25][26][27]. In such theories, the driving role is often standing negative emotions directed towards the powerful: anger, disgust, or paranoia. A handful of explanations consider conspiracy beliefs to be pathological, placing them on a spectrum that includes paranoid ideation, paranormal belief, and schizotypy [28][29][30]. A further cluster of theories focuses on the role of factors such as individual self-esteem in the face of difficult life circumstances [31,32] or in positive individuation from others [33], emphasizing the role that conspiracy endorsement can play in these processes. Conspiracy theories can provide exculpatory narratives for individual hardship. The narrative of how one came to believe in conspiracy theories can also be a powerful anchor for identity, functioning for the individual as a kind of "transformative experience" [34]. Belief in conspiracy theories appears to correlate with a need for uniqueness [35]. Drawing on qualitative work, Franks, Bangerter, Bauer, Hall, & Noort [36] suggest that conspiracy engagement may be part of an optimistic worldview that focuses on personal and social growth. Recent literature also suggests that conspiracy endorsement may constitute a distinct construct which correlates with a variety of more traditional personality traits [37,38]. One popular way of cashing out this construct is in terms of a conspiratorial worldview, in which people who endorse one conspiracy theory are more likely to endorse others [39]. Goetzel [3] suggested that conspiracy endorsers tend towards a "monological belief system" in which beliefs in any two conspiracy theories tend to be incorporated under a common umbrella [39][40][41][42]. Trait theories do not need to be mutually exclusive; several may provide useful and co-existing explanations for why people endorse conspiracy theories [43,6,24]. --- Social self-selection Psychological theories of conspiracy endorsement tend to focus on the individual abstracted from their social context. While it is clear that social context plays a role in shaping conspiracy belief endorsement in individuals, studies examining social factors associated with conspiracy belief are comparatively rare [44]. Yet social effects undoubtedly exist. Social groups affect whether ambiguous information is interpreted in a conspiratorial manner [45][46]. Studies examining the structure of communication patterns within social networks have considered how homophily can affect the way beliefs spread and persist [47][48], how beliefs can be distorted through collective memory [49], and how it can exacerbate the spread of misinformation in particular [50]. These studies focus on the effect of network structure rather than individual differences in personality and psychology. This should not be construed as a process whereby individuals are passively embedded in a social space. Individuals who endorse conspiracy beliefs are known to seek out others with shared beliefs [51], which means that active social self-selection may provide a plausible mechanism for how people assimilate multiple conspiracy theories within a conspiratorial worldview. The relationship between self-selection and stable traits taps into an old debate in both personality and social psychology. An individual's behavior depends both on their intrinsic dispositions and on the situations in which they find themselves. At short timescales, the interaction between personality and situation is widely accepted [52]. Longer timescales present opportunities for more complex interactions. As Allport [53] noted, personality determines which situations people will embrace and which they will avoid. In Funder's [54, p. 575] pithy formulation, "...while a certain kind of bar may tend to generate a situation that creates fights around closing time, only a certain kind of person will choose to go to that kind of bar in the first place." Buss [55] distinguished three processes at work in long-term interactions. Individuals select a social milieu, which in turn evokes certain responses from them given their traits, and over the long run they manipulate their social surroundings to create and reinforce a niche. Emmons, Diener, and Larson [56] similarly distinguished choice mechanisms and affect mechanisms. In the former, individuals' personalities lead them to consciously seek or avoid certain kinds of situation, while in the latter, people merely prefer situations that fit with their personalities and so are reinforced for choosing appropriately. While these longer-term interactions are important, studying them presents unique challenges [57]. Continuous recording of reactions is only possible over relatively short time periods in the lab. The study of longer-term interactions has primarily been approached by intermittent experience sampling [58,59] or varieties of retrospective self-report [60,61]. Both techniques provide valuable evidence but face well-known methodological challenges Individuals who actively engage with conspiracy theories in social spaces are also challenging to study using experimental designs. Conspiracy engagement often comes with skepticism about official motives, making it difficult to recruit participants. There is also a risk of selection bias in recruitment, as a small subset of conspiracy engagers tend to be disproportionately visible [62]. --- Methodological innovation: Online datasets The availability of large datasets from online social media offers a unique opportunity to observe longitudinal interactions between social groups and individual traits [63]. Participation in online forums is typically open and voluntary, allowing individuals considerable latitude in selecting their social environment. In addition, online forums provide a much larger source of data for analysis, providing enough power to examine a larger number of factors at once. The sheer size of some corpora allows for effective unsupervised analyses [64], avoiding the coding issues present in traditional survey designs. While they are restricted to studying associations rather than experimentally manipulated effects, large observational datasets can be used to generate new hypotheses and guide future research designs. Studies examining or simulating the behaviors of people expressing conspiracy beliefs online have primarily been focused on how the spread of conspiracy beliefs are facilitated by network structure [65][66][67]. Social reinforcement and homophily play an important role in this spread, a fact that has been demonstrated both by modeling [68] and observational studies [69,70] of social networks. Community feedback and reinforcement also plays an important role in shaping users' actions in online forums [71,72]. One important source of online conspiracy theorizing is the website Reddit.com (or 'Reddit'). Reddit is a network of around 1.2 million online forums (known as subreddits), with around 330 million monthly active users. Reddit data have been used to examine the structure of conversations and propagation of information [73], and hateful and offensive speech [74][75][76], in addition to general linguistic analyses [77,78]. Reddit has also been identified as a key part of the "propaganda pipeline" [79] that amplifies conspiracy theories on their way to more visible websites (such as Facebook) and mainstream media [80]. Reddit includes a dedicated subreddit (r/conspiracy) for discussing conspiracy theories. Examination of the comments that Reddit users who post in r/conspiracy therefore provides a unique window into a socially significant subset of individuals who actively engage with conspiracy theories in a social space. --- The present research There is at least one study about how Reddit users interact within the r/conspiracy subreddit after salient events [81], and one which examines the diversity of interests among Reddit users who posted to an online forum for conspiracy beliefs [62]. However, we know of no studies examining their behavior over time and before they first post in r/conspiracy. Our aim was to examine what makes Reddit users who would go on to engage with conspiracy theories different from other Reddit users. We undertook an exploratory analysis using a case control study design, examining the language use and posting patterns of Reddit users who would go on to post in r/conspiracy. (the r/conspiracy group). We analyzed where and what they posted in the period preceding their first post in r/conspiracy to understand how personal traits and social environment combine as potential risk factors for engaging with conspiracy beliefs. Our goal was to identify distinctive traits of the r/conspiracy group, and the social pathways through which they travel to get there. We compared the r/conspiracy group to matched controls who began by posting in the same subreddits at the same time, but who never posted in the r/conspiracy subreddit. We conducted three analyses. First we examined whether r/conspiracy users were different from other users in terms of what they said. Our hypothesis was that users eventually posting in r/conspiracy would exhibit differences in language use compared to those who do not post in r/conspiracy, suggesting differences in traits important for individual variation. Second, we examined whether the same set differed from other users in terms of where they posted. We hypothesized that engagement with certain subreddits is associated with a higher risk of eventually posting in r/conspiracy, suggesting that social environments play a role in the risk of engagement with conspiracy beliefs. Third, we examined language differences after accounting for the social norms of where they posted. We hypothesized that some differences in language use would remain after accounting for language use differences across groups of similar subreddits, suggesting that some differences are not only a reflection of the social environment but represent intrinsic differences in those users. --- Materials and methods --- Participants Users and ethics approval. Our study participants were Reddit users who posted comments to online forums between 2007 and 2015. They were selected from a publicly available dataset comprising 1.10 billion comments from 1,419,406 users posted to 224,625 subreddits between October 2007 and May 2015 (see S1 Appendix). Participants whose data was used were not contacted. The data were originally collected and made available under the terms permitted by the Reddit Terms of Service. As we were using publicly available data examined and reported in aggregate, ethics exemptions were granted by both Macquarie University and the Australian National University. Selection of users. Reddit allows posts by automated programs known as bots, which post comments in ways that can skew descriptive statistics. To remove accounts associated with bots, we first looked at each poster in a target set of subreddits (including r/conspiracy) and calculated the number of other subreddits in which they posted (their forum diversity). A list was compiled of usernames whose forum diversity was more than 15 standard deviations above the mean. Manual inspection revealed that every member of this list was probably a bot, whereas more aggressive cuts also included posters who were clearly human. This was combined with a list of usernames corresponding to known bots posted on Reddit itself (See S1 Appendix). This process identified 466 bots, which were excluded from subsequent analyses. The r/conspiracy group was defined as the set of users posting at least 3 comments in r/conspiracy, and at least 4 times in each of the six contiguous 30-day periods immediately prior to their first post in r/conspiracy. Users who posted in r/conspiracy but did not meet both criteria were excluded from the analysis. All comments posted by included users made before their first post to r/conspiracy were included in the subsequent analysis, and these were used to characterize their language use and topics of interest. Posts by this group after their first post to r/conspiracy were not used in the analysis. Manual validation. Reddit has its own culture with a complex set of norms. Some users post in r/conspiracy because they want to debunk conspiracy theories, while others enjoy "trolling" by deliberately provoking conspiracy theorists. Previous work on r/conspiracy suggested that between 4% and 12% of posters in r/conspiracy might fall into one of these categories [62]. We manually examined the posts of 100 identified r/conspiracy users and determined that at most 9 of them were consistently either skeptical or non-serious. We took this to be an acceptable noise rate. Posters in r/conspiracy who do not engage seriously with conspiracy theories should be expected to be more like other posters on Reddit; at most, then, the presence of such individuals in our dataset would only reduce sensitivity, rather than create false positives. Matched controls. Reddit is a diverse community. Many differences between the average Reddit user and a user posting in r/conspiracy may simply reflect that diversity. To minimize spurious differences, we constructed a control group by matching target users to posters whose first post was in the same forum at nearly the same time. Each user's matched control thus "enters" our dataset at the same place and time but ends up on a different trajectory. To construct the matched control group, we first created a candidate control group by identifying users who never posted in r/conspiracy, and who had posted at least 4 times in any 6 contiguous 30-day periods. From the candidate control group, we then constructed matched pairs for each user in the target group. For each r/conspiracy poster, we identified their first post on Reddit. We then identified users from the candidate group whose first post was in the same subreddit within 24 hours of the r/conspiracy poster. We then iteratively assigned the user whose first post was closest in time to the first post of the r/conspiracy poster, under the constraint that matches had to be unique. We examined only comments between their first post and the final post of their matched control. To ensure matched controls had enough posts to reliably compare, we eliminated 480 matched pairs in which the control user had not posted at least 35 comments in that restricted timespan. This process identified 15,370 users in each group (30,740 total), which were used for all subsequent analyses. Preprocessing. Reddit posts consist of an initial post followed by nested comments underneath. The dataset includes only the nested sets of comments that follow the original ("link") posts, not the link posts themselves. These comments and their associated metadata were the basis for analysis. When analyzing the r/conspiracy users, we examined only comments from their first post to their final post before posting in r/conspiracy. When analyzing matched controls, only comments posted in the period between their first post and their matched partner's first post in r/ conspiracy were considered. We pre-processed comments posted by included users to remove escape characters, URLs, and any lines which began with a '>' (which is typically used to mark text quoted from another author). Comments with fewer than 3 words after processing were omitted. We then concatenated each user's comments, with subsequent analyses performed on a per-user basis. --- Measures Language use. Psychological traits shape the language that individuals use. Computational analysis of language usage has been successfully used to investigate personality traits [82,83] as well as individual differences in emotionality and social relationships [84]. Linguistic features are a good marker of whether a discussion will be constructive, both experimentally [85] and on Reddit [86]. Computational analysis of word use within the r/conspiracy forum has provided evidence about common narrative structures of conspiracy engagement [87] and individual differences in user's interests [62]. To measure word use across particular language categories we used Empath [88,89], an open-source Python package which extracts linguistic characteristics from written text. Empath categories are built in a multi-stage process. First, categories and corresponding seed words are derived from pre-existing semantic knowledge bases such as ConceptNet. A vector space model is then trained on a large corpus of text, including Reddit comment data, and each category is expanded to include terms which occur near seed terms in the vector space model, indicating semantic similarity. Finally, categories are pruned via human inspection to eliminate intruders [82,83]. Although we used pre-defined Empath categories, the library allows for expansion to other user-defined categories via the same procedure, making it a flexible tool for examining textual data. Empath scores themselves are weighted word frequencies across members of the category. Empath normalizes for aggregate comment length, returning frequency counts per category as the primary data. Empath scores are highly correlated (r = 0.91, see [88]) with those of the more widely-known LIWC Linguistic Inquiry and Word Count (LIWC) package where they overlap. Empath has a broader range of empirically derived lexical categories than LIWC. Further, its categorization scheme was partly trained on Reddit data, so it has found significant use in linguistic analysis of online discussion, including the spread of hate speech on Twitter [90][91][92] and YouTube [93], and the interface between media and technology [94,95]. Empath has also been used specifically to study Reddit, including community growth [96] and selfexpressions of mental illness [97]. Empath evaluates a large number (194) of lexical categories, many of which are irrelevant to the present study. We focused on a subset of 85 categories corresponding to 6 different psychological theories about the antecedents of conspiracy belief (Table 1). To determine which lexical categories were included for each factor, the three authors each independently chose candidates; categories chosen by at least 2 of the three raters were included. Each of the proposed theories could themselves be operationalized in a variety of ways, and so the procedure was designed to err on the side of inclusion. For each category, we examined whether there was a significant difference in posting frequency of terms in that category between the r/conspiracy group and the group of matched controls, using Welch's t-test with an alpha of 0.01 (corrected for multiple comparisons). To estimate the magnitude of the difference in effect, we calculated Cohen's |d| (hereafter 'd'). For this and subsequent analyses, we considered only terms which showed a significant difference and had d>0.2. These high-d factors were the bases for subsequent analysis. Social environment. To determine which subreddits might represent important pathways through which users travel to reach r/conspiracy, we looked for over-representation of r/conspiracy users in the subreddits relative to the control group. To do this we examined each subreddit and counted the number of r/conspiracy users and matched control group users that had posted at least one comment. To avoid spurious results and potential re-identification of individual users, we analyzed the set of subreddits in which r/conspiracy and control group users had posted at least once during matched timespans, and a minimum of 100 users across both groups had posted at least once. To be able to examine how language use differed within certain communities on Reddit, we grouped similar subreddits by theme community. We constructed a similarity network based on simple co-posting behaviors, without considering the chronology of the posts. Each subreddit was represented by a node in the network, with undirected edges between the nodes defined by the number of shared users (users who posted in both subreddits at least once) divided by the total number of users who posted in either subreddit (i.e. the Jaccard similarity [98]). We then applied a community detection algorithm to the similarity network to group subreddits by theme based on the number of users they shared. Community detection algorithms are used to identify clusters of well-connected nodes in a network. Most algorithms aim to identify clusters by maximizing the number of connections within each community compared to the number of connections between communities. We applied the greedy modularity optimization method [99], which is commonly used for large networks. In this application, the algorithm starts with all subreddits in separate communities and then merges according to a gain in modularity-a measure of the density of connections within versus between communities. The number of communities is not specified in advance; rather, the algorithm stops when no further merging of communities improves modularity. For each group of subreddits within a theme community we calculated two measures characterizing the differences between r/conspiracy users and the matched control group users. The user-count ratio was defined as the number of r/conspiracy users posting at least once in the constituent subreddits relative to the matched controls. The post-count ratio was defined by the total number of posts from r/conspiracy users in the constituent subreddits of the theme community compared to the number of posts from the matched control group users. Each value can be interpreted as a signal of the risk associated with posting to that subreddit. Interactions between language use and social environment. For each high-d Empath factor identified in the language use experiment, and each theme community identified in the social environment experiment, we examined the contrast between language use by control and r/conspiracy users but restricted just to posts made in any of the subreddits in that theme community. As before, differences were tested by Welch's t-test with an alpha of 0.01 (corrected), and Cohen's d was used as an estimate of the magnitude of effect, where we again used 0.2 as a threshold for indicating a substantial difference. --- Results The 15,370 r/conspiracy users and the 15,370 matched controls posted to a set of 38,797 unique subreddits, and of these 1,834 met our inclusion criteria for analysis. Within this set of subreddits, r/conspiracy users posted a median of 743 (interquartile range 333 to 1,749) comments, with a median of 20,599 (IQR 8,302 to 52,321) total postprocessed words of comments. Their matched controls posted a median of 300 (IQR 142 to 707) comments, and a median of 8,082 (IQR 3,407 to 21,068) total postprocessed words of comments. The results indicate that r/conspiracy users posted at a substantially higher rate. We were unable to measure whether the groups were posting at different times of day and we did not measure whether comments were spread across a broad set of posts or concentrated within longer conversations on individual posts. --- Language use From the set of 91 Empath categories included in the analysis, 75 exhibited a significant difference between r/conspiracy users and their matched controls. Among those with significant differences, 26 differences had d>0.2 (Fig 1a). Where r/conspiracy group users posted certain terms more frequently than the matched control group users, the most prominent differences were in the Empath categories 'crime' (d = 0.45),'stealing' (d = 0.43), and 'law' (d = 0.38). The categories of 'dispute', 'domi-nant_hierarchical', 'power', 'government', and 'terrorism' each produced d>0. 35. There were relatively few significant negative differences: the only categories where matched control group users posted certain terms substantially more frequently were in the Empath categories 'friends' (d = -0.31), 'optimism' (d = -0.22) and 'affection' (d = -0.21). These terms were drawn from the "Maintenance of self-esteem" and "Personal values and individuation" categories (Table 1), though the higher frequencies among the matched control group users is suggestive of alienation rather than positive bonding in r/conspiracy group users. Other categories suggested by theories in Table 1 did not make the threshold for inclusion, typically because their effect size was too low. Notably absent are Empath categories encompassing specific negative affects like 'fear' (n.s.),'sadness' (d = 0.09), and 'nervousness' (d = -0.1), for which the differences are either small or in the wrong direction from what would be expected given the theory. --- Social environment When applied to the similarity network of 1,834 subreddits, the community detection algorithm identified 16 theme communities. The communities included between 44 (the 'Basic Reddit' theme community) and 334 subreddits (the "Gaming & Television" theme community). The communities were characterized and named by examining their top 10 subreddits and choosing names that indicated the typical contents of those subreddits (Table 2), revealing differences in the topics of interest. Some of the theme communities covered more than one area of interest (for example, the "Guns & Cars" theme community), while others were relatively closely related, which is apparent in a visualization of the complete network (S1 Fig). The user-count ratios varied by theme community (Fig 1b). The highest user-count ratio was in the "Politics" theme community, where there were 2.4 times as many r/conspiracy users as control users that posted in at least one subreddit in the group. The lowest user-count risk ratio was for the "Basic Reddit" theme community, which included several of the most popular subreddits including "r/AskReddit", "r/pics", and "r/funny", where nearly equal numbers of users from each group had posted at least once. For some theme communities, r/conspiracy users were consistently over-represented across most of the constituent subreddits, whereas other theme communities included smaller clusters of over-representation of r/conspiracy users among a larger set where there was less over-representation (S1 Fig). The r/conspiracy group users tended to post more frequently across all theme communities (Fig 1b) but there were notable differences relative to the user-count ratios. For example, r/conspiracy users were over-represented in the "Pornography", "Tech Culture", and "Music" theme communities (posting across many of the subreddits at least once) but had relatively low post-count ratios suggesting they may have been less engaged with those communities. Conversely, in the "Internet Culture" and "Toxic Reddit" theme communities, r/conspiracy users were not only over-represented in the constituent subreddits but also had relatively high post-count ratios, suggesting ongoing and stronger engagement with the themes and with other users in the subreddits in those theme communities. Differences between the r/conspiracy group and the matched controls. Differences between the r/conspiracy group and the matched control group by: (a) language use, including all Empath categories with significant positive (red) and negative (blue) differences and Cohen's d>0.2; (b) posting differences by theme community given by usercount ratio and post-count ratio; and (c) differences in language use accounting for theme community. Positive (red) and negative (blue) differences are colored where Cohen's d>0.2. Grey circles indicate significance which did not reach the effect size threshold. https://doi.org/10.1371/journal.pone.0225098.g001 --- Interactions In the "Basic Reddit" theme community there were clear differences between the language use of the r/conspiracy group relative to the matched controls, and for 16 of the 26 Empath categories the difference was substantial (d>0.2). For example, users who would go on to post in r/ conspiracy were much more likely to use "aggression" terms in the constituent subreddits in the "Basic Reddit" theme community. Examining differences in language use within each of the theme communities indicates that there were significant differences between r/conspiracy users and matched control group users within most of the theme communities (Fig 1c), but these differences were not as clear as the overall differences in language use. The results suggest that many of the clear differences observed between the two groups in the overall language use analysis were likely to have been because of where the r/conspiracy users were posting rather than what they were posting. For example, in the "Politics" and "Pornography" theme communities, where r/conspiracy users were heavily over-represented relative to their matched controls, there were no significant differences in any of the 26 Empath categories. The results were similar in the "Tech Culture" and "Social Support" theme communities, where r/conspiracy users tended to closely match the control group in language use. --- Discussion --- Language and social factors The r/conspiracy group users exhibited clear differences from other similar Reddit users in terms of both where they posted and what they posted. These differences in language use and social environment provide support for some of the theories of conspiracy belief. First, there were clear differences in overall language use between r/conspiracy group and the matched control group. Most of the Empath factors exhibiting strong differences were associated with prior literature suggesting that a "conspiratorial mindset" leads to endorsement of conspiracy theories (Table 1). In general, Empath factors for which we observed a clear positive difference were aligned with issues of hierarchy and abuses of power. Also notable were Empath categories like "deception" and "terrorism", which can be linked to an idea that is central to many conspiracy theories: that of hidden enemies among us. Some have argued that the key psychological feature of conspiracy theorists is a "monological belief system" in which everything connects to everything else [3,39,42]. Recent work on r/conspiracy suggests that users with monological belief systems are responsible for the majority of posts but make up only a small percentage of users [62]. However, these results are not necessarily incompatible. A monological belief system may simply be the most extreme, and most salient, version of a more general conspiratorial mindset. Further, one lesson from these results might be the need to distinguish factors which lead people to engage with conspiracy theories in the first place from the factors which distinguish more and less extreme engagement with conspiracy theories. This would fit well with recent work emphasizing the multidimensionality of conspiracy constructs [100]. We did not find evidence to support previous literature observing differences in personality traits or varieties of compensation or psychopathology. Where previous literature focused on negative emotional states as drivers of conspiracy theory endorsement, we only found evidence for the non-specific 'negative_emotion' Empath category (d = 0.24). Equally striking was the lack of difference in use of language related to anger, disaffection, or other compensatory emotions. This contradicts some of the accounts that focus on the hostility of conspiracy endorsers [101], but concords with more recent work that highlights the lack of hostility in comments from conspiracy endorsers. For example, Wood and Douglas [102] carried out a study of conspiracy related comments on a news website. Comments were divided into "conspiricist" (those arguing for a conspiratorial explanation of events) and "conventionalist" (those arguing for a conventional account of events) comments, with a focus on comments judged to be aimed at persuading others. These comments were then rated for tone. Interestingly, comments from conspiricists were rated as less hostile than the comments from "conventionalists". Our findings lend support to this conclusion. We found evidence that r/conspiracy users were less likely than the control group to use terms from Empath categories "affection", "optimism", and "friends", which might be suggestive of alienation or social isolation [18,22]. Some of the divergence from previous findings may come from the use of matched controls. Our study compared Reddit users who would go on to post in r/conspiracy with users who began posting on Reddit at the same time and in the same subreddits. People who endorse conspiracy theories may appear angrier or more disaffected compared to a general population, but this may be more common across online discourse and Reddit users in general. Importantly, Wood and Douglas [102] point out the need to distinguish the target and type of hostility: to whom and regarding what features is a comment hostile? Conspiracy theorists might often be hostile towards others for being "dupes" of the system; non-conspiracy believers might be hostile towards the perceived paranoia of conspiricists, or their propensity to creative, ad-hoc additions in order to shore up their theories, and so on. This is a potential confound in our study. Whereas Wood and Douglas first selected comments as either conspiricist or conventionalist, our study of conspiracy posters includes those who go on to argue against conspiracy theorists as well as for them. If non-conspiricists tend to be angrier towards those who forward conspiracy theories, this may affect what we found in the tone of users who ended up in the

Many individuals who engage with conspiracy theories come to do so through a combination of individual and social factors. The interaction between these factors is challenging to study using traditional experimental designs. Reddit.com is a large connected set of online discussion forums, including one (r/conspiracy) devoted to wide-ranging discussion of conspiracy theories. The availability of large datasets of user comments from Reddit give a unique opportunity to observe human behavior in social spaces and at scale. Using a retrospective case control study design, we analyzed how Reddit users who would go on to engage with a conspiracy-related forum differed from other users in the language they use, differences in the social environments where they posted, and potential interactions between the two factors. Together, the analyses provide evidence for self-selection into communities with a shared set of interests which can feed into a conspiratorial world-view, and that these differences are detectable relative to controls even before users begin to post in r/conspiracy. We also suggest that survey-based and experimental studies may benefit from differentiating between passive private endorsement by individuals and active engagement with conspiracy theories in social spaces.

posting on Reddit at the same time and in the same subreddits. People who endorse conspiracy theories may appear angrier or more disaffected compared to a general population, but this may be more common across online discourse and Reddit users in general. Importantly, Wood and Douglas [102] point out the need to distinguish the target and type of hostility: to whom and regarding what features is a comment hostile? Conspiracy theorists might often be hostile towards others for being "dupes" of the system; non-conspiracy believers might be hostile towards the perceived paranoia of conspiricists, or their propensity to creative, ad-hoc additions in order to shore up their theories, and so on. This is a potential confound in our study. Whereas Wood and Douglas first selected comments as either conspiricist or conventionalist, our study of conspiracy posters includes those who go on to argue against conspiracy theorists as well as for them. If non-conspiricists tend to be angrier towards those who forward conspiracy theories, this may affect what we found in the tone of users who ended up in the conspiracy forum versus those who did not. Moreover, as we have suggested, there may be a greater effect of anger in general on reddit, which could make communities look more similar on this variable. That said, we looked at hostile language across a variety of subreddits, not just conspiracy-focused ones, suggesting that hostility is not being driven solely by conspiracy-related factors. There may also be important differences between the phenomena we have focused on and those that have been the focus of previous studies. As we discussed, we examined people who have sought out a forum dedicated to conspiracy theories who actively discuss and share thoughts on the topic. This might be a different phenomena to simply passively endorsing conspiracy theories when questioned about them. This might be relevant to our findings on powerlessness. One possibility is that the type of sharing and active engagement seen in the forum is itself a type of reclaiming of power, a place to put forward ones thoughts, help out one's peers and the wider community to see the truth, and so on. Passive engagement, by contrast, may stem from or promote powerlessness (and would be difficult for this method to detect). This might potentially be a source of difference when it comes to results regarding feelings of powerlessness. There was also a clear difference in the risk profiles of different theme communities. The highest risk by far was in the "Politics" theme community, where there were 2.4 times as many r/conspiracy users posting in the subreddits compared to the control group, and they posted 5 times as many comments overall. Though there was the appearance of a skew to the political right in the subreddits included in the "Politics" theme community, this group also includes subreddits such as r/progressive; as well as relatively neutral subreddits such as r/PoliticalDiscussion and debate-oriented subreddits like r/DebateReligion, which cater to a wide variety of political leanings. Some of the spread is likely due to the vigorous debate across political positions that characterizes Reddit, but it appears that political debate (broadly construed) is especially attractive to users who would go on to post in r/conspiracy. A useful framework that encompasses both the language use and social environments was suggested by Douglas and Wood [103,102,40], who note that endorsement of certain firstorder conspiracy beliefs seems to be mediated by higher-order beliefs about the existence of cover-ups. Similarly, McCauley and Jacques [14] suggest that individuals believe, on Bayesian grounds, that conspiracies are more likely to be successful. As has been emphasized in the past (including by members of r/conspiracy), some conspiracy theories have proven to be true. As we noted above, for example, there is a relationship between conspiracy endorsement about medical experimentation among the African American community and awareness of actual abuses and cover-ups around the same issue. The conspiratorial mindset need not be read as wholly irrational: it may instead reflect awareness of actual past abuses of power. This is consistent with the "conspiratorial mindset" markers noted in the broad language analysis. Notable over-representation by both user-count and post-count also occurred in the theme communities we labeled "Drugs and Bitcoin" and "Toxic Reddit". The former includes a heterogeneous set of topics (including UFO and paranormal speculation) but can be characterized by a willingness to engage with socially "fringe" ideas of many kinds. The "Toxic Reddit" theme community also represents fringe engagement, but instead on the edges of acceptable taste. The most popular subreddits appear comparatively innocuous, but include r/KotakuI-nAction, which is a known hotbed of sexism and racism. Further, the subreddits in which r/conspiracy posters are also most over-represented include several that have since been banned for questionable content, such as r/WhiteRights and r/fatpeoplehate. The inclusion of these subreddits suggests that the "conspiratorial mindset" tag may be in need of further refinement. On the one hand, it skirts tautology if read literally: claiming that people find a particular conspiracy attractive because they find conspiracy theories generally attractive carries relatively little explanatory power. On the other hand, the label may be overly restrictive. The more general affective consideration may be that conspiracy theories are outside of the mainstream of ordinary thinking, and that some people are attracted to a range of non-mainstream beliefs. That would assimilate conspiracy endorsement to a broader range of endorsements, which may in turn suggest novel lines of research. Some of the discrepancies between our results and previous experimental studies may be due to differences in the population under study. In our analyses, we observed conspiracy engagement-users who were actively posting comments on stories in the r/conspiracy subreddit. Most experimental studies focus on willingness to endorse conspiracy theories, which appears to be more prevalent [11]. General powerlessness may make acceptance of conspiracy theories more attractive-but it requires a conspiratorial mindset to engage with and spread conspiracy theories in a social context. Taxonomizing individuals by the contents of their belief (i.e. by discussing "conspiracy theorists") may thus be too coarse a cut for scientific purposes, and more fine-grained categorizations may be needed to capture the full dynamics of conspiracy endorsement. Our results suggest that people who are willing to discuss conspiracy theories in a social context are different from, or a special subset of the relatively broad populations who would endorse conspiracy theories when asked in isolation. --- Interactions In the first two analyses, we identified the personal traits and social factors associated with future engagement with conspiracy beliefs. But these analyses are unable to shed light on whether, for example, r/conspiracy users appear angrier because they happen to be posting in subreddits which host particularly vigorous debates, or whether they exhibit anger in their posts even in the context of the social environments they inhabit. A primary goal of the study was to disentangle self-selection effects from other cohort effects. Users from the r/conspiracy group differed from their matched cohort both in where they post and in the language they use in their posts. We interpreted the observed interaction between language and social factors as showing that this difference is primarily due to selfselection, rather than to the effect of either invariant traits or situational evocation. Several patterns of interaction are theoretically possible. A complete lack of significant differences, especially in high-risk theme communities, would suggest that people self-select: that language use by r/conspiracy subjects is different because they tend to post in communities where that language finds a welcoming home. Conversely, consistent differences in the same linguistic factors across themes that vary in their association with eventual r/conspiracy posting (that is, in their user-count or post-count ratios) would suggest the importance of traits regardless of social communities. Differences in certain theme communities across factors would suggest that certain theme communities selectively enhance traits, possibly as part of a "radicalization" phenomenon. Finally, more complex patterns would suggest a more complicated causal story incorporating multiple processes. The evidence for self-selection is twofold. First, across nearly all theme communities, there were relatively few significant differences in language use, and even fewer that met the pre-specified criterion we used in the first language use analysis. The lack of effect was most striking in the highest-risk theme communities like "Politics". For example, r/conspiracy users discussed terrorism more than the control group, were more likely to post in political subreddits than the control group (and more often), but within the political subreddits their focus on terrorism is unremarkable. If the differences between the groups were due solely to extreme individual traits, we would expect to see language use differences persist when analyzed within the theme community. Second, the exception to this general pattern is what we have dubbed the "Basic Reddit" theme. These are subreddits in which nearly everyone posts (i.e. the user-count ratio is close to 1.0). They are among the most popular subreddits (such as r/AskReddit, r/funny, and r/pics), and are generally innocuous in nature. Within this group, the language differences observed in the first analysis remained significant and strong in the third analysis. This suggests that the differences in the first analysis cannot be explained by situational factors because the differences between r/conspiracy users and the matched controls are still apparent within the subreddits that are most general. The picture that best fits these observations is situational self-selection. In situational selfselection, individuals with a conspiratorial mindset select and post in subreddits where they appear relatively unremarkable. Further, this appears to be a process closer to the "choice mechanism" of Emmons et al. [56]: individuals appear to post just as stridently in subs where this would not necessarily be reinforced. Of course, to say that the language within the politically themed subreddits is generally aligned with the social setting does not rule out the possibility that what is asserted is more conspiratorial in nature. Consider the following (deliberately obfuscated) comments from around the same time in politics-themed subreddits from an r/conspiracy user and their matched control: r/conspiracy user: "Do you really deny that a politician might make decisions, after winning the race, that would help people who funded their campaign (or even to hurt people funded their opponents?) I'm not saying that only rich people win elections, I'm saying that money can corrupt political decisionmaking." matched control user: "The Tea Party movement took off when Glenn Beck began endorsing them. I am sure that MSNBC would cover a thoughtful left-wing counter-movement. What we would really need is enough push to make the movement credible, and then have some attractive faces in the media to promote it." Both quotes are concerned with questions of power, influence, and public perception. But the former is intuitively more suggestive of a conspiratorial mindset than the latter. Finally, we note that the social environment analysis was relatively coarse-grained. Within each theme, there are certain subreddits where r/conspiracy posters are substantially over-represented when measured by user-count ratio. For example, the "Geek culture" theme includes subreddits such as r/collapse (devoted to discussion of "Resource depletion and ecological breakdown leading to the end of civilization"), r/WikiLeaks, and r/Anarchism. There were 8 times as many r/conspiracy group users posting in these subreddits as there were users from the matched control group. While the topics of the subreddits are aligned with traditional geek culture, they are more amenable to discussions related to conspiracy theories. The "Basic Reddit" theme community included subreddits such as r/Libertarian and r/MensRights, where there were 5 times as many r/conspiracy users as matched controls. The overall grouping still makes sense (as these are popular subreddits), but topics of discussion were also more likely to align with known conspiracy theories. This raises the intriguing possibility of more fine-grained "gradients" within theme communities. Even when agents' affiliations are driven entirely by self-selection, they face a discovery problem: it is not always obvious, especially in a crowded field, which groups will be most welcoming. To continue Funder's [54] analogy: even if I like seedy bars, I might have trouble finding appropriately violent ones when I move to a new city. A good solution is word of mouth: I seek out the roughest bar I can find, and I find what the patrons already there say about other bars in the city. If there's one that sounds more exciting, I try it. By iterating this process, I can eventually find action sufficient to my tastes. Alfano, Carter, and Cheong [104] have dubbed this process "self-radicalization". We suspect that a similar self-radicalization process may be at work in online forums. There is considerable traffic between, and discussion about, different subreddits. This word of mouth should aid the discovery process of new subreddits. Consider Fig 2, which shows chronological pathways of both r/conspiracy users and control group users through selected subreddits in the "Guns and Cars" theme community. Although the numbers are small, movement through increasingly risky subreddits towards r/conspiracy occurs more often in the r/conspiracy group compared to the control group. --- Limitations and future directions Our study was subject to several methodological limitations. The dataset on which this study was based may have gaps in the availability of some of the comments from users, indicating that there is per-user risk of approximately 4% that one or more comments may be missing (the rate of missing comments is highest in 2009) [105]. However, since the study design relies on identifying differences between groups of users, missing data of this structure and magnitude would be unlikely to affect the results. The dataset tracks Reddit users rather than individuals, and individuals can have multiple user accounts. To minimize this limitation, we constrained our set of participants to include only those users who posted with a minimum frequency over an extended period. Similarly, we only used information about users who were active participants in subreddits and could not determine whether users were reading forums without commenting ("lurking"). We think it is reasonable to take commenting to indicate active participation. However, we cannot rule out the possibility that some of our user accounts represent "alts": that is, accounts made by individuals specifically to hide their less socially acceptable activities from searches. The presence of alts is a plausible explanation for the pattern observed in the "Pornography" theme community, which has a relatively high user-count ratio and a relatively low postcount ratio. However, we think the presence of alts would not fundamentally change our conclusions. Indeed, the maintenance of multiple social identities online might serve to aid selfselection of social groups, by reducing the need to mediate conflicts [106,107]. Large-scale online work may thus represent a valuable tool for looking at the negotiation of social identities. Differences in language are useful but noisy proxies for psychological states. We note that other linguistic analyses have been used to study straightforwardly psychological phenomena. There are a range of other studies that use language markers from social media users to predict behavior changes relative to mental health conditions [108][109][110]. We think that the same logic readily extends to other, non-pathological psychological states. The robustness of our findings suggests that the results are a reasonable signal of differences in psychology. Lexical analyses using a bag-of-words approach omit important context and can overlook subtle differences in how topics are discussed. The emotion-based Empath categories serve as something of a proxy for sentiment analysis, but proper sentiment analysis might give further distinguishing information. More powerful unsupervised methods such as topic modelling can also pick up differences in rhetorical and narrative style which differentiate different attitudes. Previous work on r/conspiracy suggests that skeptics could be differentiated by conspiracy endorsers by such means [62]. Developing more principled means of manual analyses of identified posters and comments might similarly aid interpretability. Reddit is a global phenomenon with around 330 million monthly active users. As such, the sample is likely more diverse than many smaller experimental studies. The demographics of Reddit are skewed, however. Around 63% of Reddit users self-identify as male; 80% are between 18 and 35 years old; 82% are white; and 59% are single (See S1 Appendix). As such, while our findings are a reliable characterization of the population of Reddit users, we may not have reliably characterized engagement with conspiracy theories among minority populations [3]. However, further diversity would likely support rather than undermine our findings. In addition, Reddit is known to have played a role in spreading and amplifying misinformation from other parts of the web [80], suggesting that the importance of studying Reddit goes beyond the community itself. We note again that because we studied Reddit users, we examined only people who have engaged with conspiracy theories in a social space, rather than the broader set of people who endorse or accept conspiracy theories. Both populations are important. We have suggested that some of the divergence between our findings and experimental results might reflect differences between these two groups. Experimental studies may be able to incorporate some of these insights by focusing on willingness to disseminate and discuss, rather than merely endorse, conspiratorial theories. --- Conclusion Large-scale data analyses of online forums can shed light on how and why people engage with conspiracy theories. Results from analyses of what Reddit users post and where show that there are consistent language use differences between users who will eventually become engaged in a conspiracy theory forum compared to similar users who do not. The results also suggest that many of these differences in language are related to users actively selecting to engage with social groups whose interests and motives tend to fit with an incipient conspiratorial mindset. This does not rule out the possibility that further engagement with those groups ultimately helps to enhance conspiratorial leanings, but this would suggest amplification of existing biases rather than a de novo radicalization process. Further research would benefit from better understanding of the differences between people who endorse or accept conspiracy theories relative to those who engage with conspiracy theories in social spaces, as well as a deeper understanding of the confluence of personal traits and social circumstance that precedes engagement with conspiracy theories. --- The analysis uses a publicly available dataset; access instructions are at: (https://www.reddit.com/r/datasets/ comments/3bxlg7/i_have_every_publicly_ available_reddit_comment/). A torrent of the dataset can also be found and downloaded here: (http://academictorrents.com/details/ 7690f71ea949b868080401c749e878f98de34d3d). The authors confirm that they had no special access privileges for the dataset.

Many individuals who engage with conspiracy theories come to do so through a combination of individual and social factors. The interaction between these factors is challenging to study using traditional experimental designs. Reddit.com is a large connected set of online discussion forums, including one (r/conspiracy) devoted to wide-ranging discussion of conspiracy theories. The availability of large datasets of user comments from Reddit give a unique opportunity to observe human behavior in social spaces and at scale. Using a retrospective case control study design, we analyzed how Reddit users who would go on to engage with a conspiracy-related forum differed from other users in the language they use, differences in the social environments where they posted, and potential interactions between the two factors. Together, the analyses provide evidence for self-selection into communities with a shared set of interests which can feed into a conspiratorial world-view, and that these differences are detectable relative to controls even before users begin to post in r/conspiracy. We also suggest that survey-based and experimental studies may benefit from differentiating between passive private endorsement by individuals and active engagement with conspiracy theories in social spaces.

Introduction Stroke has a withering impact on individuals as a common and long-term condition. The narrative of stroke patients is an interesting source for modern literature. In novels, stroke may function as an enforcer of change in the sense of self, i.e. the individual's experience of continuity and unity. In this paper, we compare the narratives of two people affected by stroke. One, Cristoforo, is the central character in a novel published in 1906 [1] ; the other is a patient, living with stroke in 2010. Pirandello described society as being a higher entity than the individual ( fig. 1 ). From this hierarchical per- spective it is understood that human individuals strive to adjust to the demands and expectations of society. The question we pose, and aim to answer, in this paper is: do social trends influence how stroke patients prioritize aspects of their rehabilitation? --- Methods We recruited a stroke patient to take part in an extended interview. Our selection criteria were the presence of two principal residual symptoms: right hemiparesis and aphasia. Importantly, the aphasia could not be severe otherwise the patient would not have been able to tolerate the lengthy conversation required to explore her narrative. Furthermore, the patient had to have been in recovery for some time after the stroke in order to be able to reflect on the recovery process and draw conclusions from it. We conducted a 3-hour interview with a 43-year-old stroke patient, Mrs. K., 2 years after her intracerebral hemorrhage. The intracerebral hemorrhage was caused by an arteriovenous malformation in the basal nucleus area on the left side, with an extension of the hemorrhage to the left frontal ventricle. Despite the severity of her intracerebral hemorrhage, Mrs. K. retained a good level of abstractness, mental flexibility and intellectual understanding (IQ 1 100). The interview was tape-recorded and was conducted in the patient's home. The interview schedule was divided into three parts: the patient in society, the patient as an individual, and the role of the doctor. We selected the literature of Luigi Pirandello, in particular the short story 'La Toccatina'(1906) (literally, 'The Light Touch'), as the source for our literary narrative [1]. 'La Toccatina' -a metaphoric title -was the stroke which changed Cristoforo Golisch's life. The problem of identity is a central concern of Pirandello's oeuvre. In many of his works his characters' experiences reveal to them that they cannot have a fixed identity; an individual's identity depends on how others see them, and how they perceive others as seeing them. Diseases, such as stroke, serve to reinforce the concept of the fragility of the unified self. --- Results --- Patient in Society When comparing 'La Toccatina' to Mrs. K.'s narrative we detected striking differences in the priorities and associated goals of both of the patients. Cristoforo, a 48year-old man, lost his speech as well as his awareness of the right half of his body. Immediately following his stroke, Cristoforo focused on improving his mobility by kicking a lever to exercise his paralyzed muscles, and in recent times such early rehabilitation has been found to be highly effective [2]. In contrast, Mrs. K. revealed that, above all, she focused on restoring her communication skills. Both appeared to have the same residual symptoms, but they prioritized different rehabilitation needs and goals. Mrs. K. found the communication group in the stroke patient union very helpful as a forum in which to discuss social struggles. In the communication group she felt free to practice her communication skills. In Cristoforo's narrative the importance of peer contact is similar. When he was able to walk, he asked his sister to take him to meet his friend Beniamino, who also had suffered a stroke. Cristoforo and Beniamino practiced their mobility skills, while Mrs. K. and the other stroke patients in the group worked on improving their communication skills. Life adjustments are central both to Pirandello's work and to Mrs. K.'s narrative. According to Pirandello, the need for individuals to make adaptations derives from social pressure for the patient to change, or conform. The focus of contemporary society on communication is evident, with an ever-increasing trend towards high volumes of rapid communication using a range of media from speech and nonverbal expression to online social networking. Considered in this way, contemporary society stresses the need for individuals to communicate. In the interview, Mrs. K. indicated that society finds it difficult to respond to her 'invisible' impairment, aphasia: 'They (social environment) are able to cater for physical problems, but in case of communicating they are not.' In addition, she stresses the current pressure for rapid communication. For example, when she went out to buy paracetamol, at the counter she could only recall the word 'aspirin'; the word 'paracetamol' did not come to her. After some minutes, a queue had built up behind her and the cashier became impatient. Society became impatient. --- Patient as Individual Illness is truly an 'ontological assault', affecting our very being and not simply our activities [3]. This is certainly true of stroke. According to Pirandello, it is in the power of human adjustability to deal with this dissolution of the sense of self. Here, we define the sense of self as the experience of continuity and unity of the patient. Immediately after the stroke, Mrs. K. experienced a strong feeling of loss of a sense of unity. She explained: During recovery she not only improved physically but she also regained her sense of unity. In contrast, her sense of continuity was not restored, nor was it gone; it was changed. She explained that there was continuity before the stroke and a new kind of continuity in life after the stroke. She had made a new life plan. Interestingly, Pirandello was familiar with this awareness of change in continuity: 'Suddenly he had become German, Cristoforo: in the meaning of a different man, because he never exactly was German.' The only connection between Germany and Cristoforo was his parents; he had never even been to Germany. He experienced an interesting phenomenon called polyglottal aphasia [4]. Prior to his stroke, it seemed to Cristoforo that he had forgotten how to speak German. However, German, his mother tongue, had'survived' the stroke attack, but the Italian language that he had learned in later life seemed to be lost. Pirandello used this metaphor to highlight Cristoforo's emergent and altered sense of continuity following the stroke. These examples demonstrate that Mrs. K. and Cristoforo responded to the ontological assault in very similar ways. Mrs. K. coped with the enforced change in her life plan with hope. She expects the future to be positive in the sense of having a small job and taking an active part in society. Literature influenced her coping behavior. Her husband heard about the story of Dr. Jill Bolte Taylor [5]. He read her narrative to his wife, of the way Dr. Jill Bolte Taylor recovered 8 years after her stroke. Hope was verbalized when Mrs. K. said: 'It is just two years ago for me.' Before Cristoforo suffered from a stroke, he met his old friend, Beniamino, shuffling through the streets of Rome. Beniamino, stammering and with eyelids which constantly were closing, did not resemble the friend Cristoforo had played pranks with as a youngster. The change in Beniamino made Cristoforo ill, and for weeks he spoke of nothing else. 'Really? he said. One light touch (mild stroke) and it is that far? No, goddamn, no! I won't let that happen.... I'll shoot myself, I'll kill myself, for God's sake!' One month later Cristoforo had a stroke. Rather than wanting to commit suicide, as he had thought he would, he was very pleased the first time he was able to move his hand slightly. He still could not move his leg, but he was full of hope that it would happen someday soon. Pirandello shows us the perception of those in the 'notstroke world' about having a stroke, and how this opinion is changed when the same person enters 'the stroke world'. --- Doctors in Time A change was seen when comparing the role of the doctors in both stories. In 'La Toccatina' Pirandello describes a typical biomedical doctor: 'The doctor tried to give a scientific explanation to the symptoms. He stated the name of the disease: hemiparesis. He determined the treatment.' This is almost the only time the doctor comes into play in 'La Toccatina'. Please note the lack of mention of aphasia in the doctor's diagnosis. For Pirandello, and most probably for other laymen as well, aphasia was just a result of the hemiparesis, which of course is a purely biomedical view. For Pirandello, the doctor represents positivism and its belief in science and rationality. However, Pirandello, together with other authors, was probably already disappointed about the possibilities of modern medicine in the late 19th century [6]. Therefore, he describes a doctor who does believe in science and rationality and yet fails to understand the patient. This could be seen as a metaphor for the failure of the scientific movement. The doctor 'rationalizes' the state of the patient and is completely unable to grasp the existential difficulties experienced by the patient. Half a century later, in response to an acknowledged 'need for a new medical model' [7], Engel theorized a model, his biopsychosocial model, which moved away from reductionism of a disease to its biomedical cause. Mrs. K.'s doctor, a biopsychosocial doctor, told her she had two main residual symptoms, namely, hemiparesis and aphasia. In addition, she had few cognitive problems. Engel described how, in contrast to doctors who adopt a biomedical approach to diagnosis and treatment, biopsychosocial doctors are able to broaden the scope of the help Pirandello's Analogy: The Social Impact of Stroke Eur Neurol 2012;67:92-97 95 they offer to patients. Their approach enables them to address biological, psychological and social factors, all of which play a significant role in human functioning in the context of illness. In addition, the biopsychosocial model acknowledges how symptoms or 'being ill' does imply not purely the disappearance of a function but a new condition for the whole patient, which is a suggestion previously made by Hughlings Jackson, about a hundred years ago [8]. However, Mrs. K. consulted her doctor only about biomedical problems; psychological and social problems were dealt with by her husband or her mother. She explained: 'You should see him (the doctor) only if you really need him.' Mrs. K. has reduced the role of the doctor back to that of a biomedical doctor; she does not understand biopsychosocial practice as being a doctor's role. --- Discussion In conclusion, we compared the experiences of a fictional character from 1910 with those of a patient living with a stroke in 2010. Both were affected by stroke in similar ways, yet in 2010 patients' priorities differ from those of patients in 1910. Cristoforo and Mrs. K. regained a sense of unity while working on improving their motor and communication skills. Over time, for both, the experience of continuity was resolved to a new post-stroke continuity. With regards to emotional coping behavior, both patients stayed positive and full of hope, attitudes not usually understood by those in the 'not-stroke world'. Both patients displayed a response shift, the adjusting of internal norms or standards regarding quality of life in illness. This phenomenon is true for patients with, for example, cancer as well, who adjust the level at which they judge their quality of life over the course of their chemotherapy with all its major side effects [9,10]. Similarly in this case, both stroke patients adjusted their judgment of their quality of life levels during rehabilitation. Narratives can be divided into three types as described by the sociologist Arthur Frank in 1995 [11]. Frank is particularly interested in patients from the'remission society': these patients are unable to return to the status quo ante, as is the case for stroke patients [12]. The three types of patient narratives have been described, namely, restitution, chaos and quest. A typical quest narrative is that of Brodal, a professor in neuro-anatomy, who recounts his personal experience of stroke. In his systematically arranged case report he does not engage in vain restitution narratives nor does he allow himself to sink into chaos [13]. A more recent patient account provided by Bolte Taylor is typical of a restitution narrative [5]. In this narrative Bolte Taylor is diagnosed as having a serious illness, stroke. She struggles for some period of time against the illness with the help of proper healing authorities and in the end the struggle is successful. In contrast, Cristoforo's narrative is one of chaos; after the stroke he cannot make any sense of his current situation. The narrative of Mrs. K. is ongoing. In the beginning it appeared chaotic, as has been described by other stroke patients [14]. However, 2 years later Mrs. K.'s narrative more closely resembles that of Brodal: a quest narrative. It is important to note that the perspective of the narrator, Pirandello, is that of a person who did not suffer a stroke himself. The author imagines what it would be like to suffer a stroke. At the same time, as pointed out by Bassanese, Pirandello's wife was known as a person with enduring confusion and the disability to bond with society due to mental illness [15]. This unfortunate circumstance may have helped Pirandello develop insight into the experience of suffering a stroke and its consequences. Another important factor is the role of the doctor which Pirandello uses as a vehicle to convey his views on the contemporaneous scientific movement. Pirandello and his contemporaries appear to have been disappointed as the possibilities of modern medicine had not been realized [6]. This sense of disappointment is reflected in the French literature of the time, especially those tracts describing the struggles experienced by Jean-Martin Charcot as he attempted to identify the etiology of hysteria and hypnosis [6]. Similar confusion reigned regarding contemporary understanding of the etiology of stroke, as seen in the work of Adrien Proust [16], supervised by Charcot [17]. The etiology of stroke became clearer following the publication of the pathological work of Rokitansky and Virchow [18]. Pirandello's 'La Toccatina' was written and published in the so-called Interbellum: a period in 20th-century Europe when mechanization and rationalization of the production of goods was dominant. This implied that society attached great value to physical capabilities and skills in individuals. Pirandello explicitly describes this aspect of physical action and movement in Cristoforo's medical history during his rehabilitation. van One hundred years separates the two stories. Today Pirandello's work continues to entertain, but does it still have a useful message for doctors in 2010? Take physical improvement: it is not necessary to look up 'La Toccatina' to determine the best treatment, but when a doctor is interested in the ontological being of a stroke patient he is certainly helped by Pirandello, whose philosophical message is that society is a higher entity than the individual, and therefore individuals have to adjust to society's norms. For Pirandello, this demonstrates the strength of human adaptability to existential problems. This idea is still relevant in 2010, as our comparison of 'La Toccatina' to the narrative of Mrs. K. demonstrates. Society can be seen as a variable in the concept of human adaptability. Society certainly has changed in the last hundred years, particularly in recent decades with the rise of the internet and mobile communication technology. These communication media have extended the social environment of the individual. In addition, major differences in the way that health care systems were organized one hundred years ago and at present undoubtedly impact on the survival of patients with various illnesses, e.g. stroke. These differences reflect the importance that society attaches to objectives of medical care. It seems safe to state that in Pirandello's epoch, being able to move -again -after a stroke was a major objective of medical management and rehabilitation. At present, being able to move -again -remains a major goal of medical care. However, current developments in society emphasize communication and interaction to a great degree. This is reflected in our patient's narrative. Even in the 21st century, (medical) care for patients with physical problems tends to focus on physical aspects, e.g. the use of physiotherapy to teach patients with a stroke to re-use their physical capacities again. However, modern journals in neurology and other medical subdisciplines make it clear that, increasingly, the so-called biopsychosocial model is likely to be adopted. In that model, medical (physical) management is complemented by psy-chological management, e.g. cognitive behavioral interventions and social interventions, e.g. patient organizations [7]. This shift in practice is reflected in the increasing tendency of social insurance systems for health care costs to also cover the costs associated with psychological and social interventions. Nonetheless, the individual has remained unchanged, as demonstrated by the similar effect of stroke on the sense of self and on emotional intercourse in 1910 and in 2010. Both Cristoforo and Mrs. K. developed a new sense of continuity after stroke and revealed similarities in how they faced life after stroke, by being very positive and full of hope. The inner core of the individual did not change over time. The essence of being a stroke patient did not change -society did, thereby justifying the different priorities of patients in different contexts. Doctors may find useful the analysis presented here, as it aids a better understanding of patient needs. Patients will always be trying to respond to society's call, i.e. to respond to the demands and expectations of society. Currently, society demands participation in a large social environment and that is reflected in patient priorities. However, as society is constantly changing, doctors should be aware of and remain responsive to associated changes in patient priorities. Importantly, this analysis serves to provoke awareness of the impact society has on the individual and especially the patient, within a temporal context. --- Disclosure Statement None.

neous demands and expectations. Currently, society demands participation in a large social environment and this is reflected in stroke patients' priorities. This analogy could enable medical professionals to better understand the social impact of stroke, and consequently offer appropriate interventions to improve rehabilitation outcomes for individual patients.

Background As HIV care and treatment access continues to expand, people living with HIV/AIDS (PLHIV) are living longer and healthier lives. For the PLHIV whose health has been restored their concerns are shifting from ill health and medications to achieving full integration into communities and living a productive life, including having children [1,2]. In Africa, studies have documented societal expectations in relation to childbearing, specifically, pressures to have children, the need to have boys as heirs, and large families [3,4]. Such expectations and pressures also influence the fertility desires among PLHIV [5,6]. Whereas several studies show that PLHIV are more likely not to want to have more children once diagnosed with HIV, literature also shows that a substantial proportion (20-50%) of men and women living with HIV desire to have children [7,8]. Family planning (FP) support and decisions for HIV infected individuals have been a major focus of HIV prevention interventions, especially prevention of mother to child HIV transmission [9]. Prevention of unplanned pregnancies among PLHIV is the second prong among the recommended PMTCT approaches and scale up of these interventions has been ongoing over the last decade [10]. However, the scale-up of FP for PLHIV has largely focused on availability of contraceptives, and has not comprehensively addressed their fertility decisions and desires [11]. Focusing on only preventing unplanned pregnancies may lead to increased risk of HIV transmission to sexual partners and children, for PLHIV who attempt to have children without adequate information and support. Furthermore, PLHIV who want to have children but perceive that such desires are stigmatized by their providers and thus cannot turn to their providers for support, may be vulnerable to discontinuing HIV care, having children unsafely, and increasing risk of transmission to their partners and unborn children [12]. Thus, providers should offer comprehensive support to meet the needs of both the PLHIV who want to have children and those who are sexually active and wish to prevent pregnancy [13]. However, this balance is not always achieved for various reasons including health system challenges, provider attitude and stigma [6,12,14]. This paper broadly explores the FP decisions among HIV infected men and women at two HIV clinics in Uganda, including their decisions to have or not to have a child and the support that is availed to them as well as their contraceptive preferences, fears and challenges. The two clinics had integrated FP services but one offered information and contraceptives on site while the other offered only information, with informal referral for contraceptives elsewhere. --- Methods This was a descriptive cross-sectional study, using qualitative data collection methods, including focus group discussions, in-depth interviews and key informant interviews. The qualitative interviews were conducted during February to June 2011, as part of a larger study to assess family planning practices among HIV infected clients at the two HIV clinics in Kampala, Uganda. --- Study sites The study was conducted at Mulago Immune Suppression Syndrome (ISS/HIV) clinic located within Mulago national referral and teaching hospital in Kampala, and Nsambya Home Care (NHC), a Catholic founded faith-based clinic/ department of Nsambya hospital in Kampala. Mulago had fully integrated FP including onsite delivery of contraceptives whereas NHC only provided information with no onsite provision of contraceptives. Both Mulago and NHC had over 9,000 registered HIV clients in care. However, NHC had a prominent community component including visits to client homes, while Mulago predominantly provided facility-based care. NHC also provided HIV care and treatment for children and adolescents while the Mulago HIV clinic provided only adult care. NHC was deliberately included because we anticipated that the patients in this clinic may be more disadvantaged in terms of accessing family planning services. Thus, we wanted to explore their experiences and challenges as well as coping strategies. --- Data collection methods We conducted focus group discussions and in-depth interviews with patients at both clinics. Interviews were conducted with adult men and women and adolescent boys and girls (15-19 years) in order to get the experiences of these distinct categories of PLHIV. Additionally, key informant interviews were conducted with HIV care providers (including clinicians, nurses, and counselors) and clinic administrators. We conducted FGDs in order to obtain the broader views regarding participant (patient) experiences with contraceptives, their contraceptive preferences as well as fertility desires. Having obtained the big picture from FGDs, we then conducted IDIs with the PLHIV to explore their individual 'lived' experiences. Interviews with providers assessed their views and support provided to the patients. Overall, 106 participants were interviewed, including 84 through FGDs, 14 in-depth interviews, and 8 key informant interviews. The 84 FGD participants included 12 adolescent boys, 15 adolescent girls, 25 adult males and 32 adult females. The providers interviewed included two clinic managers, two doctors, and four nurses/counselors. The number and category of interviews conducted are summarized in Table 1. We purposively selected sexually active men and women (those who reported that they had sex within 12 months), aged 15-49 years (within the reproductive age group) and had attended the clinics for at least six months. We included duration of attendance at the clinic, since some of the questions were related to the services delivered at the clinics. Sexually active adolescents were included since the adolescents may encounter different challenges from those of the adults in access to FP services. At each study site, a research assistant with the help of a provider, nonsystematically selected participants from the outpatients waiting to be seen by clinicians. The provider explained to all patients about the study related to FP needs of PLHIV, before the selection of potential participants. A brief screening tool was used to assess eligibility of selected participants (age, sexually active, duration of enrollment). Selection of providers was done with the help of clinic management; the clinic managers were requested to identify providers who were involved in counseling or provision of FP services at the clinic. The interviewers then approached each of the selected providers to schedule and conduct the interviews. All the FGDs and IDIs were held in the local language (Luganda) while key informant interviews were conducted in English. Interview guides were developed for the focus group discussions, in-depth individual interviews and key informant interviews. Open-ended questions were used to allow for exploring new leads and generating rich personal narratives, and prompts were used when needed. The key questions or areas of focus included: What are their contraceptive preferences and are they able to access these methods? What challenges, if any, do they experience in accessing contraceptives? For NHC where contraceptives were not available, are the PLHIV able to access supplies at other sites? What influences the decisions to have/not to have children? What are the influences of HIV status (individual and partner HIV status) on fertility desires? What support do they get from providers when they want to have children? --- Ethical issues Participants provided verbal informed consent, following explanation of the purpose of the study and procedures. Interviewers read to them pre-designed information about the study and documented the participants' agreement to be interviewed. The participants were assured of anonymity and confidentiality of the data; the interviews were conducted in a private environment and the transcripts did not bear the participant names. The sexually active adolescents (15-19 years) were handled as'mature' minors, with waiver of parental consent. The Uganda National Council for Science and Technology (UNCST) defines children (mature and emancipated minors) who may independently provide informed consent to participate in research. Mature minors are individuals 14-17 years of age who have drug or alcohol dependency or a sexually transmitted infection; while emancipated minors are those who are pregnant, married, have a child or cater for their own livelihood [15]. Obtaining consent from the parents or guardians of sexually active HIV infected adolescents may expose them to risks of stigma, discrimination or other such harms from parents/guardians who may otherwise not know that they are sexually active or HIV infected. Because of these considerations, adolescents provided consent but were given the option of involving their parents and/or guardians in the consent process. They were thus treated as'mature minors'. The participants who were clients at the clinics were given 5,000 Uganda shillings (equivalent to 2.5 USD at the time) as compensation for their time while providers received 10,000 shillings. The study was approved by Makerere University School of Public Health Higher Degrees Research and ethics committee, and the UNCST. --- Data management and analysis All interviews were digitally recorded and a designated note taker was present in all groups and individual interviewsthe notes augmented the recording. Experienced research assistants directly transcribed and translated the recordings from Luganda into English. Based on the key questions and study objectives, a coding system was developed before the transcripts were examined. The initial step in the analysis was to read through all the transcripts several times while making notes in the transcript. The notes were reviewed by multiple readers and themes identified and coded, to ensure that all the key themes were captured. The research assistants and investigators used an empirical approach to modify the pre-determined themes. After verifying and reviewing the coded and labeled responses, the authors identified major themes. Open coding was done and the codes were grouped into categories in order for themes to be identified (as stipulated by the methods of Graneheim & Lundman, 2004 [16]. Codes were grouped into categories and then themes and subthemes further identified. This was intended to indentify similarities as well as differences in experiences and opinions across various categories of participants (men, women, adolescents, providers, and the two clinics). Qualitative latent content analysis technique was used. The data were therefore condensed without losing quality. --- Results All the respondents both providers and clients appreciated the role of FP and emphasized the need to integrate FP into HIV services. Providers highlighted the need to have more comprehensive reproductive health services for PLHIV, including cervical cancer screening for HIV infected women. Adolescents (both girls and boys) appreciated the need for FP but thought the adults needed it more since they were having too many children. Participants noted that the education on family planning needs to be broadened beyond the current focus on using contraceptives only, to include planning for and spacing of children as well as having the number of children that one can afford to care for. 'We are 11 children in our family, and our parents left us. I don't live in good conditions. Family planning would have helped a lot'. Male Adolescent NHC --- Preferred contraceptive methods and access Most IDI and FGD participants, adolescents, adult men and women, preferred condoms. They noted that the clinics emphasized condoms to prevent HIV re-infection and unplanned pregnancies. They also noted that the condoms have limited side effects and can prevent HIV re-infection or transmission of sexually transmitted infections. 'Some men fear to disclose their HIV status to their women but find it easy to use condoms under the pretext that it is for family planning', said one adult male FGD participant. Some providers however felt that the condoms were largely marketed for prevention of HIV and not as a method of family planning 'The message on condom use has been packaged to emphasize prevention of STDs and HIV but we have not gone ahead to emphasize it as a method of FP' Female provider NHC. Male condoms were the most preferred method among both men and women 'they are easily accessible, cheap and they are easy to use', said an adult male at Mulago. However, some women and men said condoms reduce sexual pleasure. Some women cited challenges with asking their partners to use condoms and as such preferred methods that they could use without telling their partners or asking for their permission (e.g. injectables; IUDs). They however noted that the intrauterine devices and implants were not easily accessible and were expensive. Some men also noted that the IUDs are good and have no side effects but said most people have not had an opportunity to be educated about them. 'My wife was wondering how a ring that is inserted in her body can prevent one from getting pregnant. What if this ring disappears in her body or gets into her blood stream...?' said one adult man at Mulago. Both adult and adolescent women mentioned pills but had concerns about taking additional pills. Despite this concern, some women said they liked pills 'because they enable one to enjoy sex without reducing the pleasure like a condom' said one adult woman at Mulago. Adolescent girls had concerns about pills and injectables, 'Pills and injections can prevent women from having children in the future' Female adolescent NHC. Some women said they had experienced several side effects with pills and injectables. Men also said pills and especially injectables have side effects including abdominal complications, prolonged periods, infertility and child abnormalities and noted that injections cause weight problems, high blood pressure, heart palpitations, and sleeplessness. However, some women who had injectables said they did not have major issues with them and thought they were better since they did not need to use them daily like pills. They however noted that the cost of the injectables had increased and was prohibitive. 'Most women use injections because you do not need to be on tension like swallowing pills. But injections have become expensive. It used to be about 2500/= [1.25USD] then increased to 3500/= [1.75USD] and as we talk now an injection costs 5000/= [2.5USD]. This is expensive and some of us may not afford.' Adult female NHC Some men said they had heard about vasectomy but had mixed feelings about it and were not aware of anyone who had done it. "... men have a fear that this could lead to their inability to have sex" said one adult man at Mulago. Men also noted that providers focus mostly on the women and ask them to bring their wives when they ask FP related questions. 'As men we should also be given this information, not to say that every time you want to know about family planning you should bring your wife first'. Adult male Mulago Unlike the adults, adolescents mentioned abstinence as a method of preventing pregnancy. All adolescent interviews highlighted challenges with accessing FP information. They said that they attended workshops organized by counselors but FP issues were not discussed. They noted that some of them would want to use contraceptives but they are not aware of the options and the advantages and disadvantages of the different types of contraceptives. They noted that some of their colleagues were sexually active but feared to tell the counselors. '...the counsellors see us as young and rarely tell us about family planning, we only see posters in their office', said one female adolescent at NHC. --- Challenges with accessing services at the clinics and other facilities Respondents from NHC mentioned'moon beads' a rhythm method that is used to educate women at their clinic. Some clients however felt that the moon beads were not very reliable. '...most people do not know how to use these beads; seasons change, people's lives change and if they go by these moon beads they find themselves pregnant and when they come back here in tears healthcare workers may not believe them'. Adult man NHC Some women said the FP information was not given frequently enough. 'It is only counselors who ask us about FP every time we go to their rooms', said one adult female at NHC. The respondents at NHC said they were given information on contraceptive use and referred to get the supplies from other facilities. However, they noted that some people did not go to the facilities they were referred to. 'I wish they could also give us the moon beads to take home. They use them for teaching but we cannot own them'. Female adult IDI NHC. Some clients appreciated the HIV services and felt it was their responsibility to get the FP services elsewhere. However, women noted challenges with using private and other facilities for FP services. '...we use services of the private clinics or doctors who are not aware of our medical condition....you cannot go telling everybody that you are positive; they may give us a drug or injection which conflicts with the ARVs we are taking', said one adult woman at NHC. Other respondents, especially adolescents, noted that the cost of the contraceptives is high. 'In other clinics family planning services are expensive so it can only be accessed by those who have money'. Female adolescent NHC. The Mulago respondents noted that the information was freely provided and supplies were available although a few cited stock out of condoms occasionally. They also noted that sometimes the health workers are very busy, with other activities or the clients are many, and they do not want to wait for contraceptives so they leave after getting other drugs. Respondents (adolescents and adults) noted the need to have children in order to be accepted and to 'please our parents' as one male adolescent said. The desire to have at least one child was raised in all adolescent interviews. Adolescents expressed the desire to have children in future and a fear of dying without having a child. 'If a person passes on without a child, you are taken as a person who has lived a meaningless life. In Buganda, it is like a taboo'. Adolescent male NHC The desire to have more children for PLHIV who already have children Respondents across all categories felt that it was not good to have only one child. They felt this was unfair to the child and that every child needs to have a brother or sister. 'Personally I was diagnosed HIV positive before I had any child, we have so far had one child and I would like to have 5 even though I am HIV positive'. Adult male Mulago They noted that those who have HIV infected children try to have more children in an attempt to get an HIV free child. Some respondents also said their partners may want to have more children because they are not aware of their HIV positive status. Ability to care for more children was cited frequently as influencing the decision to have more children. Respondents expressed the need to have a male child so that they can have an heir. 'My two children are girls, so I have no one to inherit my property when I die' said one adult man at Mulago. However, respondents who had only boys also expressed the need to have girls. 'I have two boys, one is 15 years and the other is 9 years old but I would like to have some girls; I want to have 4 children in total'. Adult female IDI NHC Respondents mentioned cultural pressures to have children and especially large families as a problem. 'Even our parents put us on pressure to produce', said one adolescent girl at NHC. They cited having large families and having twins as prestigious. They also said men want to have boys. 'A man might want a boy. Then they produce 12 children, still looking for a boy' said one female adolescent during a FGD at NHC. 'They say that the happiness of a parent comes from having many children', said another adolescent girl at NHC. Respondents noted the need to have a child in order to strengthen and maintain their relationships. They mentioned that even those who already have children may be forced to have more when they get a new sexual partner. '... Imagine a situation where you have a man who is taking care of you but you have not produced with him. To keep the relationship going and strong, I will be forced to produce so that I do not lose the man'. --- Adult woman, FGD Mulago Respondents also said they wanted to have children so that they can have someone to care for them later in life. 'I wish to have children for security when am very old or sick'. Adult female NHC. However, some adolescents said the pregnancies are sometimes accidental. --- Decisions not to have children Several clients noted that it is easier to decide to have children when their partners are also HIV infected. They said they worried about surviving in order to look after their children but felt this was less stressful than concerns about infecting the other partner. 'My wife is negative and I am positive. We have 2 boys and she wants to have a girl. Every time my wife says that we should have another child, I tell her I am sorry I can't do that. Who will take care of the children when we are all gone, if I infect her? IVF would be the way to go but I hear it is very expensive...'. Adult male Mulago. Respondents also noted that people that already have several children may not want to have more when they learn their HIV positive status. 'I had 5 children when I learnt I was HIV positive. I do not want to have any more children. People living with HIV should be sensitized not to have any more children but those who are childless should be helped to have children without infecting them'. Adult male, FGD Mulago They felt that having many children when one is sick could be a burden. Most respondents raised ability to care for the children as very important and cited various costs such as feeding, clothing and school fees. Others cited ill health as influencing the decision not to have children. However, they noted that this may change when they improve after getting into care or starting treatment. '...we all went through that stage but this usually changes as time goes by and we become stronger. I spent 4 years thinking I would not have any more children. But with time one gains courage and they decide to have children'. Adult male NHC --- Information and support given by providers on contraceptive use and childbearing Clients noted that counselors talked about contraceptive use and when to have children for those that want to have children. They also talked to them about PMTCT services to ensure that their babies are protected. They noted that this usually happens when they are about to start on ARVs. They said they are advised to use condoms all the time to protect their partners and to avoid pregnancy but those who want to have children are also allowed to have children. 'They ask about the CD4 count of the husband and wife. If the CD4 is okay then they can tell you to proceed with having a child'. Adult female NHC They however noted some challenges for those who want to have children. One adult man noted in a FGD 'They ask us whether we want to have children and then emphasize condom use all the time. How do we have these children if we are using condoms all the time?'. The desire to have more guidance on childbearing issues was also expressed by adult women and adolescents. Adolescents noted that the information is not very comprehensive and does not address all their concerns. '...we are still young and need to bear children. So we need to be well guided on how we can best go about issues of family planning. If am using family planning I need to know when do I stop it if I want to give birth', said a female adolescent NHC. 'My last born is about 18 years and my husband died a few years ago. I got another man and would like to have children with him. I am 43 years and need guidance on how to conceive and produce a healthy baby without any problem'. Adult female Mulago However, another participant from the same clinic said that those who want to have children are asked to talk to the doctors for advice. 'They [doctors] allow you one week of not using condoms and after that you resume using them every time'; Adult man Mulago. One respondent who was not yet on ARVs on the other hand did not seem to be aware of the family planning services. 'For me I have not heard about any family planning methods given at this clinic. I think FP is a new thing here'. Adult man Mulago. --- Attitude and support from health care workers (HCWs) in relation to childbearing The clients reported that some healthcare providers at the HIV clinics were sympathetic and supportive to clients who wanted to have children. All respondents (IDI and FGDs) from Mulago reported that they are supported when they want to have children. 'They support the idea of having children but emphasize that we should seek help here to prevent the baby from being infected. They do not discourage us at all'. Adult female Mulago However, the voices from NHC were divided. Some said the reception from the providers was good. 'If one wants to have a child, you are told to come back and see the counselors; they measure the CD4 count and advise you on how to give birth to a healthy baby'. Adult female NHC. However, other respondents felt some providers were harsh to clients who want to have children. 'I know of a woman who wanted to have an abortion because she feared to come back to the clinic while pregnant'. Adult male NHC 'Health workers do not want to hear that you want to conceive or bear children.' 'When we conceive, we have to first hide for some time, about 4 months, because counselors and doctors here do not want us to conceive'. Adult female NHC 'They do not support any one who wants to give birth. This has also forced some women to shy away from treatment due to the fear of how the counselors or doctors will treat them. The time I was pregnant, the doctor shouted at me and scared me that I was going to die, I went back home when my pressure was high and I really suffered'. Adult female NHC Unlike the adults, all the adolescents at NHC noted that the counselors were supportive and asked them to be open about their plans to marry and have children. --- Health workers voices All the health workers who were interviewed at both clinics said PLHIV have a right to have children and should be helped to do so safely. They felt that clients should consult and be helped when they want to have children and they should have children when they are clinically stable and their CD4 counts are high; they should be taking ARVs well, should attend ANC and be able to deliver at a health facility and receive PMTCT services to ensure the baby is HIV free. 'When we had just started giving ARVs we thought they should not get pregnant but over time, I now feel it is okay. When they want to have a baby and they are financially okay and prepared, I think it is okay'. Female HCW NHC 'It is a good idea for them [PLHIV] to have children; but how we implement it is where the gap is. I feel that they should be in regular consultation with their healthcare providers before and during pregnancy up to childbirth'. Female HCW NHC Some health workers were however more sympathetic to those clients who had no children at all but felt those who have should not be getting more children. 'Some [clients] are careless because you find that someone has HIV and already has 4 children but is going ahead to conceive another child........ But for a couple who may be newly married and have not had children surely they should give birth but they should consult the counselors and doctors'. Male HCW NHC 'It is not bad, but it depends on the type of patient. There are those that already have children. Like someone has 6 children. But then there are those that have 1 and want to have another. We advise them accordingly'. Female HCW Mulago Providers noted that those that have fertility problems are referred to the fertility clinic; those that cannot afford the fees at the paying department at NHC are referred to Mulago for free services. NHC providers noted that contraceptives were not available on site 'because of our policy as a faith based organization'; female HCW. Some providers suggested that access to contraceptives be improved through generating a list of centres which provide FP in order to facilitate referral to those that offer free services. A summary of the patient and provider perspectives is presented in Table 2. --- Discussion Most studies have focused on prevention of unplanned pregnancies among PLHIV, without due attention to the client contraceptive preferences. Studies have also shown Preferred contraceptive methods • Largely condoms: easy to use, accessible and do not affect their fertility • Condoms most preferred: easy to use, cheap and easy to access; limited side effects; prevent pregnancy and HIV transmission (men who fear to disclose their HIV status can use them under the pretext of FP) • Some preferred to abstain • Some women liked injectables, implants: no challenges with remembering to take pills daily, do not like to use or cannot tell partners to use condoms (limit sexual pleasure); can use without telling their partners or asking their permission Information on contraceptive use was provided at both clinics, but some misconceptions and fears still existed about virtually all the methods that were cited, indicating the need to avail a wide range of options, in order to meet the varied preferences. Clients knew about the need to prevent unplanned pregnancies as well as reduce risk of HIV transmission to sexual partners and unborn children. However, with the exception of the condom, use of dual contraceptive and HIV prevention methods was not mentioned in the interviews. Information gaps in relation to contraceptive use were more prominent among the adolescents. Respondents at NHC highlighted challenges with accessing contraceptives elsewhere, including failure to complete the referral process, challenges with disclosure of HIV status to FP providers at the alternative sites, and cost of contraceptives. Whereas the contraceptives were given free of charge at Mulago the clients at NHC who utilized services at private facilities had to pay for them. These challenges have been cited by several studies and highlight the need for formal referral linkages, in the absence of fully integrated FP services [20,21]. Access to contraceptive supplies and cost of contraceptives as well as factors such as cultural, social and health concerns influence contraceptive use among women and need to be addressed [19]. The findings from this study show an overwhelming desire to have children among adult men, women and adolescents, with all respondents noting that they needed to have children and more than one child at that. The desire to have children was influenced by sociocultural pressures; pressures to have a child in order to be accepted by family and to have both girls and boys. The family size and gender composition has a strong bearing on the decision to have more children and on the contraceptive choices [22,23]. In this study several respondents cited issues of inheritance and the need to have boys as a key issue in determining fertility [5]. Fertility desires also influenced the contraceptive choices among both adults and adolescents, who selected methods that they felt would preserve their fertility. Whereas providers seemed to consider the number of children, health status (e.g., CD4 count) and adherence to medications by clients and were more sympathetic to PLHIV who had no children at all, the influences of fertility desires among clients go beyond numbers, to issues such as family composition (girls and boys) and new partnerships. Other than ill health and sero-discordance, which related to concerns about risks of transmission to uninfected partners, the reasons for wanting to have children among HIV infected individuals are largely similar to those that have been cited in studies of uninfected individuals [22,23]. Strong social and cultural pressures to have children were prominent in childbearing decisions within our sample, much like other studies of PLHIV in sub-Saharan Africa [5,22,23]. Providers need to expand their understanding and appreciation of such influences in order to provide the necessary support for clients, even where the client decisions may appear to be irrational to providers. Despite the strong desire by the PLHIV to have children, there were gaps in the support from providers. Clients highlighted the need for more guidance on when and how they can have children safely. The provider views were generally positive and emphasized the need for consultation with other providers who have greater knowledge about safer childbearing. However, some studies have shown fears and challenges around client-provider discussions in relation to fertility [11,12]. These fears are probably influenced by previous negative experiences such as those cited by some clients in this study. Such fears may lead to challenges with retention and adherence to medications for those clients who wish to have children or get pregnant. Whereas providers indicated that their views towards childbearing had changed, some clients still felt otherwise, reflecting a level of perceived stigma from providers. Safer conception options such as timed intercourse, manual insemination and sperm washing, coupled with ART are becoming increasingly available [13,24,25]. However, only one client cited timed intercourse and providers only mentioned reduced transmission to the child and not the partner, suggesting limited knowledge of such methods among both clients and providers. This is not surprising considering that the FP-HIV integration guidelines at the national level in Uganda do not include provisions for safer conception strategies [26]. We were not able to differentiate between those respondents that had fertility desires and those that had intentions (those that were trying to conceive at the time of the interview). However, the study provides useful insights into the fertility and contraceptive needs of PLHIV. --- Conclusions In summary, these findings indicate the progress in integration of FP and HIV services at these two clinics but highlight several gaps including providing a wide range of contraceptive options and contraceptive information gaps among adolescents. The study also reveals the need to increase safer conception knowledge among clients and providers, and to improve support for PLHIV who wish to have children. --- Competing interests The authors declare that they have no competing interests. Authors' contributions RKW initiated the topic, coordinated the data collection and analysis and wrote the first draft of the paper. GJW, MRK, and NMT made input into the design and review of the paper. MN and FWM contributed to the interpretation and review of the paper. All authors read and approved the final manuscript.

Background: Some people living with HIV/AIDS (PLHIV) want to have children while others want to prevent pregnancies; this calls for comprehensive services to address both needs. This study explored decisions to have or not to have children and contraceptive preferences among PLHIV at two clinics in Uganda. Methods: This was a qualitative cross-sectional study. We conducted seventeen focus group discussions and 14 in-depth interviews with sexually active adult men and women and adolescent girls and boys, and eight key informant interviews with providers. Overall, 106 individuals participated in the interviews; including 84 clients through focus group discussions. Qualitative latent content analysis technique was used, guided by key study questions and objectives. A coding system was developed before the transcripts were examined. Codes were grouped into categories and then themes and subthemes further identified. Results: In terms of contraceptive preferences, clients had a wide range of preferences; whereas some did not like condoms, pills and injectables, others preferred these methods. Fears of complications were raised mainly about pills and injectables while cost of the methods was a major issue for the injectables, implants and intrauterine devices. Other than HIV sero-discordance and ill health (which was cited as transient), the decision to have children or not was largely influenced by socio-cultural factors. All adult men, women and adolescents noted the need to have children, preferably more than one. The major reasons for wanting more children for those who already had some were; the sex of the children (wanting to have both girls and boys and especially boys), desire for large families, pressure from family, and getting new partners. Providers were supportive of the decision to have children, especially for those who did not have any child at all, but some clients cited negative experiences with providers and information gaps for those who wanted to have children. Conclusions: These findings show the need to expand family planning services for PLHIV to provide more contraceptive options and information as well as expand support for those who want to have children.

Introduction Social capital has been considered an important factor in determining health status since its introduction in the 1990s [1]. Although many dimensions of social capital exist, it has been generally accepted as an asset for promoting beneficial economic, social and health outcomes [2,3]. Among the components of social capital, social trust, as a cognitive component, has been known to facilitate social interaction and the exchange of information [4]. Social trust is usually assessed by the question, "would you say that people can be trusted?" This question evaluates the trustworthiness of one's neighborhood, which may impact one's behavior in the community [5]. Because social trust can also influence health behavior, one's metabolic profiles may change depending on the level of social trust. While abundant investigations have been performed to study the association between social capital and various health outcomes, such as all-cause mortality [6] and depression [7], there is a dearth of information on the relationship between social capital and metabolic syndrome (MetS). With its increasing incidence and predictive value for cardiovascular risks and diabetes [8], MetS has become an important global health issue. Therefore, determining the effects of social trust on MetS may be crucial for public health implications. Evidence for a significant association between social capital and MetS is lacking and only studies that used proxy measures for MetS are available. While some studies showed a positive correlation between social trust and cardiovascular diseases [9] and obesity [10], others showed null or negative results [11]. A study in Australia found a higher objective crime rate associated with a higher risk of MetS in men, and a higher perceived crime rate associated with a higher risk in women. Both total and violent crime rates were associated with MetS in men, but only the perceived crime rates of neighborhoods were associated with MetS in women [12]. Another study in Canada found a negative correlation between network social capital and waist circumference. It did not, however, find a significant association between social trust and waist circumference [13]. Because the association between MetS and social trust has not yet been established, elucidating the relationship may help improve public health outcomes. As MetS has become such a syndemic [14], the primary prevention of MetS requires more societal and structural changes. Therefore, the objective of this study was to elicit the association between community-level social trust and MetS using a national cohort study of Korean population data. It was hypothesized that a higher level of social trust was related to a lower likelihood of developing MetS. --- Methods --- Study Population This was a longitudinal, retrospective study that collected health information from existing data. The study population was extracted from the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC). In South Korea, the NHIS is a universal healthcare system for all Korean citizens, collecting health service utilization records for insurance claim purposes that include outpatient and inpatient hospital visits, health screening examinations, diagnostic and treatment-related procedures and pharmaceutical prescriptions. The health screening exams contain a self-reported questionnaire on lifestyle behaviors, anthropometric measurements and urine and blood tests biannually for enrollees aged 40 years or older. Parts of these data are available for research purposes, and many large-scale epidemiological studies have used the NHIS database. The validity of the database is described in detail elsewhere [15,16]. Among 211,125 participants aged 40 years or older in the NHIS-NSC, 724 enrollees who died before the index date were excluded. Two thousand seven hundred and seven and 836 were excluded for missing values for covariates and MetS criteria, respectively. Those who did not answer social capital-related questions (2069 people) and who were already taking statins, hypertension medication or diabetes medication (116,000 people) were removed from the study. This study only included participants who lived in the metropolitan area. A total of 47,289 participants were excluded from the study for living in rural areas. The participants meeting the inclusion criteria were followed from 1 January 2010 to 31 December 2011, and again from 1 January 2012 to 31 December 2013 for waist circumference, blood pressure, fasting blood glucose, triglycerides and high-density lipoprotein cholesterol (HDL-C). The study was approved by the Seoul National University Hospital Institutional Review Board (IRB number: E-1806-076-951). Because the NHIS-NSC database is anonymized according to strict confidentiality guidelines prior to distribution, the requirement for informed consent was waived. --- Key Variables Social trust values were measured using the Kawachi method and the details and validity of it have been described in previous papers [17]. The Korean Community Health Survey (KCHS) had a question to assess social trust, which was conducted by the Korean Centers for Disease Control and Prevention in 2011. It is a nationally and district-representative community-based cross-sectional survey that contains community-level information according to administrative district sites [18]. Social trust was assessed by the statement, "the people in my neighborhood can trust one another," and the responses were categorized into two answers: trusting and non-trusting. Social trust was calculated by determining the proportion of those who answered "yes" to the social trust question for each administrative district site. A total of 253 district sites, with a mean (standard deviation) land area of 55.1 (79.9) km 2, covers the entire South Korea land mass. The social trust values were then merged with NHIS-NSC according to each participant's residential district (a total of 253 districts). Rural areas were then excluded and only residents from 74 districts were included in the study. Participants were then categorized into five groups evenly according to the level of social trust, the 1st quintile having the lowest level of social trust and the 5th quintile having the highest level of social trust. All Korean citizens have universal healthcare access managed by the NHIS, which covers nearly all health care services and biannual health screenings for people 40 years and older. The healthcare database contains waist circumference, fasting blood glucose, HDL-C, and triglyceride levels and blood pressure. The definition of MetS was derived from revised the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria [19]. It requires at least three of the following components: (1) abdominal obesity (waist circumference <unk>90 cm for men, or <unk>85 cm for women); (2) triglycerides <unk>150 mg/dL and/or drug treatment for elevated triglycerides; (3) HDL-C <unk> 40 mg/dL for men or <unk>50 mg/dL for women; (4) systolic blood pressure <unk>130/85 mmHg or antihypertensive medication treatment and/or a history of hypertension; and (5) FSG <unk> 100 mg/dL and/or treatment with medications for type II diabetes mellitus. --- Statistical Analysis Multivariate logistic regression was used to determine the adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for MetS as a composite outcome and each component of MetS (waist circumference, fasting blood glucose, HDL-C, triglyceride levels and blood pressure). The incidence of developing MetS was calculated compared to the 1st quintile of the social trust group. Social trust was divided into five groups, with the lowest being the 1st quintile and the highest being the 5th quintile. The covariates considered included age (categorical, 40-49, 50-59, 60-69 and <unk>70 years), sex (categorical, male and female), household income (categorical, 1st, 2nd, 3rd and 4th quartiles), residence (categorical, capital city and metropolitan area), smoking behavior (categorical, never smoker, past smoker and current smoker), drinking behavior (categorial, none, 1-2 times per week, 3-4 times per week and <unk>5 times per week) and Charlson Comorbidity Index (CCI), (continuous). Household income was derived from the insurance premium. The algorithm for calculating CCI using claims data was derived from elsewhere [20]. These covariates were adjusted at three different levels. Model 1 adjusted only for age, income and residence, while model 2 adjusted for smoking, drinking and physical activities in addition to model 1. In model 3, CCI was also considered. The stratified analyses were performed for lifestyle behaviors-smoking, drinking and physical activity. Fully adjusted model 3 was used to determine the effects of each lifestyle behavior on the incidence of MetS. Multivariate logistic regression was also used to calculate the aORs with 95% CIs. Statistical significance was defined as a p-value of <unk>0.05 in a two-tailed manner. All data collection and statistical analyses were conducted using STATA 15.0 (StataCorp, College Station, TX, USA). --- Ethics Committee Approval This study was approved by the Seoul National University Hospital Institutional Review Board (IRB number: E-1806-076-951). The requirement for informed consent was waived as the NHIS-NSC database was anonymized according to strict confidentiality guidelines prior to distribution. --- Results Table 1 depicts the descriptive characteristics of the study population. The ranges of social trust for each quintile are 42-53%, 54-59%, 59-61%, 61-68% and 69-88%, respectively. There was no significant difference among the groups, except for the location of residence. There were no capital city dwellers in the 5th quintile of social trust group. The aORs for MetS for the total population and male and female subgroups are shown in Table 2. A lower aOR for the incidence of MetS was shown in the 5th quintile group when compared to the 1st quintile of social trust in total and both sexes. Compared to the 1st quintile of social trust of the total population, the 2nd quintile group has an adjusted odds ratio of 0.88 (95% CI 0.80-0.96), the 3rd quintile 0.97 (0.88-1.07), the 4th quintile 0.87 (0.79-0.95) and the 5th quintile 0.87 (0.78-0.97) in model 1. The numbers did not differ significantly in models 2 and 3. In the case of males, the adjusted odds ratios with 95% CIs were 0.95 (0.83-1.05) in the 2nd quintile group, 0.96 (0.85-1.08) in the 3rd quintile group, 0.89 (0.79-1.01) in the 4th quintile and 0.88 (0.76-1.01) in the 5th quintile in all three models. The female population exhibited aORs with 95% CIs of 0.79 (0.66-0.95), 0.97 (0.82-1.15), 0.80 (0.66, 0.96) and 0.82 (0.68-0.98) in the 2nd, 3rd, 4th and 5th quintile groups, respectively, when compared to the 1st quintile group of social trust. Table 3 shows the aORs of each MetS component when adjusted for age, residence, income, smoking, drinking, physical activity and CCI. Among the components of MetS, only waist circumference reduced the aOR of new incidences MetS in a statistically significant manner. The aOR for HDL-C was statistically significant only in the 5th quintile group of social trust. The aOR with 95% CI for waist circumference for the 5th quintile group of social trust when compared to the 1st quintile group was 0.92 (0.85-0.99) for model 1. The aORs with 95% CIs for model 2 and model 3 in the 5th quintile group were 0.91 (0.84-0.99) and 0.91 (0.84-0.99). When the 5th quintile group of social trust was compared to the 1st quintile group, the aOR with 95% CI was 0.88 (0.81-0.96) in model 1. For models 2 and 3, the aORs with 95% CIs were 0.88 (0.80-0.96) and 0.88 (0.80-0.95), respectively. Lastly, stratified analyses on the association between social trust and MetS, taking into consideration smoking, alcohol intake and physical activity, are shown in Table 4. Never smokers and non-drinkers reduced the incidence of MetS. The aORs with 95% CIs in never smokers when compared to the 1st quintile group of social trust were 0.85 (0.75-0.97), 0.95 (0.84-1.09), 0.84 (0.74-0.95) and 0.85 (0.74-0.99) in the 2nd, 3rd, 4th and 5th quintiles groups. On the other hand, the aORs with 95% CIs for past and current smokers were 0.93 (0.81-1.06), 1.00 (0.87-1.16), 0.91 (0.79-1.05) and 0.89 (0.76-1.04) in the 2nd, 3rd, 4th and 5th quintile groups of social trust when compared to the 1st quintile population. In non-alcohol drinkers, the aORs when compared to the 1st quintile group of social trust were 0.89 (0.77-1.02), 1.03 (0.90-1.18), 0.82 (0.71-0.94) and 0.82 (0.70-0.95) in the 2nd, 3rd, 4th, and 5th quintile groups of social trust. The alcohol drinkers showed aORs with 95% CIs of 0.88 (0.77-1.00), 0.92 (0.80-1.05), 0.92 (0.81-1.05) and 0.93 (0.80-1.07) from the 2nd to the 5th quintiles of social trust. Then the physically active group and inactive group were also compared, and the protective effect of physical activity on MetS was not significant. The physically inactive group had aORs with 95% CIs of 0.81 (0.71-0.95) and 0.88 (0.75-1.03) in the 4th and 5th quintiles of social trust groups, respectively, when compared to the 1st quintile, while the physically active group had aORs with 95% CIs of 0.91 (0.80-1.04) and 0.87 (0.76-1.00) in the 4th and 5th quintile groups. Criteria for metabolic syndrome was defined as meeting three or more of the following conditions, as suggested by NCEP ATP III: (1) Impaired Fasting Glucose (<unk>100 mg/dL), (2) Elevated WC (>90 cm for men and >85 cm for women), ( 3) High Blood Pressure (SBP: <unk>130 mmHg and DBP: <unk>85 mmHg), (4) High Triglycerides (<unk>150 mg/dL), ( 5) Reduced HDL-cholesterol (<unk>40 mg/dL for men and <unk>50 mg/dL for women). Data presented are N (%) and aOR (95% CI). Logistics Model --- Discussion This population-based, longitudinal study examined the association between social trust and MetS. The beneficial effect of social trust on reducing the incidence of MetS persisted even after taking into account differences in age, income, area of residence, lifestyle behaviors-smoking, alcohol drinking and physical activity-and CCI. In stratified analyses with lifestyle behaviors, smoking, alcohol intake and physical activity all showed a statistically significant impact on MetS incidence in a previously healthy population. To our knowledge, this is the first longitudinal study to demonstrate that district-level trust was associated with a lower incidence of MetS in individuals, using nationally representative cohort data. Previous studies have investigated the association between social trust and proxy measures of MetS. In a Canadian paper that investigated the causes of health inequality, Indigenous people with higher social support were associated with a lower cardiovascular disease risk score [21]. Another study conducted with Americans aged 50 years and older, found a statistically significant association between higher perceived social cohesion and a lower incidence of stroke [22]. On the contrary, a nationally representative study conducted in China in 2017 showed that higher social trust was associated with a lower likelihood of obesity, and harmonious social relationships were correlated with higher chances of becoming obese [3]. Most of these investigations were cross-sectional and could not prove causality, while this study was longitudinally designed to capture the effect of social trust on the incidence of MetS. We also used the direct measure of MetS and its components rather than proxy measures. It was determined that higher social trust was associated with a lower incidence of MetS. Furthermore, by adjusting out age, income, area of residence, lifestyle behaviors and CCI, we tried to eliminate the confounding factors that were not pre-determined in the study design. The aORs of developing MetS remained lower in higher social trust groups even after adjusting for covariates. Different mechanisms have been proposed to explain the association between social trust and MetS. First, people with higher social trust are likely to have a higher sense of security, which may help in the exchange of valuable information or instrumental support within society and in absorbing health-promoting behaviors [17,23]. Second, in societies with higher social support and network groups, people have easier access to transportation systems and healthcare [24]. Furthermore, when residents live in a safer neighborhood, they are more likely to exercise [12]. Another explanation is collective efficacy. Members of a community may act together to promote health-promoting behaviors and against harmful behaviors, such as collecting signatures for a smoking-free zone [25]. Lastly, psycho-social pathways also help explain the association between social trust and MetS. A lower level of social trust may increase social anxiety and stress, which in turn may elevate blood cortisol levels. The stimulation of the hypothalamic-pituitary-adrenal (HPA) axis can cause inflammation and diseases, such as cancer [26] and cardiovascular accidents [27]. In this study, the aORs of MetS incidence were found to be lower in women than in men. This may be explained by women having more a trusting and pro-social nature than men. Women's tendency to adopt communal and interpersonal facilitative behavior may work together towards healthful behavior in a community [28]. In addition, women tend to relay information among members of a community more frequently than men. Men rely more on the information communicated with their spouses than with other community members. Moreover, the aORs were statistically less significant in the middle quintile groups of social trust. Social trust may need to be at the extreme ends to exert influence on people's lifestyle behaviors. Generally, higher social trust was associated with positive health outcomes that can be explained by the abovementioned mechanisms. However, the relationship did not prove to be as significant in fasting blood glucose, blood pressure or triglyceride levels. These three components of MetS are more closely related to eating habits, which this study did not consider. The members of a community may share similar diet patterns and different diets affect metabolic profiles differently [29]. Several limitations must be considered when interpreting the results of this study. Social trust was measured at one point in time, and changes were not considered. Additionally, the participants were only followed up for a short period of time because HDL-C levels were only collected in 2009. It may have been insufficient to determine the effects of social trust on the development of MetS. However, social trust is usually influenced by the environment, which does not change rapidly. Because social trust is closely knitted into the lives of community members, one year may have been enough to exert influence over the members' health outcomes. In addition, although we adjusted for household income and area of residence, we could not fully take into account the effects of the neighborhood environment, education level and friends on health outcomes. The education level and diversity of friends were associated with chances of becoming obese in previous studies [30,31]. Lastly, we excluded the samples from rural areas due to population biases towards older adults and higher levels of social trust. This study tried to be more representative of the general population of the country. In rural areas, social trust is high and MetS incidence is low. Further analyses may be necessary to determine the influence of social trust on MetS in rural adults. In conclusion, higher social trust decreased the likelihood of developing MetS. Quitting smoking, drinking in moderation and being physically active also reduced the risk. Therefore, it is important to create a community where healthy lifestyles are encouraged among members of society. Since it is known that reducing MetS requires collective effort as a society, public health policy should aim to create health-conducive environments by increasing social trust through building recreational facilities and creating community memberships. --- Author Contributions: H.P., conceptualization, methodology, software, validation, formal analysis, investigation, writing-original draft, writing-review and editing; S.C., conceptualization, methodology, software, writing-review and editing; K.H.K., writing-review and editing, methodology, project administration; E.K., writing-review and editing, validation, investigation; A.K., writing-review and editing, project administration; S.M.P., software, resources, data curation, supervision, conceptualization, funding acquisition. All authors have read and agreed to the published version of the manuscript. --- Conflicts of Interest: None of the authors reported disclosures.

Background: Social trust, assessed by the trustworthiness of one another in a community, is known to have beneficial effects on health outcomes. However, the impact of social trust on metabolic syndrome (MetS) is unclear. Methods: The study subjects were extracted from the Korean National Health Insurance Service, and social trust was obtained from the Korean Community Health Survey (KCHS). Previously healthy participants were followed up from 1 January 2010 to 31 December 2011, and again from 1 January 2012 to 31 December 2013 for waist circumference, blood pressure, fasting blood glucose, triglycerides and high-density lipoprotein cholesterol (HDL-C). Multivariate logistic regression was used to calculate the adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for newly developed MetS according to social trust quintiles. Stratified analyses were performed to determine the relationship between lifestyle behaviors and social trust. Results: Compared to the participants within the first quintile of social trust, those in the remaining quintiles had lower risks of developing MetS. The aOR with the 95% CI was 0.88 (0.79-0.98) in the 5th quintile group of social trust. Among the diagnostic criteria for MetS, waist circumference and HDL-C were statistically significant with aORs of 0.91 (0.84-0.99) and 0.88 (0.80-0.95) in the 5th quintile group. The stratified analyses showed protective effects of positive lifestyle behaviors. The aORs with 95% CIs were 0.85 (0.74-0.99) in never smokers, 0.82 (0.70-0.95) in non-drinkers and 0.87 (0.76-1.00) in the physically active in the highest level of social trust. Conclusions: Higher social trust was associated with a lower incidence of MetS. Therefore, building community with psychosocial support may be helpful in improving public health.

INTRODUCTION The rate of preterm birth (PTB) is increasing in the United States and in Sweden, affecting more than 450,000 children each year in both countries combined. These infants have a greater risk of morbidity and disability compared with full-term infants, and the rates are particularly high among poor and ethnic minority populations. Medical advances, such as infertility treatments, have also contributed to the increased rates of PTB. Unfortunately, prevention has been disappointing and largely unsuccessful, in part because the etiology of PTB is poorly understood. Maternal education is one aspect of socioeconomic status that most consistently predicts poor birth outcomes [1]. Other maternal demographic, social and health-related factors have been associated with these adverse birth outcomes, such as single marital status [2], smoking [3][4][5][6][7][8][9][10][11], diabetes [12][13][14] and low social capital [15]. For example, we recently showed that women from Turkey, Iran, Asia, and Latin America, who in Sweden often live in segregated, deprived neighborhoods, [16] had more than a 50% higher risk of non-normal birth outcomes than Swedish-born women [17]. In other previous studies, we have shown that adverse health behaviors (e.g., smoking, poor diet, inactivity) that may be associated with PTB are more prevalent in deprived settings [18]. Sweden, like many countries, has experienced dramatic demographic changes during the last few decades. Due to increasing global migration, it has become a multicultural society in the new millennium. Today, approximately 20% of all people living in Sweden are first-or second-generation immigrants [19]. This large influx of immigrants, together with the nationwide health and sociodemographic data available in national registers, provides a unique opportunity to study risk of poor birth outcomes in first-and second-generation immigrants from multiple countries and regions around the world and compare the risk in these groups with the risk in native-born Swedes. The nationwide data incorporates information on the entire population over a period of 30 years, including all Swedish born second-generation immigrants registered with their biological parents in Sweden. Our first aim is to determine whether country of birth affects the risk of preterm birth among immigrants after accounting for maternal age at birth, marital status, geographical region, body height, and smoking history as well as period of birth, family income, and gender of the infant. The second aim is to study whether any such association remains in the second-generation immigrants. --- MATERIAL AND METHODS --- Data Sources Data used in this study were retrieved from a national research database, the WomMed II Database, located at the Center for Primary Health Care Research at Lund University. This database contains information from the Swedish Medical Birth Register, i.e., on all pregnancies, prenatal care, and birth records, hospital admissions, and death records for children and mothers in Sweden between 1973 and 2006. This register covers 99% of all births in Sweden beginning in 1973 and includes prospectively collected information about complications during pregnancy and delivery [20]. WomMed II database also contains data from the National Board of Health and Welfare (in-care register, and death register), and Statistics Sweden (population register and multi-generational data). In the present follow-up from January 1, 1982 Marital status: based on the mother's marital status at the time of birth and divided into two groups: married/co-habiting and never married/widowed/divorced. Family income: based on the mother's family income in the year of the birth, divided by the number of people in the family, i.e., individual family income per capita. This variable was provided by Statistics Sweden (the Swedish Government-owned statistics bureau). The income parameter also took into consideration the ages of people in the family and used a weighted system whereby small children were given lower weights than adolescents and adults. The calculation procedure was performed as follows: the sum of all family members' incomes was multiplied by the individual's consumption weight divided by the family members' total consumption weight. The final variable was calculated as empirical quartiles from the distribution. Geographic region of residence was divided into (1) large cities (cities with a population of more than 200,000, i.e., Stockholm, Gothenburg, and Malmö), (2) middle-size towns, and (3) small towns/rural areas (according to the Swedish 1990 Census). Mother's geographic region of residence was used as a proxy for the family's region of residence. Employment: based on the mother's employment status at the time of the birth and divided into two groups: yes and no. Maternal body height: based on the mother's body height. Smoking history: based on the mother's smoking history during the pregnancy and divided into three groups: yes, no, and missing smoking history. --- Immigration status: The WomMed II Database includes people from 64 countries and regions of birth. Immigration from a number of these countries and regions began relatively recently, so the number of people may be relatively small in certain categories. For this reason (less than 10 cases of any SGA births in the children), these countries of birth were excluded from the study. As a result, we included 10 regions (Nordic countries, Southern Europe, Western Europe, Eastern Europe, Baltic countries, Central Europe, Africa, North America, Latin America, and Asia) and 23 countries (Denmark, Finland, Norway, Greece, Italy, Great Britain/Ireland, Germany, Austria, (former) Yugoslavia, Croatia, Romania, Bulgaria, Estonia, Poland, Hungary, Chile, Turkey, Lebanon, Iran, Iraq, and Russia) in our analysis. --- Statistical analysis Risks for PTB births were calculated by maternal birth country, using estimates obtained in logistic regression analysis. Odds ratios (ORs) with a 95% confidence intervals are presented. All risk estimates were adjusted for maternal age at birth, marital status, geographical region, body height, and smoking history as well as period of birth, family income, and gender of the infant. The reference group in the analyses was children with both parents born in Sweden. Because the initial sex-specific analysis showed no sex-specific effects, data are given for both sexes together. We used SAS version 9.2 for the statistical analysis [21]. --- Ethical considerations This study was approved by the Ethics Committee of the Lund University, Malmö, Sweden. --- RESULTS The first singletons of the native-born Swedish mothers constituted by far the largest group in our study. They constituted about 1,874,567 individuals; 91,849 singletons were preterm born and 15,172 were very preterm born (Table 1). This group was the reference category in the OR calculations. A total of 15,893 and 2,868 singleton children whose mothers were born outside Sweden were preterm born or very preterm born. PTB represented 4.9% and 5.0% of the births in Swedish-born and foreign-born parents, respectively. PTB birth were progressively prevalent among both Swedish-born and foreign-born mothers for the variables older maternal age at first birth, never married/widowed,/divorced, low family income, short stature, and a positive smoking history. Children to mothers from Spain, Western Europe (the Netherlands, Great Britain and Ireland, and Germany), the Baltic Countries, Africa, Turkey, and Lebanon had decreased risks of being born preterm. The risks of very PTB in singleton children by maternal country of birth was calculated separately. The risks of very PTB were increased among children to mothers from Eastern Europe (Yugoslavia), Central Europe, Africa, and Asia (Iraq) compared to the control group. Children of Finnish mothers also had a decreased risk of very PTB. To ascertain whether or not the increased or decreased risk of PTB in first-generation immigrant women was present in the next generation, ORs in second-generation immigrant women were calculated. The odds for PTB in the children were analyzed in the second generation by their grandmother's birth country (Table 3). Because of the limited numbers of observed events in some countries, we only used selected regions and countries. However, no large significant effects were observed, except for somewhat decreased risks in mothers originating from Nordic or a Western European countries. --- DISCUSSION The results of this study indicate that country of birth affects risk of PTB and very PTB birth in first-generation immigrant women. Mothers from Central Europe, Africa, and Asia had a significantly increased risk of delivering PTB and very PTB singletons. To our knowledge, this is the first large-scale study to investigate the association between immigration status and risk of PTB and very PTB births in first-and second-generation immigrant women; in total around 2.2 million singleton births were included in the study. The findings of the present study represent new knowledge because the study was conducted in Sweden, which has a universal health care system including maternity clinics that cover urban as well as rural areas in the entire country. The Swedish maternity clinics offer health care free of charge to all pregnant women in Sweden. However, our findings show that even in an egalitarian country like Sweden that offers free health care to all pregnant women there are significant individual-level associations with PTB and very PTB. We found that singletons whose mothers had a low level of family income, which can be seen as a proxy for low socioeconomic status, had a higher frequency of PTB and very PTB events. In addition, the proportion of mothers with a low family income was higher in foreign-born mothers than in native Swedish mothers (43.4% vs 20.9%). Family income is one aspect of socioeconomic status (SES) that most consistently predicts poor birth outcomes [1]. Socioeconomic disparities in PTB are consistent findings in perinatal epidemiology both in Sweden, other European countries, and the U.S. [22][23][24][25][26][27]. For example, even in such countries as Sweden [28], Finland [29], Scotland [30], and Canada [31] with smaller socioeconomic differences than in the U.S. and universal access to high-quality prenatal care [22], there are higher rates of PTB among mothers with low income than those with high income. A Canadian case-control study found that mothers with low income had a three-fold increased odds of having preterm premature rupture of membranes [32]. Other work has shown that deterioration of SES conditions for women of reproductive age increases the risk of PTB [33]. In the U.S., data from the National Maternal and Infant Health Survey demonstrated that low educational and occupational status, especially among white mothers and fathers, and African American fathers, were significantly associated with premature delivery [22]. In addition, a study from Quebec, Canada, found that single mothers had increased risks of PTB [34]. Our findings that immigrants from Central Europe, Africa and Asia had significantly increased odds of PTB and very PTB compared with women born in Sweden are partly consistent with a previous study that showed that foreign-born women in Sweden have an increased risk of PTB [28]. In Norway, the proportion of preterm infants was substantially larger in Asians and North Africans [27]. Socio-cultural differences in pregnancy strategies, suboptimal performance of health care routines in the perinatal care system, delay in seeking health care, inadequate medication and interpersonal miscommunication may lie behind these differences [35]. In addition, smoking, undernutrition, and diabetes have been shown to be independent determinants of PTB. Diabetes mellitus, which is increasing rapidly in women of childbearing ages, will exert an increasing burden on these birth outcomes, especially among low-income women. For example, in northern California there has been an increase in the yearly cumulative incidence of gestational diabetes mellitus independent of changes in age and ethnicity of the study population. Many refugees have been forced to migrate and, in the migration process, they face a new society and a new language. They may also lose their social, cultural, and economic connections with their country of origin. Immigrants may often be unemployed and/or live in deprived neighborhoods, which puts them under strong pressure in their daily life. The present study found reduced risks of PTB among women from Western European countries, Baltic countries, Africa, Turkey, and Lebanon, compared to native-born Swedish women. This is partly in agreement with the reported decreased risks of PTB in black and Hispanic migrant women in the USA [36]. In addition, we found several decreased risks for PTB among the first-generation immigrant women, but this advantage disappeared among their second-generation offspring. This is in agreement with previously reported findings from the USA [37]. The findings that the second-generation immigrant women became more similar to the reference group could partly be explained by environmental factors in the host country rather than genetic factors in the immigrant women. Similar birth outcomes were found in Nordic-born immigrant women. Underlying mechanisms may be that Nordic countries are rather homogeneous in terms of language and culture [38]. The present study has several limitations. First, we did not have information on maternal risk factors such as excessive alcohol drinking and/or drug use that may be related to the risk of PTB and very PTB. It is also possible that residual confounding exists because socioeconomic status cannot be measured entirely by family income, educational attainment, and employment status. This study also has a number of strengths. For instance, our study population included a well-defined open cohort of first-and second-generation immigrant women. Because of the civic registration number assigned to each individual in Sweden, it was possible to trace the records of every person for the whole follow-up period. Data on socioeconomic status were nearly 100% complete. --- CONCLUSION The findings of the present study showed that the odds of PTB and very PTB were increased or decreased in some first-generation immigrant women and that these effects disappeared in the second-generation. Maternity care should pay a special attention to women from certain population groups. --- Conflict of Interest Statement There are no conflicts of interest. --- Table 1. Total population and PTB and very PTB events in singleton births

Objective. To examine, nationwide, if there is an association between country of birth in mothers and preterm birth and to study whether any such association remains in second-generation immigrant women. Methods. In this follow-up study, a nationwide research database located at Lund University, Sweden, was used to identify all preterm born singletons in Sweden between January 1, 1982, and December 31, 2006. Incidence ratios were standardized with regard to maternal age at birth, marital status, geographical region, body height, and smoking history as well as period of birth, family income, and gender of the infant. Singletons of mothers born in Sweden were used as reference group. Results. There were 2 192 843 records for singletons over the study period, of whom 4.9% were preterm births and 0.8% were very preterm births. Increased risks of preterm birth was observed for mothers from Austria, Yugoslavia, Romania, Central Europe, and Asia. Increased risks of very preterm birth was observed for mothers from Eastern Europe, Central Europe, Africa, and Asia; these increased risks disappeared, however, in the second-generation female immigrants.Country of birth in mothers affected the risk of preterm birth; maternity care should pay a special attention to women from certain population groups.

Introduction Climate change is expected to exacerbate the incidence of wildfires and further complicate the lives of fire managers and forest engineers, who are regularly called upon to solve increasingly complex decision-making problems (Martell, 2011). Furthermore, fire management decisions should be made by establishing a balance between the economic, ecological, and social effects of the fire, and the benefits and harms caused by the fire should be carefully examined in this context (Martell, 2015;Nyongesa and Vacik, 2019). The urgency of this environmental crisis necessitates a review of the existing Wildfire Management (WFM) (Santos et al., 2021). Global WFM strategies are transitioning from a response-based paradigm to a more collaborative/resilienceoriented framework based on prevention and community participation (Patr<unk>o, 2014;Khatun et al., 2017). Researchers have examined numerous interactive approaches, revealing that there are effective ways to increase homeowners' knowledge and support of fire management (McGee, 2011;Welch and Coimbra Jr., 2021). When an appropriate institutional framework is provided, the CBIFM approach facilitates the efficient use of resources, the integration of domestic and modern information systems, and remote fire management (Dube, 2013;Lineal and Laituri, 2013). Marta-Costa et al. (2016) state that the early adoption of a participatory methodologies stage in the planning process encourages dialogue and open communication between various stakeholders and considers community views when drafting policies. Furthermore, this stage is essential in order to prevent damages that may occur as a result of wildfire and creating appropriate management for the region (Marta-Costa et al., 2016). The involvement of private forest owners in WFM has been discussed in many studies (Aguilar and Montiel, 2011;Santos et al., 2021), many of which tend to be related to fuel management. The result of the increasing marginal costs of burnt land necessitates that this new paradigm must also include the economic relationship between private forest owners. Fuel treatment activities to maintain the landscape represents a significant challenge with important societal implications. However, the planning of fuel treatment activities raises complex decision-making problems with spatial and temporal dimensions (Minas et al., 2014). Valuing and integrating different forms of information and understanding locally lived realities are prerequisites to creating a more systemic approach to anticipate and collectively adapt to the increased risk of future bushfires. This could be achieved by developing bottom-up strategies that focus on combining traditional fire knowledge and scientific ecological knowledge (Devisscher et al., 2019;Mistry et al., 2019). The Integrated Fire Management (IFM) approach is established and implemented to understand the diverse uses of fire and the traditional ecological knowledge of local people and its practical applications. Thus, it can be said that the IFM framework aids the implementation of cost-effective approaches by preventing damage caused by fires and maintaining the desired fire regimes and participation of local people (Nyongesa and Vacik, 2018). Moreover, the difficulties regarding decision-making processes will reduce thanks to the active local community participation in WFM (Nyongesa and Vacik, 2019). In general, due to the increase in the rate of global migration from rural to urban areas, urban sprawl enters abandoned agricultural areas, and at the same time, it is seen that there is a similar trend of migration from rural areas to cities due to the decreasing population in rural areas (Fischer et al., 2016b). For this reason, people's living spaces and natural areas are intertwined, and potential wildfires can result in great damage in terms of economical, ecological, social, and public health (Bouillon et al., 2018;Moritz et al., 2014). The inclusion of WUI in WFM is thus crucial to minimizing loss of life and property and because there are many elements that can increase the severity of fire in the city (Ferster et al., 2013;Fischer et al., 2016a;Reams et al., 2005). Some policies that reduce the risk of wildfire in the WUI interface have been indicated in studies by J. Cohen (2008Cohen (, 2010) ) and Kramer et al. (2018). These policies combine enhanced modeling, the investigation of forest fire risk in densely populated areas, fuel reduction in the home ignition zone (HIZ), the use of fireproof landscaping and construction materials, and the strategic placement of fuel reduction treatments around communities, and given the dangers posed by wildfires, community education and the planning of building locations (Cohen, 2008(Cohen,, 2010;;Kramer et al., 2018). Further, Fischer et al. (2016a) stated the benefits of assessing wildfire risk by recognizing and accounting for the interactions of socio-ecological systems, also known as coupled human and natural systems (CHNS). Figure 1 shows the CHNS components and their related scales, along with a list of prevention, mitigation, preparedness and suppression methods. The social capital regarding preparedness and the acceptance of preparedness requirements of fire directorate for wildfires is more accepted in WUI areas where this wildfire disaster has been experienced before (Bihari and Ryan, 2012;Ghasemi et al., 2020). Recent developments in the decision support system (DSS) have led to significant enhancements in the evaluation of the participation factor in forest fire management. In WFM planning, in order to help integrate activities, which are usually carried out independently, research has been conducted to further develop decision support tools (Pacheco et al., 2015). Figure 1. The CHNS: a synthetic view of the ingredients, human and natural causes of ignition, and possible initiatives for disaster risk reduction (Tedim et al., 2016). The complex decision environment in WFM is characterized by changing fire conditions, partial control, and uncertainty. Therefore, the development and implementation of systematic and risk-based approaches to support decision-making where forest fire risk is expressed as a function of the likelihood of the fire, fire severity, and fire effects has boosted confidence (Pacheco et al., 2015;Wei et al., 2018). However, additional efforts are required to mitigate the destructive impacts of fire, such as replacing combustible fuel complexes (fuel management); reducing the number of human-induced fires (prevention); detecting fires with destructive potential (detection); acquiring, deploying, and dispatching initial attack resources (suppression, deployment, acquisition, dispatch); and mobilizing incident management teams to address escalating fires (large fire management). At present, forest and wildland fire management appears to be a supply chain management perspective. This concept is defined as delivering the right amount of the right fire to the right place at the right time and at the right cost, and this review deals with decision-making and planning concerning the suppression aspects of the forest and wildland fire management supply chain (Martell, 2015). Transition to a new fire management paradigm requires advanced planning and support for decision-making that assesses the natural tradeoffs between alternative management strategies and better monitoring of fire management decisions, actions, and outcomes (Marques et al., 2017). These elements form the basis of risk management. In addition, the following elements are evaluated: sufficient consideration of uncertainty, commitment to generating and using the most appropriate knowledge available, transitioning from reactive to proactive responses, and facilitating continuous improvement through organizational learning. Risk management entails proactively addressing decisions that individuals or organizations may encounter in the future, and monitoring and providing feedback to improve future decisions. Although it is known that there are problems in the operationalization of risk management, its integration and adoption are promoted in the decision-making process in WFM (Thompson et al., 2016). Pacheco et al. (2015) highlight the importance of integration between risk management and DSS development to facilitate and improve the quality of decisions under uncertainty and to ensure harmonious fire management in an uncertain environment. Calkin et al. (2011) reviewed three risk-based decision support tools developed for WFM in the US, while similar risk-based approaches have been developed in other countries (Chuvieco et al., 2010). There is a need to consider a wide variety of approaches, including enhanced communication with communities for risk-based approaches (Dombeck et al., 2004). Calkin et al. (2011) emphasize that resources and opportunities are provided to develop risk-based decision support systems and that managers should develop their skills to use them. Leveraging technologies such as automated resource monitoring and machine learning algorithms can help bridge the gaps between monitoring, learning, and data-driven decision making in WFM (Plucinski, 2019). Thompson et al. (2019) state that to take full advantage of its analytical potential, organizations need to accelerate cultural shifts that develop a stronger appreciation for data-driven decision processes and develop informed skeptics who effectively balance both reasoning and analysis in decision making. Marques et al. (2017) state that the Pareto frontier, a posteriori multi-criteria decision method, can be used to support the integration of wildfire risk into multi-purpose forest management planning contexts. The main purpose of this study is to explore how the development of the CBIFM's understanding of how local people participate in forest fire management and its evolution across different situations and regions. The study also aims to assess the progression of the decision-making processes regarding this issue. --- Materials and methods In this study, a systematic literature review was conducted based on the subject and research objectives. Systematic reviews are specified as a rigorous and transparent form of literature review that involve identifying, synthesizing, and evaluating all available quantitative and/or qualitative evidence to produce a robust, empirically derived answer to a focused research question (Mallett et al., 2012). This research method was chosen because it is compatible with the purposes of this study, which is to explore the latest knowledge of the principles of participation and volunteering in WFM. The systematic review guide written by Okoli (2015) was adapted for this study. Considering these guidelines, the systematic review was carried out in three stages, including (i) research questions, (ii) search strategy, and (iii) data. --- Research questions The research questions were chosen by considering the local people's participation in fire management, fire management at the intersections of wildlife and urban life, and the role of private forest owners in fire management. In this context, the research questions are as follows: --- Search strategy The search string was determined in four areas, according to the research topic and purpose: Wildfire, Participation, Management and Local people. In the Wildfire domain, the "Wildfire" and "Forest fire" keywords were included, while in the participation domain, the "Participation" and "Volunteering" keywords were included. In the Local people domain, the "Local people" and "WUI" keywords were included. In the management domain, only the "Management" and "Decision making" keywords were added to the study string. The search string was created by combining four domains-Wildfire, Participation, Management and Local people-using 'AND' in databases. Searches conducted using these keywords were made by scanning the "Abstracts" in databases. Certain pilot trials were conducted before the search string was completed, and as a result, the relevance of this search string was reached. The search sequence used in this study is as follows: (Wildfire OR Forest fire) AND (Participation OR Volunteering) AND (Management OR Decision making) AND (Local people OR WUI) In this study, the Web of Science and EBSCO databases were chosen as search platforms to access the relevant literature. As examining the reference sections or featurerelated parts allows for a "backward search" of other relevant articles, while certain resources, such as Google Scholar and the ISI Citation Index, allow a "forward search" to find all cited articles that authors may find particularly relevant (Okoli, 2015), a "hand search" was employed to access the relevant literature, as well as the relevant databases in the study. Searches were made between 7 July 2022 and 20 July 2022 in order to access suitable studies for the subject. Specific inclusion criteria were established in this review to identify the relevant literature. As the principle of participation in forestry was discussed in detail at the Rio conference, studies made before 1992 were not included in this study (The Rio Conventions, 2017). Table 1 presents the inclusion criteria applied in this review. --- Data In this study, a total of 61 records were accessed before the criteria for the relevant subject was applied. Figure 2 shows the data definition flowchart based on the PRISMA 2020 guidelines (Page et al., 2021). As shown in Figure 2, the search result was processed through identification, screening, and inclusion. In this study, a total of 20 academic papers were included as a data set for data extraction, analysis, and synthesis. The information categories extracted from the studies selected for content analysis are as follows: • Whether the WUI was mentioned; • Contribution to the decision-making process; • Forestry type (public or private); • Main suggestion to mitigate wildfire hazards risk; • Main obstacle for participatory wildfire management; • Research method of the study; • Whether the prescribed burning was mentioned. If there was no information about the sections in the information category in the selected studies, "None" was written in the category section to state that the information was not included. --- Results A total of 20 records were found suitable for the study. Table 2 shows the percentage distribution of the records deemed suitable for the research according to the created titles. Aguilar and Montiel (2011) state that one of the main weaknesses in wildfire management is the lack of meaningful stakeholder participation. The articles relevant to this topic examine the problems encountered in fire policy regarding the functioning of the participation principle and their proposed solutions. It has been determined that conscious citizen participation in policy making is beneficial to management. Table 3 shows the data from a selection of studies on community participation in fire policy. --- Fire policy and participation Whereas Marta-Costa et al. (2016) discuss this situation in the Portuguese locale, Aguilar and Montiel (2011) offer a broader perspective by including every country in Southern Europe in the discussion. Marta-Costa et al. explain the difficulties caused by the heterogeneous structure of the participating groups and assert that a homogeneous community participation will be more effective. Aguilar and Montiel, on the other hand, describe fire as an ancient method used by locals involved forest fire management and mention the benefits of this method. --- Fuel management The results of the studies focusing on fuel management (Table 4) indicate that the concept of the zero-burn area is essential and that fuel management can reduce the risk of wildfire. According to Ferster et al. (2013), improving forest fuel management is important for reducing the threat of wildfire in local communities. In order to provide this benefit, studies were carried out on people both living in the region and those with forest assets. 2021) conducted a study to increase the willingness of forest owners in fuel management and enable more cost-effective policies, Ferster et al. (2013) collected information to facilitate fuel management by using both local people and forest owners. Through the participants' responses to the questionnaires, Ferster et al. (2013) also assessed the relevance of the participants' demographics and experience to their awareness, knowledge, and planned behavior when encountering wildfires. --- Hazard mitigation The solutions to minimizing the risk of wildfire and reducing the hazards caused by these fires are described in this section. Extensive studies were carried out in WUI areas to find solutions to the loss of life and property caused by fires, and the involvement of the local people in fire management was determined the most important element when attempting to solve these problems (Bihari and Ryan, 2012;Ghasemi et al., 2020). In future studies, it is strongly recommended that the people of the region, together with the managers, work with a common consciousness and that the risk awareness of the people of the region be increased by the managers (McGee, 2011;Reams et al., 2005;Tedim et al., 2016). Table 5 shows data from existing articles on hazard mitigation. While Fischer et al. (2016a) state that socio-ecological pathology, which is one of the most important factors that creates the risk of fire, is ignored and mention the necessity of making political breakthroughs in this regard, Tedim et al. (2016) point out the necessity of applying the risk reduction approach to the whole region, not only to selected or privileged parts of the region, from a holistic perspective. McGee's (2011) perspective differs from other studies in that wildfire reduction programs that involve local residents build community resilience and improve relationships between residents and government agencies. On the other hand, Ghasemi et al. (2020) highlight that the concept of trust plays an important role in perceived action effectiveness and risk beliefs among local people. Bihari and Ryan (2012) --- Resource management Academic studies are carried out to develop the understanding of prevention rather than extinguishing in fire management by ensuring the effective use of resources. In this context, the application of the principle of participation in resource management in forest fire management, along with a set of proposed solutions, is presented to the reader under this title. Table 6 shows data taken from articles on resource management. Among the studies under this title, while Ni'mah et al. ( 2018) describe what kind of contributions will be made in the fight against wildfires by increasing ecotourism activities, Dube (2013) differs from other studies in their mention of building trust and respectability among communities by granting a legal right to incineration for land use needs. While Patr<unk>o (2014) reveals the legal framework of forest fire management in Portugal on the subject, in Nyongesa andVacik's (2018, 2019) studies, which were conducted locally in Kenya, the researchers offer recommendations for further policy options that consider forest health, productivity, and socio-economic values for improving people's livelihoods, in addition to collecting data on local people's perceptions and traditional ecological knowledge. --- Traditional fire knowledge Many studies have concluded that the search for a solution to forest fires requires a new method that goes beyond face-to-face firefighting. In countries with fire-prone ecosystems, they have recognized the need to engage with the different perspectives of prescribed burning and the practices of local communities. Further, a number of studies have mentioned that burning traditions are indispensable to their livelihoods, regional administration, and cultural expression. For these reasons, in some countries, indigenous peoples are key partners in developing fire policies and responses (Mistry et al., 2019;Welch and Coimbra Jr., 2021). In this study, the author discusses the fire experiences of local people and their knowledge of firefighting, which has developed accordingly in WFM under the perspective of participation. Table 7 shows data from articles on traditional fire knowledge. While Welch and Coimbra Jr. (2021) also discuss the burning actions of the local people at the center of human rights, Lineal and Laituri (2013) touch upon the concept of trust, stating that the complex framework of inter-agency cooperation is essential for effective information sharing and communication. Further, Devisscher et al. (2019) and Mistry et al. (2019) mention the development of bottom-up strategies focused on merging TFK (Traditional Fire Knowledge) and SEK (Scientific Ecological Knowledge). Devisscher et al. (2019) conducted their studies in Bolivia, while Mistry et al. (2019) conducted their studies in Brazil. Khatun et al.'s (2017) study is a participatory REDD+ project effort that combines forest management efforts with a fire management plan, which differs from other studies in that regard. --- Discussion When reviewing the previous studies, there is a clear need for a new understanding of wildfires instead of the extinguishing firefight paradigm (McGee, 2011;Nyongesa and Vacik, 2019). Hence, the necessity of adopting a bottom-up WFM approach with the participation of local stakeholders in fire management is explained as an important breakthrough in every study reviewed (Dube, 2013;Patr<unk>o, 2014). Among these stakeholders, it is stated that the community that suffers the most from forest fires is the local people living in the region who own the forests, and it is emphasized that these groups should play an active role in forest fire management (Lineal and Laituri, 2013;Welch and Coimbra Jr., 2021). The political problems related to the participation of local communities regarding fire management are discussed (Aguilar and Montiel, 2011;Marta-Costa et al., 2016). In order for participation to be truly effective, it is stated that an education policy and awareness of the importance of knowledge are necessary for the studies under this heading. However, Marta Costa et al. ( 2016) assert that the revival of old and wise yet abandoned fire practices, which have traditionally been in the hands of rural communities, should also be included in these policies. When the studies under this title are reviewed, the literature could not be enriched by examining the legal rights of the people living in the fire areas. This situation is important for the policies created or considered regarding fire management. A significant legal study on the subject recently took place in Turkey, where state forestry is widespread. The understanding of participation, which is based on the fact that protecting the forest is a civic duty, was changed in 2018 with the introduction of law no. 7139. As of this year, the fire-extinguishing obligation of the people living in the fire area was changed on a voluntary basis. In this way, not only do people living in the region become obliged participants, but also those who wish to participate as volunteers. However, this situation causes problems in the implementation of the principle of participation in the fight against wildfires. First of all, the Regional Directorates of Forestry, which have a fire-extinguishing obligation, face the problem of not being able to recruit sufficient personnel. In addition, the fact that those willing to participate in the fire fight on a voluntary basis represent a heterogeneous mass from various backgrounds, often outside the region, creates adaptation issues (Ok et al., 2018). Under another title, "Fuel Management", two studies are discussed. These studies are aimed at collecting information about the region for fuel management. While Santos et al. (2021) collected economy-based information to understand the willingness of forest owners to pay for fuel management, Ferster et al. (2013) aimed to measure forest fuel data by enabling the people living in the region to take an active role in management. The fact that the studies under this title mainly focus on information collection is seen as a shortcoming as the result of the involvement of the local population in the removal of substances from the field for fuel management remains underexplored. For example, there is a gap within the scope of the participation principle concerning the benefits that grazing activities will bring to fuel management and what kind of problems this practice brings (Tolunay and <unk>zmiş, 2022). There are six studies under the title of "Hazard Mitigation". In all studies, it is emphasized that a collaborative approach should be adopted with local communities in order to minimize the destruction caused by fires. Fischer et al. (2016a) point out that even with a clear understanding of wildfire pathology and possible solutions, governance and management systems will evolve gradually and in flawed ways. Similarly, Tedim et al. (2016) state that new ways of governance are needed in a situation where, from a passive expectation in fire management, local communities gradually become autonomous actors of bottom-up initiatives in terms of prevention, preparedness, and rapid suppression. Fischer et al. (2016a) also explained that although we have a good understanding of fire pathology, there may be resistance to changes in and the development of future systems. Reams et al. (2005), on the other hand, assert that minimizing the risk of fire is the most important solution proposal. However, in today's world, a management approach toward the least fire risk understanding is insufficient for hazard mitigation. Unlike other studies, Ghasemi et al. (2020) focus on issues that increase community engagement in hazard mitigation. In this context, Ghasemi et al. (2020) conclude that the concepts of home attachment, past experience, and trust for fire institutions are key concepts. Similarly, Bihari and Ryan (2012) state that the concepts of place attachment and past experience increase the interest of the local people in the issue of hazard mitigation. Also, Mcgee (2011) determined that local people consider past experience, agency involvement and personal and family protection as major reasons to participate in the hazard mitigation process. Further, Bihari and Ryan (2012) explain that the only way to ensure direct public participation in hazard mitigation is through the community planning process. Fischer et al. (2016a) and Mcgee (2011) also mention that the community planning process is the only way to ensure public participation. Studies generally indicate the local community's motivation to work on hazard mitigation. However, the factors that make the people of the region reluctant to participate are not mentioned. The kinds of problems encountered by local people in the wildfire areas while participating in hazard reduction activities due to the lack of trust in public institutions is another topic worthy of discussion. Another title is "Resource Management", which comprises a total of five studies. Each of the studies agrees on the need to enhance the role of the community in land resource management in rural areas to improve fire management. Furthermore, researchers agree that a method should be established that considers the interests of the local people in resource management for wildfires. Some of the studies discuss the importance of establishing and developing the necessary legal frameworks for resource management (Nyongesa and Vacik, 2018;Dube, 2013;Patrao, 2014). Of these studies, Nyongesa and Vacik (2018) and Dube (2013) advocate the legal right of the local people to incineration for their legitimate land use needs. It is noteworthy that these two studies are located in the African continent (Kenya and Botswana). Patrao (2014), on the other hand, highlights some of the barriers faced by professionals and other stakeholders in implementing a more collaborative wildfire management framework within the legal framework of wildfire management in Portugal. Nyongesa and Vacik (2019) provide recommendations for fire management policy options that consider the improvement of people's livelihoods as a key requirement in resource management. Ni'mah et al. (2018), on the other hand, recommend increasing community participation in order to prevent the occurrence of wildfires instead of preventing forest fires by increasing ecotourism activities in the region. While several studies have attempted to increase the participation of local people in resource management by focusing on local socio-economic values, it is concluded that this is done without discussing the limits and balance of policies and legal rights on a local, regional, and global scale. In terms of studies, this appears to be a shortcoming. The "Traditional Fire Knowledge" title comprises a total of five studies. All the studies under this heading emphasize the importance of the benefits of traditional combustion methods. In their work, Devischer et al. ( 2019) and Welch and Coimbra Jr. (2021) state the necessity of making use of the burning practices of the local people, and have even left this process to the local people in firefighting in some regions. On the other hand, Khatun et al. (2017) also evaluated the damage caused by the carbon emissions resulting from the practices of the region's inhabitants, including practices related to hunting. Lineal and Lauturi (2013) and Mistry et al. (2019) state that natural resource managers should take an active role in developing the personal skills of local people in these fire practices, managing resources, and identifying problems that may hinder the management planning process. While the studies mention that the traditional fire knowledge the local people possess significantly contributes to the development of effective fire-fighting practices, the precise methods are yet to be explored. Hence, it is necessary to conduct detailed research on the evolutionary fire-fighting practices developed by the inhabitants of these regions and to make recommendations based on this. --- Conclusion This study discussed the impact of the local people's participation in WFM on the decision-making process. It is obvious that a new paradigm is needed in the fight against wildfires due to the changing ecological and social regimes of people caused by climate change and global warming. Therefore, this study recommends that the IFM method replace direct fire-fighting methods. As IFM combines ecological, political, social, anthropological and legal principles, it has crucial advantages as a fire-fighting method. Another concept under IFM, CBIFM planning, is a participatory approach to fire management that involves local communities, civil society, development organizations, and government officials with the aim to achieve ecological and socio-economic sustainability. Local community participation in WFM is examined under this planning title. This study concluded that this approach is not a choice but a necessity in order to produce fast and effective solutions to the problems caused by wildfires. In terms of cost efficiency, aircraft, helicopter, fuel, and personnel costs in direct firefighting have the potential to be minimized thanks to this approach. Fast diagnosis and early intervention are important factors in neutralizing wildfires. For this reason, people who live in WUI areas or have assets in the region aim to accrue the least damage possible when extinguishing fires in order to protect both their assets and their families. This illuminates how critical the participation of the local community is to ensure early detection and first response. In addition, some indigenous communities living in fire areas have developed some methods to minimize this damage throughout their history. It is thought that these methods will be useful, but in order for these methods to be applied in a controlled manner, they should be carried out together with forestry organizations. In particular, the prescribed burning method is highly beneficial in terms of eliminating fuel loads in the region before fire times. However, if it is not applied in a controlled manner, other fires can emerge, causing further disruptions to social life in the region. Another issue that needs to be addressed is the expectations of local people from forest areas. In some regions, the people in the region only live their lives intertwined with nature, while in others, the public sees the forest as a source of income. For this reason, decision makers need to measure people's perceptions about the region, and they must take this into account when choosing the most effective method to apply. Furthermore, local people contribute significantly to the data collection process in the region. The collection of local people's perceptions of the region, as well as their knowledge about the region, is also important in establishing the right fire management mechanism. Further, another issue is to increase local people's knowledge of risk management. This can aid the prevention of fires that may occur due to the attitudes of people in the region, and it also enables them to approach the region with a more protective attitude against external elements. After the training and educational processes, the place attachment of the local people is channeled to fire-fighting. In order for these processes to work beneficially, it is necessary to ensure the trust of the society. In some regions, local people want to participate in the direct fight against wildfires. However, the fact that they do not have adequate training in the fight against wildfires causes them to endanger their own lives and to interrupt the work of the firefighting teams. The training given to the groups who want to join the fight directly in the region before the wildfire period starts is a part of this study. Even if the said benefits are obtained with the participation of local people in WFM, it is observed that there are situations that cause disruptions in the functioning of this management. The most important of these problems are the difficulties experienced in creating appropriate policies due to the unique nature of each region and people's distrust of institutions. Besides, the fact that the top-down management approach is still accepted poses another issue. Moreover, the lack of adequate funding, constant change of the people in the touristic areas, and lowrisk awareness of the people in some regions, due to a lack of fire experience, are additional problems. Some of the income-generation activities of the people of the region are in conflict with the fire-fighting activities (hunting, agriculture). The negative attitudes of some groups engaged in these activities are also of concern. Furthermore, the lack of active participation of local people in WFM presents an additional challenge for the CBIFM approach. --- Suggestions First of all, it is necessary to adopt regional policies instead of centralized policies by accepting that each region has its own characteristics and to provide a more efficient bottom-up management approach. The creation of applications based on information technologies will facilitate the operation of the system in order to collect information from local people about both the region and their firefighting experiences. After the literature review, it is seen that only a few studies on the direct participation of forest owners in wildfire management. There is a need for more studies on this subject. Further, few studies on the subject have focused on the continents of Australia and Asia, where wildfires are prevalent, and it is recommended that more studies be done in these regions. The existing studies mention that fire management should be formed by considering the socio-economic values of the people of the region; however, sufficient suggestions are not offered for the creation of fire-related jobs for the people of the region. Business areas such as extinguishing, surveillance, and village guards are beneficial in terms of ensuring the economic development of the people of the region. WUI interaction is not mentioned in any of the studies on resource management and traditional fire knowledge. In particular, the necessity of studies in which the concepts of resource management and WUI are combined is advocated. Further, there were no suggestions considering the publiccivil balance in studies for establishing or improving equipment, organization, etc. There is a need to improve in these subjects for effective wildfire management. Controlled grazing is not discussed in the studies within the scope of local community participation in wildfire management. It is also known that these practices cannot be implemented successfully due to a lack of trust in the public institutions. Controlled grazing is beneficial in terms of fuel management in wildfire management and is a topic worthy of further investigation. Studies are carried out in countries where private forestry is intense. In countries like Turkey, where private forestry does not exist, there is a research gap regarding how the participation of local people in wildfire management progresses. In order to facilitate the communication of decision makers with the people of the region, additional training on the subject is also recommended. --- Ancknowledgement The author would like to thank Professor Jose Borges for his encouragement in the development of this study. In addition, the author's gratitude also extends to Professor Kenan Ok, who read the draft manuscript and contributed to its development. I would also like to acknowledge Max Dade for this insight in improving the language and overall clarity of the manuscript.

Wildfires have caused considerable economic, ecological, and social damage in recent years. For this reason, decisionmakers in wildfire management (WFM) have face increasingly difficult challenges. While decision support systems help decision-makers, it is clear that some deficiencies still persist. In this context, it is thought that the active role of local people involved in wildfire management can eliminate these deficiencies because they have experience and direct knowledge about fighting wildfires in Wildland Urban Interface (WUI) areas. Hence, their expertise can be utilized in future wildfire containment efforts. In this study, the author presents some general information about WUI, public participation, and the decision-making process and its relation to wildfires. In addition, the author will also examine previous studies on the participation of local people in wildfire management and investigate the decision-making processes regarding this issue by using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) technique. The results of this study suggest that there should be a widespread adoption of the community-based integrated fire management (CBIFM) approach, instead of the top-down management approach commonly employed in wildfire management. The results strongly suggest that decision-makers should reach a consensus as to how the principle of participation in fire management should work by reviewing the socio-economic interests of the local community.

Introduction Skilled attendance at delivery is a critical intervention to reduce maternal mortality [1,2], given that approximately three quarters of maternal deaths occur from complications during labor, delivery, and the first 24 hours postpartum [3]. These complications are difficult to predict, but can be effectively managed and deaths averted if they are recognized and treated promptly. Thus, the World Health Organization recommends every delivery ought to be overseen by a skilled birth attendant (SBA)-a health professional who can identify and manage normal labor and delivery; and identify and treat complications or provide basic care and referral [1,3,4]. Unfortunately, the proportion of deliveries by SBAs is still below recommended levels. In Sub-Saharan Africa (SSA), about half of births are assisted by SBAs-with wide disparities by socioeconomic status (SES) [5][6][7]. Even in countries where antenatal care (ANC) is common, a large proportion of deliveries occur at home without the help of a SBA [8,9]. Ghana exemplifies the experience of many countries in SSA. The maternal mortality ratio in Ghana is 380 maternal deaths per 100,000 live births [10]. More than 95% of Ghanaian women have at least one ANC visit during pregnancy, and about 80% attend the recommended four or more visits [11][12][13][14]. In 2008, only about half of births were assisted by a SBA, with wide disparities by SES. Only 36% of births among women with no education were assisted by SBAs, compared to 92% among those with secondary education or more; and 24% among women in the poorest wealth quintile compared to 95% among those in the richest quintile [12]. The 2011 UNICEF multiple indicator cluster survey and the 2014 Ghana Demographic and Health Survey (GDHS) key findings show the proportion of births assisted by SBAs increased to 63% in 2011 and to 75% in 2014, but the SES disparities still remain [13,14]. These statistics raise two questions that motivate this research: (1) What accounts for the disparity in ANC attendance and use of SBAs in Ghana? (2) What accounts for the SES disparities in use of SBAs within the country? Many studies have examined the determinants of use of SBAs or deliveries in health facilities, with a number of reviews on the topic [15,16,5,6]. These reviews all show large socioeconomic and rural/urban disparities in skilled attendance, with higher education, higher wealth, and urban residence consistently associated with higher use of SBAs. In Africa, even a primary education is associated with higher utilization compared to no education. Women in the second lowest wealth quintile have higher utilization than those in the lowest wealth quintile. These disparities persist even after controlling for other factors, many of which have been examined in qualitative studies [17][18][19][20]. Few quantitative studies have, however, empirically examined the factors underlying these disparities. This is likely because current models do not provide clear pathways-with measurable mediators-for how distal factors like SES may affect maternal health-seeking behavior. The goal of this paper is to help bridge this gap. In this paper, we propose a new framework-the Disparities in Skilled Birth Attendance (DiSBA) framework-that explicitly lays out potential mediating pathways through which distal factors like SES may affect use of SBAs. We then empirically examine factors underlying SES disparities in SBA use in Ghana, as well as the gap between ANC attendance and SBA use. In addition, we identify gaps in the existing data that limit our understanding of the sources of disparities in service utilization and make recommendations for future research. --- Existing frameworks to understand use of skilled attendants The DiSBA framework draws on prior research on maternal mortality and the determinants of use of maternal health services. In particular we draw on three prior models [21,15,5]: McCarthy and Maine's (1992) framework for analyzing the determinants of maternal mortality; the three delays model by Thaddeus and Maine (1994), which posits three delays-the delays to seek, reach, and receive care-that lead to maternal mortality from the onset of an obstetric complication; and the recent expansion of the three delays model by Gabrysch and Campbell (2009) to include preventive obstetric care. McCarthy and Maine's comprehensive framework highlights the influence of contextual factors yet it does not illustrate the complex interactions amongst the intermediate determinants. Thaddeus and Maine's three delays model focuses on pregnant women and their careseeking behavior when they experience a complication. This model has been widely used, yet it implies a single pathway for the effect of SES-a single arrow from socioeconomic/cultural factors to the delay to seek care. But socioeconomic/cultural factors can also affect the delay to reach and receive care through a number of pathways. Gabrysch and Campbell's model includes care seeking for uncomplicated pregnancies and partially addresses the multiple pathways for socioeconomic/cultural factors by separating out economic factors from sociocultural factors, with sociocultural factors affecting to the delay to seek care, and economic and physical accessibility affecting the delays to seek, identify, and reach care. However, certain sociocultural factors may still lead to other delays besides delays in deciding to seek care. For example, sociocultural factors related women's autonomy can potentially affect the time to reach care, given situations where women cannot travel freely or are not allowed to use certain types of transportation, which may be the most readily available form of transportation [15,22]. None of these models address the effect of socioeconomic factors on the delay in receiving adequate and appropriate treatment. SES can impact the timeliness and quality of care received in several ways. First, in settings where patients are expected to buy supplies and medication upon reaching the health facility, higher SES women who can afford such supplies are much more likely to receive prompt attention. It has also been demonstrated that higher SES women are treated differently than lower SES women, suggesting that quality of care may be better for women with means [23][24][25]. In addition, higher SES women have the means to choose facilities-such as private, non-government facilities-that may offer better quality of care [26][27][28][29]. These factors will in turn affect their perceptions of the quality of care, which will affect future decisions of whether or not to return for care [5,24,30]. These examples suggest a complex interaction between socioeconomic factors and the phases of delays that are not explicitly illustrated in the three delays models. Our framework builds on the strengths of these earlier models and attempts to address their limitations to provide an integrated, yet simple, conceptual framework for understanding the sources of disparities in the use of SBAs. In addition, we draw on the health belief model, which posits that people are more likely to act if they perceive a need (based on their perceived susceptibility, perceived etiology, and severity of the condition), perceive that benefits of the action outweigh the barriers; and have cues to action and reinforcements [31]. --- The Disparities in Skilled Birth Attendance (DiSBA) framework The main premise of the DiSBA framework is that the decision to use maternal health (MH) services, including use of SBAs, is based on three factors: perceived need for care, perceived accessibility (physical and financial) of the service; and perceived quality of the care. We refer to these three factors as the proximal determinants of use of maternal health services. SES and place of residence, the most common determinants of service use, are distal factors that affect use through these three proximal factors. Perceived need is influenced by women's current health status (e.g., having a pregnancy complication and the type and severity of the complication), reproductive factors (including age and parity), prior health status or pregnancy complications, health knowledge (general and specific to pregnancy), as well as by unknown factors that influence the development of pregnancy complications [21]. In addition, perceived need is shaped by socioeconomic and sociocultural factors. Perceived accessibility is influenced by actual accessibility (physical access and cost of services) [15], as well as by socioeconomic factors, and may be modified by illness factors. As noted in the three delays model, accessibility has a dual role: it indirectly influences the decision to use the service through perceived accessibility and directly influence reaching the service once the decision to use the service has been made [15]. Perceived quality is based on an assessment of quality of care from a personal previous experience, or the experience of others [15,32]. The assessment of quality can be based on the structure, process (technical or interpersonal) or outcome of care as described by Donabedian (1988), though it may be dominated by the interpersonal aspects of care; and can be based on any type of prior encounter with the health system [15,33,34]. In addition, perceived quality of care is influenced by socioeconomic and sociocultural factors [30]. All the factors are influenced by larger contextual factors in which the health system and sociocultural factors are embedded. This paper provides a framework to guide questionnaire development, data collection, and quantitative analysis of factors that mediate SES disparities in use of SBAs. The simplicity of the model is not to undermine the numerous factors associated with use of SBAs in the literature, but to provide a way of thinking about the key predictors. It will help maternal health researchers to move beyond simply including covariates in regression models to thinking about what role the covariates are playing. The DiSBA framework is illustrated in Fig 1. The key assumption of the DiSBA framework is that SES differences in perception of need, access, and quality of care account for the SES disparities in use of SBAs. Depending on the purpose of the research, the context, and type of data available, we may pay greater attention to one or more proximal factors. It is our hope, however, that the framework will guide work from the conceptualization phase of projects that involve primary data collection and ensure that we collect data on all the proximal factors, in addition to data on the factors that influence them, to ensure more complete analysis. For the case of Ghana, where ANC attendance is much higher than use of SBAs, with large SES disparities in use of SBAs, but not in ANC attendance; and where quality of care has been mentioned as a reason for nonuse of SBAs [35][36][37] we ask three questions: 1. Does quality of ANC predict use of SBAs among women who attend ANC at least once during pregnancy? 2. Does quality of ANC explain some of the SES disparities in the use of SBAs? 3. Compared to the other proximal determinants, what is the relative contribution of ANC quality to the SES disparities in the use of SBAs? We focus on ANC quality because the only measures of quality in our data are from ANC. Also, since the effect of quality of care on the decision to use a SBA must be from a prior encounter (personal or vicarious) with the health system, looking at the effect of ANC quality during pregnancy on the delivery provider for that pregnancy captures this temporal ordering. --- Methods --- Data The data for this analysis are from the 2007 Ghana Maternal Health Survey (GMHS). The survey was conducted by the Ghana Statistical Service and the Ghana Health Service with technical assistance from Macro International, and has been described in detail elsewhere [38]. Based on a multistage cluster design, households were randomly selected from all regions of Ghana and household and women's questionnaires were administered face-to-face by trained interviewers. Verbal consent was obtained from respondents. The response rate was 99% at the household level and 98% for the individual women, with 10,858 completed household interviews and 10,370 individual interviews with women aged 15-49 years [38]. Unlike the Ghana Demographic and Health Survey (GDHS) [8], the GMHS collected health service utilization data for all women who had a birth (live or still birth, not only live births) in the five years preceding the survey (N = 5,088, or 49% of all women interviewed); this is the base sample for the analysis. The analytic sample consists of 5,042 women (99.1% of the base sample) because 46 observations are missing on key study variables. The main analysis is further restricted to women who had at least one ANC visit during their last pregnancy, since quality of ANC cannot be measured for women who did not have any ANC. Ninety seven percent (N = 4,868) of women in analytic sample had at least one antenatal visit. The full analytic sample is examined in sensitivity analysis. This study was granted an exemption under the University of California, Los Angeles Institutional Review Board exemption category 4 for research involving the study of existing data. Ethical approval for the GMHS was however obtained from the Ghana Health Service Ethical Review Committee. --- Variables Dependent variable: Delivered with a skilled birth attendant or not. Women in the survey were asked: "When you gave birth to [name of last child], who assisted in the delivery? Anyone else?" Options included doctor, nurse or midwife, auxiliary nurse or midwife, traditional birth attendant (TBA), relative or friend, other, or no one. We created a binary variable "use of a SBA": coded as 1 (delivered by a SBA) if doctor, nurse or midwife, or auxiliary nurse or midwife was mentioned; and 0 (not delivered by a SBA) if otherwise. Key independent variables: Socioeconomic status. We operationalize SES in this analysis as education and wealth. We examine education as a categorical variable (highest level of education attained by respondent). Wealth is measured in quintiles-calculated from a wealth index based on principal component analysis of variables on household assets [39]. Mediating variables: Proxies for the proximal determinants. Perceived quality of care: We operationalize perceived quality of care as an additive index based on women's responses regarding whether they received nine ANC services at any point during their last pregnancy. The services included measuring weight and blood pressure, conducting urine and blood tests, prescribing iron supplements and an anthelminthic, vaccinating against tetanus, and instructing women on the signs of pregnancy complications and on where to go in case of a complication. Each question has a binary response (1 = Yes; and 0 = No). Although this index is arguably a better measure of actual quality than perceived quality, it is the best available proxy given the data collected. The index (previous described elsewhere [26]) ranges from 0 to 9; the mean is 7.4. For this analysis, we dichotomized the index: good quality ANC (coded as 1) is receiving at least eight of the nine antenatal services (requiring a score above the mean); and poor quality ANC is receiving seven or fewer of the services (coded as 0). The assumption is that women who received good quality ANC (i.e. reported receiving more services) will have higher perceived quality of maternal health care than those who received poorer quality ANC, which will have a positive effect on their use of SBAs. However, considering this measure does not include questions on the interpersonal dimensions of quality [33,34] or disrespect and abuse [24,40], this measure may underestimate the role quality plays as a determinant of SBA utilization. Perceived accessibility: We used place of residence-whether one lives in an urban or a rural area-as crude measure of perceived accessibility, absent better data regarding perceptions of access. Urban areas are defined as localities with 5000 or more persons, while rural areas are localities with less than 5000 persons [41]. Studies consistently find that urban women are more likely to use services than those in rural areas. Place of residence however reflects larger contextual factors beyond just physical access, including things like ability to pay, beliefs about use of health services, information availability, and quality of services [5,42]. Thus the urban effect will capture more than just access, including capturing some of the effects of the other potential mediators. Perceived Need: The GMHS does not include data on perceived need for delivery services for all women; even though thinking it is "not necessary" is a common response when women who delivered at home are asked why they chose to deliver at home [29]. Since perceived need is influenced by current and past pregnancy and complication experiences, we constructed an index of perceived need based on six questions: whether women experienced a complication during the index pregnancy, had a multiple gestation (or a singleton), sought ANC for a check up or because of a problem (a proxy for early onset complications), had a past stillbirth, had a past miscarriage, and had a sibling who experienced a maternal death. In addition, we included two questions on whether the respondent has ever used contraception and knows where to get family planning as proxies for familiarity with the health system. The index ranges from 0 to 6 (no one responded positively to all 8 questions), with an average of 1.8. Because of the skewed distribution, we use it as a binary variable. Low need was a score of 0 or 1, coded as 0, and higher need was a score of 2 to 6, coded as 1. The assumption is that women with a higher need score will have a higher need for skilled birth attendance. But because perceived need is also influenced by health knowledge and sociocultural factors not captured in these data, this index also likely underestimates the effect of perceived need on behavior. Control variables. We control for various factors that have been shown in the literature to be associated with use of SBAs: age, parity, marital status, and age at first union, which may tap into women's autonomy; and religion and ethnicity, which may capture some sociocultural factors [5]. We also examine the frequency and timing of ANC visits and the type of ANC facility and provider. --- Statistical methods Initial analyses involved descriptive statistics and examining the bivariate associations between the independent variables and the dependent variable using chi-squared tests. We then examined associations using multivariate binary logistic regressions to account for the effects of other factors. The models are built starting with the null model, then adding the key independent variables, the control variables, and finally the mediating variables. Mediating variables are those variables that explain the relationship between the key independent variables and the dependent variable. In this analysis the mediators are the proxies for the proximal determinants. When the dependent variable is continuous, the mediated effect is the change in the coefficients of the key independent variables when the mediators are added to a linear regression model. However, because the addition of variables to a logistic model changes its scale, it is not accurate to consider the difference in the coefficients in nested logistic models as the magnitude of the mediated effect [43,44]. We therefore used the 'khb' rescaling method to calculate the magnitude of the mediated effects. In this method, the residual of the mediators are applied to the reduced model to fix the scale of the reduced model to that of the full model, so that the coefficients for the key independent variables can be compared across the nested models. The coefficients of the key independent variables in the models with the residuals of the mediators (the rescaled reduced model) are their total effects (c); and the coefficients of the key independent variables in the models with the actual mediators (the full model) are their direct effects (c'). The difference in the coefficients (c-c') in the two models are the mediated effect, and the proportion of the total effect mediated is (c-c')/c [43,45]. All the analyses are weighted using the sample weights provided with the data to account for the complex sampling design. Robustness checks. We checked for collinearity and performed diagnostic tests to ensure the models were well specified. We used weighted single level logistic regression because we do not have the data to reconstruct the weights for multilevel analysis. To check the robustness of our results, we estimated unweighted multilevel (individual-level 1, cluster-level 2, and districtlevel 3) models with random intercepts for our final models using the "xtmelogit" command in Stata [46,47]. --- Results --- Sample distribution Table 1 shows the distributions of key study variables for the 97% of women who received ANC at least once during their last pregnancy (N = 4,868). These are similar to the distributions for the full sample, which have been described elsewhere [26,48]. The average woman in the sample is about thirty years old, has had about four pregnancies, and is married (72%). About a third of the women have no formal education and only about 8% have attended senior secondary school or higher. As expected, the analytic sample is almost evenly distributed between the five wealth quintiles. About two-thirds of the women live in rural areas. Of the women who attended ANC at least once, about 80% had four or more visits as recommended by WHO. About 61% received higher quality ANC (8-9 of the 9 services), and 58% have high need (2-6 of the need variables). A SBA assisted a little over half (57%) of the women at delivery-10% by doctors and 47% by nurses or midwives. --- Bivariate results Table 2 shows the bivariate distributions for the key study variables by the delivery assistant. Use of SBAs increases with both education and wealth: 35% of those with no education used SBAs, compared to about 90% of those with secondary education or more; and 30% of the poorest women used SBAs, compared to 92% of the richest. Forty-one percent of women in rural areas were assisted by a SBA, compared to 87% of women in urban areas. About 64% and 65% of women with high need and those who received higher quality ANC respectively were assisted by a SBA, compared to 48% of those with low need and 45% of those who received lower quality ANC. --- Multivariate logistic regression results The results from the weighted multivariate logistic regression for use of SBAs are shown in Table 3. We present three sets of models, model 1 contains the key independent variables controlling for age, parity, marital status, age at first union, religion, and ethnicity; model 2 adds on the mediators; and model 3 adds on ANC frequency, timing, facility, and provider. All three models show that use of SBAs still increases with education and wealth net of other factors. Women with a middle school education or more and those in the highest wealth quintiles have over two times higher odds of using a SBA than those with no education and those in the lowest wealth quintiles respectively. The effects of the mediators are also significant net of other factors. Women who live in urban areas have about four times higher odds of using a SBA than those living in rural areas. Women who received higher quality ANC have about 47% higher odds of using a SBA than those who received lower quality ANC; and those with higher perceived need have about 28% higher odds of using a SBA than those with lower perceived need. We also find that women ages 20-24 are less likely to use a SBA than older women, while primiparous women are more likely to use a SBA than women with higher order births. Women who are cohabiting, those who belong to the Traditional/other religion group, and those of Ewe, Mole-Dagbani or Hausa ethnicity are less likely to use SBAs than those who are married, Christian, and Akan respectively. The other factors that are positively associated with using a SBA in model 3 are attending ANC four or more times and receiving ANC from a doctor (compared to a nurse). Also, women who received ANC in lower-level facilities like health centers and health posts are less likely to use a SBA at delivery than those who did so in higher-level government facilities like hospitals or polyclinics. The mediation analysis is based on models 1 and 2. We exclude the ANC frequency, timing, facility, and provider from the mediation models because these variables are all associated with SES, rural/urban residence, and quality of ANC, as in previous studies [26,49,50]. In addition, they are associated with our perceived need measure-women with high need are more likely to start ANC early and be seen by doctors in higher-level facilities. Because these variables lie in the mediation pathway from SES to use of SBAs and are theoretically antecedent to ANC quality and perceived need, including them significantly reduces the magnitude the effects mediated by ANC quality and perceived need (although they are still significant). --- Mediation results The results for the mediation analysis are shown in Table 4. Our measures of perceived access, perceived need, and perceived quality of care account for about 23% of the difference between women with no education and those with only primary school education and about 55% of the difference between women in the lowest wealth quintile and those in the middle wealth quintiles. In general, urban residence has the largest contribution to the mediated effect, which is not surprising because of its contextual nature, followed by quality, and then need-except for the difference between primary and no education where need has a slightly bigger effect. --- Sensitivity results For the most part, the findings from the unweighted multilevel logistic models are essentially the same in direction and significance of associations, and comparable in magnitude of the associations to the results from the weighted single level models presented. One exception is that the difference between those with no education and those with a primary education is not significant when the mediators are added to the multilevel model, where as there is still a significant difference in the single level model-potentially because standard errors tend to be smaller in single level models when data are clustered. The models using the full sample (including the 3% who did not attend any ANC) are essentially the same as that for the sample restricted to only women who had at least one ANC visit. In this model, quality of care is scored zero for those who did not attend ANC and an indicator variable is included in the model for whether or not the person received any ANC. --- Discussion In this paper, we propose the DiSBA framework: a conceptual model for understanding sources of disparities in the use of SBAs, which posits perceived need, accessibility, and quality as the three proximal factors that affect use of SBAs; and apply it to the case of Ghana. We find that our measures of perceived need, access, and quality do account for some of the SES differences in the use of SBAs, although the effects mediated by quality and need are smaller than what we expect based on the results of several qualitative studies. This is likely because our measures do not adequately capture all dimensions of need and quality as previously discussed. In addition, the larger contribution of urban residence, which we use as a measure of access, likely, also captures some dimensions of need and quality. Our findings for the effects of education, wealth, and urban residence are consistent with the findings from studies that examine the determinants of use of SBAs or facility deliveries [16,5,6,29,51]. Also, some of the variables we use to construct our perceived need index, like whether or not a woman has a complication and prior use of contraception, have been found to be determinants of use of SBAs in other studies [5,[52][53][54]. In addition, although very few quantitative studies have examined quality of care as a determinant of MH service utilization, nearly all qualitative studies of MH service utilization mention quality of care as an important factor, with poor staff attitudes as a recurrent problem [18][19][20]24,[35][36][37]. Our finding on the effect of quality differs from that of Stekelenburg et al. (2004) who found no effect of perceived quality of antenatal care on facility delivery in a rural district in Zambia. This is potentially because our measure of perceived quality of ANC captures more than just satisfaction, which is usually very high in surveys [30,55]. That women who reported receiving more services are more likely to use SBAs is not unexpected-ANC should be an opportunity to help women prepare for skilled attendance at delivery. Our study goes beyond simply identifying determinants of utilization to understanding how distal factors affect use of SBAs through more proximal factors. To our knowledge, no other study has quantitatively examined the factors underlying SES disparities in the use of SBAs. While we do not place heavy emphasis on the magnitude of the effects in this analysis because of the weaknesses of our measures, our findings do suggest that the three proximal factors are important predictors of use of SBAs and do account for at least some of the SES disparities. Our findings also suggest that the important proximal factors may differ for different distal factors in different settings. For instance, we find that accessibility (urban residence) accounts for a larger proportion of the wealth differences in the use of SBAs in Ghana than the education difference, while need plays a bigger role in the education difference than the wealth difference. Quality of care however has a relatively similar contribution for both the education and wealth differences-though more so for the difference between the poorest and middle wealth groups than the other differences. The contribution of ANC quality relative to accessibility and need is especially important because it supports our hypotheses that SES disparities in quality of ANC are also contributing to some of the SES disparities in the use of SBAs. This implies that bridging the SES disparities should go beyond educating women on the need to use SBAs and increasing accessibility of services to improving the quality of care provided to all women regardless of their SES. In addition the significant effect of ANC quality among women who attend some ANC suggest that improving quality of ANC will help reduce the coverage gaps between ANC attendance and skilled delivery care. --- Strengths and limitations A major strength of this paper is that it uses a theory-based approach to data analysis. We propose a conceptual model to help understand the factors underlying SES disparities and illustrate how it can be used. The DiSBA framework can be adapted to examine the sources of other disparities including place of residence and age, as well as for other maternal health services. Such theory-based analysis will help address an important gap in the MCH literature, which is the dearth of quantitative studies exploring the mechanisms underlying various associations with use of maternal health services. The main limitation is that we have had to use proxy measures for the proximal determinants, which may not adequately capture all dimensions. It would also have been preferable to have data on women's existing comorbid medical conditions or her psychological state to determine if they had a role in her care seeking. However, such data were not available. GMHS data are cross-sectional, which limits causal inference; and recall and social desirability bias are potential problems, since the data are based on self-report. The age of the data is also a limitation. Nonetheless, this dataset has an advantage over the DHS of including a nationally representative sample of women who had a birth (live or stillbirth) in the five years preceding the survey, which reduces the chances of excluding women who received the worst care, as these women may be more likely to have a stillbirth. --- Conclusions We have provided a theoretical framework to guide analysis to help improve our understanding of the sources of disparities in use of SBAs in low-resource settings. Next steps include developing and validating instruments to measure perceived need for maternal health services; perceived accessibility (physical, economic, and social), and perceived quality of care, capturing perceptions of disrespect and abuse. Such instruments should be incorporated into national surveys to allow for the collection of national data on proximal determinants. Directly collecting data on women's perception of need, access, and quality of care and the factors that influence these perceptions-especially actual accessibility (distance and cost of reaching and receiving services) and direct measures of quality of care-will be invaluable to understanding the factors underlying the persistent disparities in the use of maternal health services, particularly deliveries with skilled birth attendants. Such analysis will help elucidate the important underlying factors in different settings to ensure that programs to increase use of skilled attendants and other maternal health services target the most important underlying factors in each context. Until we have these better measures, our findings suggest that more efforts are needed not just to increase access and educate women on the need to use SBAs, but also to increase quality of care during any encounter women have the health system. Reducing disparities in access and quality of care, especially, are essential to reducing the SES disparities. --- The Data were obtained from Measure DHS. To obtain the data set researchers should submit a request for the data to the DHS program at http://dhsprogram.com/data/ dataset/Ghana_Special_2007.cfm?flag=0. All researchers will be able to download the data after submitting the request form to the DHS program. --- Author Contributions Conceived and designed the experiments: PA. Analyzed the data: PA. Wrote the paper: PA CM.

Despite World Health Organization recommendations that all women deliver with a skilled birth attendant (SBA), research continues to demonstrate large disparities in use of SBAs by socioeconomic status (SES). Yet few quantitative studies empirically examine the factors underlying these disparities, due in part to the fact that current models do not provide clear pathways-with measurable mediators-for how distal factors like SES may affect maternal health-seeking behaviors like delivering with SBAs. We propose the Disparities in Skilled Birth Attendance (DiSBA) framework for examining the determinants of use of SBAs. We posit that three proximal factors directly affect use of SBAs: perceived need, perceived accessibility of maternal health services, and perceived quality of care. Distal factors like SES affect use of SBAs indirectly through these proximal factors, and the effects can be measured. We test the assumptions of the DiSBA framework using data from the Ghana Maternal Health Survey. The analytic techniques we use include logistic regression with mediation analysis to examine the intervening effects. We find that our proxies for perceived access, perceived need, and perceived quality of care account for approximately 23% of the difference between women with no education and those with primary school education, and about 55% of the difference between women in the lowest wealth quintile and those in the middle wealth quintiles. This study suggests that proximal factors are worthy of increased attention in terms of measurement, data collection, analysis, programmatic efforts, and policy interventions, as these factors are potentially more amenable to change than the distal factors. The effects of proximal factors are also likely context specific, thus sufficient understanding in different contexts is essential to developing appropriate interventions.

Introduction In adolescents and young people risky sexual behaviour has been recognized as an important health, social and demographic concern in the developing world [1]. Adolescent and youth are vulnerable to many health problems. Because they often have multiple sexual relationships and inconsistent use of condoms [2]. Young men may have their first sexual experiences with prostitutes, while young females may have their first sexual experiences with older men, both of which increase the chance of getting sexually transmitted infections (STIs) including Human Immunodeficiency Virus (HIV) [1,2]. Substance abuse exposes the users to risky sexual behaviours such as having unprotected sex which can have economic, social, physical, psychological, and health problems [2,3]. University students are in the youth age category and are exposed to risky sexual behaviours such as unprotected sexual intercourse leading to HIV, other STIs and unwanted pregnancies [4][5][6]. Female youths are prone to unwanted pregnancies that lead unsafe abortions, severe illness, infertility and death [3,7]. Young people aged 10-24 years constitute around 1.8 billion and represent 27% of the world's population [7]. Studies noted that as they are in the youth age category, their modest or dynamic behaviour vulnerable them to risky sexual behaviours [7,8]. Sexually transmitted diseases like HIV/AIDS and other reproductive health (RH) problems are the greatest threats to the well-being of adolescents and youth [7,9]. Globally, one-third of the 340 million new STIs cases occur per year in people under 25 years of age. Each year, more than one in every 20 adolescents contracts a curable STI. Studies reported that more than half of all new HIV infections occur in people between the ages of 15 and 24 years [7,10]. In Ethiopia, young people (aged 15-24) represented one of the country's largest groups, comprising about 35% of the population [11]. To enhance the sexual and reproductive health and well-being of the young's population, Ethiopia had a national strategies and activities. Some of the strategies are delivery of all youth RHrelated interventions and policies by gender, age, marital status, and residence; addressing the immediate and long-term RH needs of young people; and strengthening multicultural partnerships to respond to young women's heightened vulnerability to sexual violence and nonconsensual sex [7,12]. Some of the activities are creating awareness of sexual health, providing youth friendly services, increasing human resource capacity, explore new opportunities and expand multtisectorial coordination [7,12]. However, most related interventions targets the general public as a result it do not directly respond to higher education institution students need and expectation, making actual coverage of behavioural and biomedical interventions extremely low [13]. Therefore, sexual behaviour among adolescents and the youth is still a major issue in Ethiopia [11]. Previous studies conducted in other universities of Ethiopia showed a 26.9% to 34.2% of students ever had sexual intercourse. Of them, 45.2% had more than one sexual partner and 59.4% had first sex at high school. Moreover, the mean age at first sexual practice was 17.9 year and 4.4% of participants had sex with commercial sex workers [4,[14][15][16]. Inadditon, different scholars also reported that different factors are responsible for the sexual behaviours of adolescents. Among those, use of alcohol and chewing khat are the common factors [4,[17][18][19]. Although Ethiopia is in a concerted effort to enhance the sexual behaviour of youths using different strategy, activities and policies at the national level, the epidemic still continues to grow steadily in the country especially in educational setting claiming the lives of the most productive segments of the Ethiopian society that can lead to high social and economic costs, both immediately and in the years ahead. Moreover, dynamicity of adolescent's behaviour; it is assumed that student's sexual behaviour varies interms of locality, civilization, urbanization and socio cultural context of the societies. Specifically, Bahir Dar University is located in areas where there is high flow of tourists, comfortable pensions and night clubs that will expose the students to be engaged in different sexual risk behaviours. However, with the above problems, there is paucity of multicentered data representing the sexual behaviours of students in higher level institution at national level and also among Bahir Dar University students.Therefore, the purpose of this study was to assess the sexual behaviours and associated factors among students of Bahir Dar University, Ethiopia. --- Methods --- Study design, period and area A cross-sectional study was conducted among students in Bahir Dar University (BDU) from December to February 2013. BDU is a public higher educational institution established in 2000 [20]. The University is located in Bahir Dar town 567 kilometres Northwest of Addis Ababa. It offers a wide range of higher education programs both at undergraduate and graduate levels [20]. BDU is now among the largest Universities in the Federal Democratic Republic of Ethiopia, with more than 35,000 students in its 57 undergraduate and 39 graduate programmes. At the time of the study, it has four campuses (Main campus, Poly campus, Zenzelma and Yibab campus) in Bahir Dar which had about 20,000 full time undergraduate students [20]. BDU has five student clinics. They are engaged in youth friendly services. At the time of data collection, information and counselling on sexual and reproductive health issues, promotion of healthy sexual behaviours through various methods including peer education, family planning information, counselling and method including emergency contraceptive methods and condom promotion and provision and abortion linkage service provided in youth friendly service. Currently each clinic has three nurses trained about youth friendly services [20,21]. --- Study population All full time undergraduate students attending at Bahir Dar University during the study period. --- Inclusion criteria Full time undergraduate students ranging from year I to year V were included in the study. --- Exclusion criteria Post-graduate, extension, summer, advance standing and distance learning students were excluded during data collection. --- Sample size and sampling technique Sample size determination The sample size was determined using single population proportion formula considering the following assumptions: P = 50% (The expected proportion of ever had sex among the students), 95% confidence level and marginal error of 5%. The formula for calculating the sample size is: z<unk>=2 <unk> <unk>2 p 1-p <unk> <unk> d 2 1<unk>4 1:96 <unk> <unk> 2 0:5 <unk> 0:5 <unk> <unk> = 0:05 <unk> <unk> 2 1<unk>4 384; n 1<unk>4 384 Assuming 10% non-response rate, design effect 2, the sample size was: n =384 <unk> 2 + 10% = 768+ 76.7 = 848. The final sample size was 848. However, only 817 BDU students completed the questionnaire adequately. --- Sampling procedure Multistage sampling was used. To assure the representativeness of the data, the sample size was proportionally allocated to each college proportional to their number of students. Simple random sampling technique was used to select the departments from each year of study in the seven colleges. Finally the study participants were selected using systematic random sampling technique. --- Variables of the study --- Dependent variable Sexual behaviours such as ever had sex, unprotected sex, having multiple sex partners, sex for the exchange of money and sex with commercial sex workers. --- Independent (explanatory) variables Socio-demographic variables such as age, sex, year of study, religion, ethncity, marital status and place of residence, alcoholism, khat chewing, attending night clubs and watching porn video. --- Operational definition --- Unprotected sex Having sex without condom during their sexual experience. --- Protected sex Using condom during each and every sexual intercourse. --- Ever had sex Penile -vaginal sexual intercourse during each and every sexual intercourse. --- Data collection procedures A structured and self-administered questionnaire, which was partly adopted from Ethiopia Demographic and Health Survey (EDHS), Behavioural Surveillance Survey (BSS) and other relevant sources were used to collect the data [22,23]. All questionnaires were completed individually in the student clinic. --- Data quality control issues To maintain the quality of data, training was given to data collectors and supervisors on how to approach and select the study participants, on the objective of the study and the content of the questionnaire. Structured and self administered questionnaire was used. Questionnaire was pre-tested by taking 85 students from the university other than the actual study participant's. The questionnaire was first prepared in English and translated in to Amharic language for appropriateness and easiness. The Amharic version was again translated back to English to check for consistency of meaning. --- Data analysis The data was analysed using SPSS version 20. Descriptive statistics such as frequencies and mean were used to describe the study participants in relation to relevant variables. Most of the variables were fitted to the bivariate logistic regression. Then all variables having a p value of <unk>0.2 in the bivariate analysis were further entered in to logistic regression model. In the multivariate analysis, backward step wise logistic regression techniques were fitted and confounding and multicolinearity were controlled. Variables having p value <unk> 0.05 in the multivariate analysis were taken as significant predictors. Crude and adjusted odds ratios with their 95% confidence intervals were calculated. The Hosmer and Lemshow gardens-of-fit test was used to assess whether the necessary assumptions for the application of multiple logistic regression were fulfilled and p-value > 0.05 was considered a good fit. --- Ethical clearance Ethical clearance was obtained from Ethical review committee of Bahir Dar University, College of Medicine and Health Sciences. A formal approval was secured from Bahir Dar University and informed consent was obtained from the respondents before proceeding to the data collection. Confidentiality of the result was also maintained. --- Results --- Socio-demographic characterstics A total of 817 full time undergraduate students with a response rate of 96.7% participated in the study. Of these, 545 (66.7%) were males. The mean age of the respondents was 21 years ranged from 18 to 30 years. Majority 618 (75.6%) of them were between 20-24 years. In ethncity, 466 (57.1%) were from Amhara and 147 (18%) were Oromo. Regards to religion, 624 (76.4%) of the respondents were Orthodox Christian follower. In this study, 704 (86.4%) were unmarried. Five hundred ten (62.4%) of the study participants were either year one or two students. About, 802 (98.2%) of the respondents live in the campus dormitory (Table 1). --- Sexual practice The overall proportion of ever had sexual practice was 297 (36.4%). In the present study, ever had multiple sex partners was 126 (42.7%) of the sexually active students. Having multiple sexual partners was 110 (48.5%) and 16 (23.5%) in males and females, respectively. Regards to condom use, 113 (38%) of the sexually active respondents had consistently used condom during sex. Watching porn videos was noted in 534 (65.4%) of respondents. The highest proportion 421 (77.2%) was found in males (Table 1). Sexual intercourse for the exchange of money was found in 12 (4%) of the sexually active respondents (Table 2). The mean age at first sexual practice was 18.6 years. Seventy two (24.3%) of the respondents initiated sexual activity before the age of 18 years. Moreover, among those respondents who ever had sex, 174 (58.6%) had started sex during secondary school. However, 33 (11.1%) had first sex during elementary school (Table 3). Regarding the reason for ever had multiple sexual partners, seeking sexual pleasure and the effect of long term relationship was the major reason in males and females, respectively. On the other hand, among respondents who were not using condom consistently, 67 (36.4%) reported that condom decreases sexual pleasure. Moreover, condom use reduces sexual pleasure was the leading reason among males while in love with a partner was the major reason among females for unprotected sex (Table 3). More importantly, need to wait until marriage, 363 (69.8%) was the major reason for not initiating sexual intercourse and other reasons are listed in Table 3. Ever had sex with commercial sex workers has been reported by 27 (7.4%) of respondents. Sixty four (21.5%) of sexually active students had an experience of sexual intercourse with older individuals. Engaging in sexual intercourse after watching porn videos, drinking alchol and chewing khat were noted in 73 (24.6%), 102 (34.3%) and 51 (17.2%) of those students who ever had sexual intercourse respectively (Table 3). --- Multivariate analysis on sexual behaviours On multivariate analysis, age difference had significant association with ever had sex and watching porn videos. Those respondents with age of 20-24 years (AOR = 9.5, CI = 3.75 -23.85) and >24 years (AOR =3.65, CI = 1.7 -7. 8) respectively were 10 and 3.6 times more likely to ever had sex. Those, respondents in the age group of > 24 years were 3 times more likely to watch pornographic material than students with age group of <unk>20 years (AOR = 3.0, CI = 1.05 -8.39). Likewise, sex difference showed significant association with history of watching porn videos, attending night clubs and ever had sex for the exchange of money. Male respondents were 4.1 times to ever had watch porno videos compared to female respondents (AOR = 4.1, CI = 2.88 -5.75). However, female respondents were almost 3.7 times to practice sexual intercourse for the exchange money compared to male respondents (AOR = 3.7, CI = 1.04 -13.2) (Table 4). Furthermore, more males were night club attendants than females (AOR = 2.3, CI = 1.25 -3.43) (Table 5). The proportion of ever had sex did not vary significantly by year of study and religion. Likewise, having multiple sexual partners did not vary significantly by sex, religion and ethncity (Table 4). Proportion of unprotected sex did not vary significantly by age, sex, residence, year of study, ethncity, religion and other explanatory variables. Students who watched porn videos were 1.8 times more likely to had sex compared to non users (AOR = 1.8, CI = 1.19 -2.59). Likewise, respondents who watched porn videos were 2.8 times more likely to had multiple sexual partners compared to those who did not watch porn videos (AOR = 2.8, CI = 1.12 -6.9). Night club attendants were 7 times more likely to had sexual practice (AOR = 7.4, CI = 4.23 -12.92) (Table 4). Similarly, attending night clubs was also the statistically significant associated factor for commencing sex with commercial sex workers (AOR = 4.6, CI = 1.8-11.77) (Table 5). Drinking alcohol regularly (AOR = 1.9, CI = 1.35 -2.83) was also an associated factor for ever had sexual intercourse. The proportion of having multiple sexual partners were more among sometimes alcohol drunkers than non drunkers (AOR =2.8, CI = 1.4 -5.6) (Table 4). For attending night clubs, drinking alcohol irregularly (AOR = 9.5, CI = 5.2 -17.5) and regularly (AOR = 3.3, CI = 1.1 -10.1) were also statistically significant (Table 5). Had multiple sexual partners was also 2.8 times more likely among khat chewers compared to non chewers (AOR = 2.8, CI = 1.4 -5.69). Chewing khat practice also significantly associated factor in engaging sexual intercourse for money (AOR = 8.5, CI = 1.31 -55.5) (Table 4). Furthermore, chewing khat regularly (AOR = 1.98, CI = 1.08 -3.64) and drinking alcohol (AOR = 4.78, CI = 3.17-7.20) were statistically significant associated factors for watching porn videos (Table 5). --- Discussion In this study 36.4% of the students ever had sexual intercourse. This result is comparable to a study conducted in Nigeria (34%) [24]. However, this proportion was higher than findings of BSS-II (9.9%) [23], studies of other universities (26.9% to 34.2%), Ethiopia [4,[14][15][16]] and a study conducted in Indian university (5% for female and 15% for male students) [25]. In contrast, it is the lowest compared to other studies in Africa. For instance, 49% to 59% of ever had sex in College and University students was reported in South Africa [26] and Uganda [27]. The possible explanation for the disparity in the proportion of sexual intercourse among adolescents of different studies could be due to different in traditional cultural back ground, sociodemographic characterstics, as well as difference in knowledge, attitude and practice towards HIV/AIDS. Age at first sexual practice is an important indicator of exposure to the risk of unwanted pregnancy and STIs. The mean age at first sexual practice (18.6 years) for both males and females in this study is comparable to the reports of EDHS (18.2 years) [22], other universities in Ethiopia [14][15][16] and students of Madagascar (18.4 years) [26]. In contrast, the mean age of first sex was a bit higher than findings of Jimma University (17.7 years) [4] and Gomo Gofa (17 years) [28]. Moreover, more than half (58.6%) of sexually active students had first sex during secondary school. This conforms with studies of other Universities in Ethiopia ranged from 58.5% to 75.2% [4,[14][15][16]. This might indicate that early sexual imitation problem is the issue not only at university level, but also at high school and elementary level. Therefore, secondary school students should be targeted with preventive interventions as youth to discourage premature initiation of sexual activity. The result of multiple logistic regression model revealed an age related increased proportion of ever had penile vaginal sex where as age increased the proportion of sexual experience was increased. Respondents aged 20 years and older significantly more likely than those below 20 years to report that they had sexual experience. This is in line with reports from 2011 EDHS [22]. The proportion of ever had multiple sexual partners among those who had sexual intercourse was 42.7%. Similar comparable finding was noted in Bahir Dar city at private college students [29] and in Gonder [30]. However, high rate of multiple sex partners was reported in Wolaita University [31]. In contrast, a study in Haramaya [15] and Jimma University [4] reported lower rate of ever had multiple sexual partners. The difference could be due to difference in sample size, study population and comprehensive university based behavioural change interventions. Engaging in risk behaviours such as Khat chewing, drinking alcohol, attending night clubs and watching porno videos were independently associated with likely hood of ever had sex and having multiple sexual partners. It is in line with study from Slovakia [32] and other universities in Ethiopia [4,[14][15][16]. This could be due to risk perception ability decreases with alcohol and khat consumption as a result students may not be capable of rational judgment and they also may not be able to predict the serious consequence of their action. The frequency of unprotected sexual practice in this study (62%) was comparable with study done in Jimma University (57.6%) [4] and higher education of Cambodia [33]. However, it was higher than study from Medawolabu University (40.4%), Ethiopia [34]. Moreover, the level of consistently use of condom (38%) among sexually active students was lower than other studies, Ethiopia [15,29,34] that documented 48% -81% of consistently condom use. This may be because of dynamicity of adolescent's behaviour, difference in knowledge on risky sexual behaviours, reproductive health issues and skills of condom use. According to this study, 7.4% of the sexually active students had sexual intercourse with commercial sex workers. This is lower than findings of other Universities in Ethiopia [4,31,34] where the rate of sex with commercial sex workers was 13.9% to 24.9%. This difference might be difference in awareness about mode of transmission and risk sexual behaviours among students in different Universities. Although attending night clubs was the only risk factor for engaging in sexual intercourse with commercial sex workers, Bahir Dar University has been started regulation mechanism that might limits the students from attending night clubs. The rules prevent students not to stay out of the campus during the night time. In this study, the occurrence of exchanging sex for the sake of money was 4%. It is comparable with the cumulative proportion of other Universities of Ethiopia (4.4%) [4,14,15]. In contrast, it is lower than other study in Bahir Dar city [35] private college students and Addis Ababa where exchange sex among adolescents was 20.6% [36] and among university students was 14.5% [37]. Exchanging sex for money was significantly practiced in female than males. In many societies young women have sexual relationship with men who are considerably older than them. This practice can contribute to the spread of HIV and other STIs because older men are more likely to have been exposed for those diseases. In this study, 21.5% of sexually active respondents had sex with older individuals. Similarly, according to EDHS study, over all 21% of women age 15-19 who had sexual intercourse had sex practice with a man ten or more years older than them and very few young men, <unk>1% had sex with older women [22]. The proportion of watching porn videos in this study (65.4%) is comparable with other finding in Ethiopia (47.2%) [30]. However, our finding was significantly higher than studies done at Medawolabu (15.6%) [34] and Jimma Universities (32.4%) [4]. The highest proportion of watching porn videos detected among males and those whose age > 24 years old respondents. This might be associated with existence of sub cultural difference. In this study, the proportion of attending night clubs is comparable with study in Bahir Dar city private college [29] and Jimma university students [4]. Male respondents were 2.2 times to attend night clubs than females. This might be associated with males feel more freedom and comfort to attend night clubs than females because of local cultural influence. Ethnical difference was also significantly associated with attending night clubs (Table 5). This might be associated with sub cultural difference and influence of the values and norms of the local community. The major limitation of this study was the nature of cross sectional study which may not explain the temporal relationship between the outcome variable and some explanatory variables. The study topic by itself assesses personnel and sensitive issues related to sexuality which might have caused social desirability bias. Thus, the finding of this study should be interpreted with these limitations. --- Conclusions The study revealed a more comprehensive understanding of the sexual behaviours of Bahir Dar University Key: COR: Crude odds ratio, AOR: adjusted odds ratio, CI: Confidence interval, --, those variables who had p-value of > 0.2 in the bivariate analysis, NA: Not applicable, 1 : Reference category, **Significant association. students. Risky sexual behaviours such as early age sex, having multiple sexual partners, unprotected sex, and sex with commercial sex workers are significantly practiced among students in Bahir Dar University. Substance use, attending night clubs and watching porno video were predictor factors for the existence of different sexual behaviours. Therefore, preventive intervention programmes should be strengthened, effectively implemented and monitored both in the earlier school and at the university level. --- Competing interests The authors declare that they have no competing interests. Authors' contributions WM Conceived and designed the study, involved in data collection, performed statistical analysis, drafted and finalized the manuscript for publication. BA Conceived and designed the study, involved in data collection and analysis, critically revised the manuscript. MY Participated in reviewing the proposal, critically revised the manuscript. All authors read and approved the final manuscript.

Background: Sexual behaviour is the core of sexuality matters in adolescents and youths. Their modest or dynamic behaviour vulnerable them to risky sexual behaviours. In Ethiopia, there is scarcity of multicentered representative data on sexual behaviours in students to have a national picture at higher education. This study therefore conducted to assess sexual behaviours and associated factors at

Introduction Tujia family is one of the 55 minority families in China. Tujia family had severe gender inequality in the past time. Women in ancient times had to obey the arrangement of their parents arrange in their lives. They had no power to refuse it. Crying Marriage is one kind of behavior that brides sing special songs with a crying tone during their weddings [1]. Tujia women use it to express their unwillingness to let loved ones go, anger, and helplessness against fate. This ritual might be the only chance for Tujia women to challenge their fate. Researchers have studied Crying Marriage's development and formation [2][3][4]. Besides, almost all researchers in this area acknowledge that Crying Marriage helped (or, at least, was planning to help) Tujia women gain their marriage rights. However, this paper here provides a different point of view on the role that Crying Marriage played in Tujia culture [5]. This study developed two concepts: Active Change and Passive Change, to explain this process. Nowadays, the techniques of Crying Marriage are disappearing since people seldomly apply this ritual to their marriage. The local governments are now advocating masters of crying marriage to teach young Tujia women to protect this special ritual. Crying Marriage is not in a good position now, and few people are still familiar with this skill. This study compared Crying Marriage with Hmong "Jali" and concluded that the disappearance of minority cultures is a result of people's preference for mainstream culture and neglect of minority cultures. Of course, Ms. Yan, the national intangible cultural heritage heir of Crying Marriage, mentioned that the local government is now actively working with all of the intangible cultural heritage heirs to teach young people the unique minority culture, hoping minority culture can be inherited. --- The formation of crying marriage Regarding the origin of Crying Marriage, there are different theories among researchers. Prof. Gu thinks, that during the Bureaucratization of Native Officers (A political action that was implemented during Ming and Qing dynasties [6]. The empowers abolished local officials and dispatched new officials from the Capital to govern local people), and Tujia culture received enormous cultural impact. The women's social status decreased significantly, causing the appearance of Crying Marriage. Before the Bureaucratization of Native Officers (BNO), Tujia women had the right to fall in love freely before marriage, and Tujia young people often started their relationships by singing "mountain songs" [7]. It can be said that Tujia relationships were very casual and free before the conversion. In addition, Tujia women had the freedom to divorce and remarry. If a Tujia woman was not satisfied with her spouse, she could choose to end the marriage. It is written in the "Hefeng Zhou Zhi"(Record of the state of Hefeng) that "in the old days, if a Tujia woman fled back from their husbands' families because of poor or verbal quarrels, her father and brother did not admonish her, taking her in for many years, indulging her in what she did, or even reneging on their original promise to her former husband and taking the opportunity to remarry her to another man." It can be seen that in the past, many Tujia women repented their marriages, getting support from their parents. Moreover, Tujia women were not required to have widowhood as Han Chinese women did. If her husband died, the Tujia woman could be married again. This shows that Tujia women had the right to decide on their marriage in the past. After the BNO, Tujia marriages were gradually transformed into Han Chinese parent-arranged marriages, in which parents asked a matchmaker to choose a spouse with suitable status for their children [8]. Tujia women not only lost their right to freely choose their spouses before marriage but also had no possibility of divorce or repentance after marriage. In addition, Tujia women could not ever see their husbands before marriage. Therefore, Tujia women began to cry at their weddings to show their injustice to fate. Thus, the birth of crying marriage reflects the lowering of the social status of Tujia women. According to Prof. Shore, "Ritualization is the human capacity to gradually stabilize our behaviors into 'rituals' through repetition" [9]. The formation of Crying Marriage follows this same pattern. In the beginning, being unable to influence their marriages, Tujia women cry at weddings to express their truest emotions without any techniques, or lyrics. Accordingly, Crying Marriage was in the beginning only an act with practical meaning. As more and more Tujia brides cried at their weddings, Crying in Marriage became a repetitive act. And it gave birth to lyrics, techniques, and other art elements. Eventually, it became symbolic (i.e., the struggle of the Tujia women against their fate) and became a mandatory ritual in all Tujia weddings. --- Analysis of the content of crying marriage --- Lyrics The lyrics of Crying Marriage show the contents that Tujia women cry for marriage. The lyrics of the Crying Marriage contain three main elements: crying for parents, crying for brothers and sistersin-law, and scolding the matchmaker [10]. In these three different elements, we can see the different emotions that Tujia women want to express. --- Crying for parents The following lyrics are a Crying Marriage song about crying for parents. Three bananas are as tall as each other, you are worried, I am worried too, you are worried about money and rice, I am worried about life. Being worried about money and rice in the first thirty years, and being worried about children for the next thirty years, contributed a lot to children but little rewards from children. If I had been born with a good life, I would have served my parents for the rest of my life, but now I have to leave my parents with another surname. The line "If I had been born with a good life" shows that Tujia brides cherish their parents' upbringing and are grateful for their contribution and want to repay them. At the same time, the song also expresses the sadness of the Tujia brides for leaving their parents and the helplessness of their fate. The line " I have to leave parents with another surname " expresses the fate of the Tujia bride. She didn't have any decision rights and had to obey the arrangements. The song and the bride and her family are powerless to change their fate. --- Crying for brothers and sisters-in-law The following lyrics are a Crying Marriage song for brother and sister-in-law". Weeping brother and calling sister-in-law, it's hard to separate flesh and blood. My brother and sister-in-law love me so well, they gave me so much love and consideration. I still haven't a chance to repay them but now ask them to take care parents In this song, the Tujia bride first expresses her reluctance to part from her brother and sister-inlaw and her gratitude to them. At the same time, in the line of ". I still haven't a chance to repay them but now ask them to take care parents ", the Tujia bride feels guilty that she not only has no opportunity to repay her brother and sister-in-law but also needs their help now. --- Scolding the matchmaker The following lyrics are a Crying Marriage song for "scolding the matchmaker". You can say fancy words and make both families smile. You can also say that there are several houses and ten thousand hectares of land. You have convinced my parents and taken your lies to heart, and they all believe in each other, leaving me in the fireplace. The matchmaker lied, and the woman in the world is pitiful. If the matchmaker lied and was not faithful, his second generation will turn into a cow and plow the field. As can be seen from the above lyrics, the 'crying matchmaker' section expresses one of the most specific emotions of the bride: hatred. After the BNO, "parents' arrangement and the words of the matchmaker replaced the choice of free marriage" [11]. Of course, in addition to hating the matchmaker for losing the right to freely choose marriage, Tujia brides also hate the matchmaker for another reason: the matchmaker's deception. As mentioned in the above lyrics, the Tujia bride scolds the matchmaker for " You have convinced my parents and taken your lies to heart ". It can be seen that matchmakers go out of their way to deceive the woman's family in some cases to promote a couple. It is only when the woman is finally married that she realizes she has been deceived, but by this time it is too late to regret it. --- Skills of Crying Marriage The lyrics of Crying Marriage songs are often seven words in each sentence. The advantage of this phrase type is that it "read strongly, clearly, and straightly" [9]. Tujia brides have different ways to express their emotions for different content. For example, for sentimental content, the bride will prolong her voice when she cries. For scolding the matchmaker and emotional parts, the bride will speed up her speech and make the tone more intense. As there are many different elements to the Crying Marriage songs, their techniques are also variable. The author of this paper has not studied the techniques of Crying Marriage songs in depth, so he will not discuss them in greater depth here. --- Discussions When the formation and skills of the Crying Marriage songs are combined, a very shocking phenomenon can be found: Crying Marriage did not help Tujia women achieve a higher social status. On the contrary, in addition to historically reflecting the low status of Tujia women, Crying Marriage has further made the social status of Tujia women even direr. It is easy to see that the Crying Marriage song has become a very well-developed and complex ritual. At the same time, in the process of forming the ritual, it has been given another meaning: the evaluation of women, which is the reason that Crying Marriage has lowered the social status of women. According to Wang, "In the old days, Tujia girls had to learn how to 'cry for marriage' at the age of twelve or thirteen. Whether they cried sadly or emotionally, was often a judgment of the girl's natural wisdom" [12]. The formation of the Tujia Crying Marriage Song is itself a reflection of the declining status of Tujia women in society. The standard of the form reflects the further decline in the social status of Tujia women. As the Crying Marriage ceremony developed, in addition to the original general criteria, such as singing ability and strength of performance, more subtle criteria were developed for Crying Marriage ceremony. For example, in addition to testing the bride's singing ability, the Crying Marriage songs also test if the bride has free expression in it [13]. Such multiple judgments diverted people's attention from sympathizing with women to judging the bride's performance. Such kind of change had already been the original purpose of Crying Marriage. As the skill of Crying for Marriage became one standard to judge Tujia women, people began to train Tujia brides how to cry for marriage in a more mean-spirited manner. Growing up, Tujia women would be subjected to more pressure as a result. For example, from an early age, Tujia women were expected to learn the skills of Crying Marriage and were ridiculed by others if they would not perform well. More importantly, the purpose of the Crying Marriage ceremony began to be forgotten, and it was seen as a routine event and standard by which Tujia women were evaluated. Worst of all, even the Tujia women themselves began to lose sight of the meaning of the Crying Marriage ceremony. In their eyes, crying for marriage is just a task for their elders, an examination and a tool to help them reap praise, rather than a way to help them cry out against injustice. If we relate this to modern times, we can consider the Crying Wedding as the SAT. While the original purpose of the SAT was to give students the ability to better understand texts, most test takers do not consider this and instead pursue many of the techniques used to do the questions simply for the sake of a higher score. Why did the Crying Marriage change its initial intentions during its development? Two reasons are proposed here: Active Change and Passive Change. Firstly, Active Change means that the purpose of the Crying Marriage ceremony was changed by human initiative. For example, to rule people better and remove factors that would lead to social instability, the rulers of feudal dynasties might ask officials from all over the country to artificially change the purpose of those local rituals. One purpose is that to reduce female rebellion in society, government officials would join forces with the more influential and less radical women of the Tujia family and work together to establish various rules for the Crying Marriage songs, such as the content of the Crying Marriage songs, the rhythm, etc. In this way, the attention can be diverted from helping women to gain their right to enjoy the songs, thus maintaining social stability. Passive Change, on the other hand, means the purposes of Crying Marriage changed naturally without any artificial interference. For example, the Tujia women naturally developed different singing styles and content, causing attention diversion Although the results of both types of change are the same, the influences on human society were different. If it is an Active Change, then the change of the meaning of the Crying Marriage ritual can only be described as a special event, for in different societies the rulers would not necessarily interfere with the rituals. However, if it is a Passive Change, then the change in the meaning of the Crying Marriage would be a general order in human societies: it would suggest that humans perhaps, unlike animals, change the initial purpose of rituals as they were developing. Not only just in the Tujia family, but also all peoples, all groups and all races in the world proceeded in such a process. This is perhaps what makes human rituals different from animal rituals. The above statement is only a hypothesis, and there needs more evidence. In the future researchers can prove (or disprove) this hypothesis by studying more ritualistic processes. --- Current situation of crying marriage Nowadays, the Crying Marriage has almost disappeared from Tujia weddings, and there are only a few people who still master the technique. Most scholars believe that the reason for the disappearance of the Crying Marriage is that after the founding of New China, Tujia women gained the right to be married independently and with freedom, causing the Crying Marriage ceremony meaningless. However, It is believed that the real reason for the disappearance of Crying Marriage is that the Tujia people no longer value their minority culture but prefer to integrate into the mainstream culture-Han culture. Based on my hypothesis of Passive Change above, Crying Marriage no longer serves the function of giving a voice to Tujia women. Therefore, Crying Marriage has lost its connection to the marital autonomy of Tujia women. The gain or loss of marital autonomy also, cannot affect the existence of Crying Marriage. Therefore, we can conclude that the real reason for the disappearance of Crying Marriage is the overall decline of Tujia culture. Here, we can draw an analogy with the "Jali" culture of the Hmong people. The Hmong "Jali" culture is like a code of social governance, covering all aspects of people's lives. But nowadays, "Jali" is also in a crisis of transmission [2]. Has "Jali" also lost its meaning? The answer is no. The "Jali" is still a well-established system of social governance, and there are no external factors influencing the "Jali". Then why does "Jali" still fall into the succession crisis? I believe that the reason for the disappearance of Jali is the same as that for the disappearance of Crying Marriage: people tend to integrate into the mainstream culture and therefore start to disregard minority cultures. Since the inheritance crisis occurred both with external factors (Tujia women were given the right to marry) and without external factors (Jali was not disturbed by any external factors), I believe that the minority culture is fading because of people's desire for the mainstream culture and disregard toward minority cultures. According to Xie and Chen, the current situation of the Crying Marriage faces three main crises: the crisis of the inheritors, the crisis of the cultural field, and the lack of overall planning and coordination [4,8,14]. In my interview with Ms. Yan Shuihua, the heir to the national intangible cultural heritage of the Crying Marriage, Mrs. Yan also mentioned the difficulty of passing down the song. According to Mrs. Yan, although she holds Crying Marriage classes in various places in western Hunan every year, very few people are willing to learn this skill. Of course, the government is now actively working with intangible cultural heirs like Mrs. Yan to organize more activities, hoping to inspire people's love for traditional cultures. --- Conclusion The Crying Marriage song has become a very well-developed and complex ritual. Although the Crying Marriage may have lost its meaning now, it is a record of Tujia culture. People may not have to learn such cultures as mathematics and physics, but they should respect and pay attention to minority cultures. By helping to preserve minority cultures, such studies are also helping the preservation the diversity of human cultures.

Crying Marriage is a special ritual of the Tujia family in the west of Hunan province, China. The reason why the Crying Marriage appeared so is that Tujia women lost their rights to marriage. The emperors of the Ming and Qing dynasty abolished local governments and dispatched officials from the capital to govern local people. Then, local people in different areas of China started to adapt the traditions of Han culture (the mainstream culture in China). In this case, since Han culture advocated arranged marriage, Tujia parents also started to arrange their daughters' marriages. Tujia women lost the right to marry so they started crying during their marriages, and then this behavior developed into a ritual. Also, during the development of Crying Marriage, more and more elements appeared, such as lyrics and skills. Although it seems like the purpose of Crying Marriage is to help Tujia women gain their rights, it backfired. On the contrary, Crying Marriage diverted people's attention from women's rights to appreciate this ritual. This study developed two concepts, Active Change, and Passive Change to explain this process.

Introduction One of the most common problems that leads to arguments in the community is bullying. According to Sullivan (2004), bullying is a series of deceptive, damaging, and aggressive behaviors performed by certain people with great authority against others who are attempting to stand up for their rights. Students who have special education needs or difficulties with learning are in risk of being excluded or bullied because of their disabilities. All of the features of bullying are present in the novel Fish in a Tree. The story is about a middle school girl named Ally who is good at math and art but cannot read because she has dyslexia. Ally has some difficulties in learning, so she does her best to avoid writing and reading assignments at school. Fish in a Tree has been first published on the 5th of February 2015. It is argued that this novel manifests bullying. Thus, the current study aims to make a contribution to the fields of linguistics and critical studies by specifying the critical stylistic tools employed to convey the concept of bullying in the analyzed data, and uncovering the underlying ideology embedded in the bullies' speech. --- Theoretical Framework --- Critical Stylistics Stylistic studies are quite similar to practical criticism in that it thoroughly examines the text and analyze its main linguistic forms for the purpose of interpretation (Jaafar, 2014).The study of critical stylistics has lately developed and has proven useful in providing discourse ideational meaning (Khalil, 2020). In order to bridge the gap between critical linguistics and stylistics, Jeffries (2010) developed the analytical area of critical stylistics (henceforth CS). Through the formal linguistic level of the text, CS tends to deliver extensive analytical tools to uncover the hidden ideology and its effects on the reader. The aesthetic decisions text creators may have ideological implications (Jeffries, 2010). The term "critical" has a very different meaning in critical discourse analysis (henceforth CDA) than it does in CS; the former suggests a method of identifying ideology in texts, whether readers agree with it or not, while the latter has a particular socialist (Marxist) view of language analysis (Jeffries, 2014, p.7). CS refers to stylistic products that study the ways in which language reflects social meanings. Critical linguistics along with critical discourse analysis paved the way for the emergence of CS forms of study and analysis. More significantly, CS is concerned with revealing underlying ideology in texts through investigating the set of tools that were used to convey any ideology (Jeffries, 2014). Ten tools of analysis are proposed to examine the worldview as portrayed by the text producer. (Jeffries, 2010). As a result, Jeffries (2010) proposed the CS model as a method of analysis that used CDA and stylistics tools to create a model that is capable of analyzing ideological attitudes inside the texts (Jeffries, 2010). The following is a description of the analytical tools of CS as presented in Jeffries' (2010): --- Naming and Describing Naming highlights the different nouns that might be used to refer to the same thing. It may be done directly by selecting nouns from the available alternatives. --- Representing Actions/Events/States Jeffries (2010) uses this tool to show how the speaker or writer describes the event in terms of acts, events, and states. It is concerned with the semantic function of the noun phrase in relation to the verbal elements. It is concerned with how the world is constructed in the texts in terms of both opposition and equation. --- Equating and Contrasting --- Exemplifying and Enumerating The use of exemplification or enumeration in a given text is based on pragmatic inference. In a certain situation, it is used to determine which is more relevant than the other. Because there are no linguistic distinctions between them. --- Prioritizing The syntactic possibilities of prioritizing one piece of information over another depend on the fact that when structuring a sentence, the crucial information is placed at the beginning as in fronting through the transformational process, and in other structures, the emphasizing information is placed at the end. --- Implying and Assuming This tool deals primarily with pragmatics since the latter is concerned with what is implicit in a language. --- Negating It is used to discuss conceptual practice as opposed to the verb in the negative. It helps the speaker in creating an imaginary version of reality. --- Hypothesizing Modality can be used to manifest the hypothetical reality in the text. Jeffries thinks that modality is ideational based on the conceptual significance that it possesses (Jeffries, 2016). --- Presenting Others' Speech and Thought This tool supplied the words and thoughts of others through direct and indirect speech according to the textual function (Jeffries, 2016). --- Representing Time, Space and Society It shows the text's time, place, person, and context through linguistic realization. The text's use of deixis makes textual ideology more sensitive (Jeffries, 2016). --- Ideology Ideologies may be traced back and extracted, through the formal aspects of language, where the writers' choices reflect the worldview they build in order to affect their receivers (Khalil and Sahan, 2022). The term "ideology" originally used in English to describe the science of ideas. Nowadays, it is most often used to refer to "a systematic body of concepts," especially those that are associated with a specific group or political party (Olaluwoye, 2015, p. 88 ). All works, whether written consciously or not, have an ideological influence. CS offers analytical techniques that let the analyst reveal hidden textual meaning. Comparing CS to CDA, CS has mostly succeeded in offering a more comprehensive and logical framework for an analytical tool (Olaluwoye, 2015). Abrams and Harpham (2011) define ideology as "the beliefs, values, and ways of thinking and feeling through which human beings perceive, and by recourse to which they explain, what they take to be reality" (p.204). Jeffries and Walker (2012) say that "ideology is often recognizable through textual analysis," but Fairclough (1995) says that ideology can't be "read off" a text. As stated by Jeffries (2010), ideology is a conceptual framework that is created, conveyed, reproduced, and contested via the use of language. It is important to emphasize that no discourse is free of ideas and, thus, ideology. As a result, it is possible to maintain that ideologies are conveyed through language and are expressed either explicitly or implicitly (Ibrahim & Hussein, 2018). --- School Discourse Discourses can be regarded as knowledge combinations and their application in practice through power. Discourses in the context of bullying are bodies of knowledge that construct bullying as a cultural object. They specify how it should be managed in practice and how it should be understood. They also emphasize how people are influenced by knowledge and power and how they are situated concerning others (Kendall & Wickham, 2003). Concerning bullying in school discourses, numerous researchers contend those students<unk> views of bullying and its underlying reasons can be connected to their roles and responsibilities within the school discourse (Fretwell, 2015). Many studies in several fields have highlighted the importance of the relationships kids experience at school on their beliefs, attitudes, and behaviors (Wubbels et al., 2015). According to Eliot et al., (2010), teacherstudent and student-student relations are definitely the most important relationships in the school discourse. The relationships between the relational climate and bullying at school are more significant in this study. In general, a negative social climate in school has been linked to a greater number of bullying behaviors (Espelage & Swearer, 2010). Negative relationships between students could be an important risk factor for victimisation. According to earlier research, victims typically report having weak peer connections that are marked by low levels of friendship, support, and reciprocity (Perren & Alasker, 2006). --- Students who are separated from significant individuals (such as teachers, faculty, administration, and other students) should behave more cooperatively. This should also apply to how students view their schools; for example, they may be less likely to follow the rules if they believe that their schools are unfriendly, unfair, and unsupportive. In an environment that is neither encouraging nor providing care, picking on and bullying other students ought to be more common. In fact, studies have shown students who attend schools with high conflict levels and lower perceptions of supportive environments are more likely to engage in bullying (Nansel et. al., 2001). As a result, bullying will be regarded as occurring less frequently if the school atmosphere becomes more supportive. Teachers play an important role in creating a supportive environment by engaging students, forming relationships, controlling the classroom, serving as positive role models for pro-social behaviours, and enforcing school rules (Di Stasio et al., 2016). Other than students themselves, teachers are a school's most important resource against victimisation and bullying (Rodkin & Hodges, 2003). Teachers determine the general tone of the classroom. According to Doumen, et al., (2011), aggressive behaviours are less common if students are more engaged in class because teachers are able to build strong relationships with students who can be difficult to educate and exhibit behaviour problems. The current study is concerned with analyzing some extracts that reflect the concept of bullying in the novel. The context within these traits is concerned with school discourse, that is the characters are school students and that bullying takes place in school atmosphere. --- Previous Studies Bullying occurs at all ages, beginning at the age of three. It may take various forms, including being shoved in the school corridor, being called names, being forced to give up lunch money, being ostracized from a group, being exposed to physical assaults on the bus, and being threatened with text messages (Perdew, 2015). A bully is often portrayed as a larger, angry child who is harsh to those who are weaker. Bullying becomes significantly more complicated when incidents, bullies, victims, and bystanders are explored in deeper detail. (Perdew, 2015). Bullies use verbal and nonverbal language to show their aggressiveness to their victims in both overt and covert ways throughout the bullying process (Tracy et al., 2005). Mocking, name-calling, and gossiping are all forms of verbal bullying. Nonverbal bullying manifests itself in two ways: physically and relationally. The physical can be in the form of beating, kicking, pushing, shoving, or shutting someone inside (Wang, Iannotti, & Luk, 2012) a direct bullying activity. Bullying, however, can be indirect. Spreading rumors about someone or removing individuals from events, for example, are indirect acts of bullying. Studies prove that girls are more likely to participate in indirect bullying, while boys are more likely to engage in direct bullying (Ockerman et al., 2014). --- The Analytical Part 3.1 Methodology of the Study Jeffries ( 2010) model is adopted to analyze the data being examined. In order to identify the ideology underlying spoken utterances, Jeffries provides a thorough and exhaustive typology of CS tools. (Jeffries, 2010). --- Data Analysis The current section presents the analysis of the data Fish in a Tree (2015) within the framework of Jeffries' (2010) critical stylistic tools. --- Extract 1 As soon as my mom is gone, Shay asks, "So, Ally?" I look over. "Why would you give Mrs. Hall that card? That's, like, really mean." Since there is no good answer to give, I stare at the page in my book. I'll ignore them. I've taken their teasing before. --- Jessica laughs. "Has your mother always been a waitress?" "No," I blurt out. "She used to be an astronaut." They break into laughter and, over near the kitchen, my mom smiles. --- She thinks I'm bonding with them. "My father," Jessica begins, "owns his own flower business, and he says_" Shay interrupts. "Ally, maybe you can be a waitress when you grow up. But can you read the flavors of ice cream for me? I'm having trouble." She points up at the slow-turning cube hanging from the ceiling that lists the flavors on each side. The movement makes it even harder to read. --- I feel my face get hot. Oh no. Do they know I can't read? (Fish in a Tree 2015. p.24) --- Context of Bullying Act The events described in this extract take place at Ally mother's restaurant, A.C. Petersen Farms, where she works as a waitress. Ally walks to her mother's workplace telling her mother about the event that has occurred at Mrs. Hall's baby shower. Mrs. Hall is Ally's teacher. At the beginning of the story, she is expecting a child and will soon begin maternity leave. At that very moment, Ally recognizes voices coming through the glass doors; it is Shay and Jessica, the most known bullies in the class. --- Analysis Shay, the most popular class bully, and her closest friend Jessica are directly and emotionally bullying Ally. Shay and Jessica's words, which reveal their ideology of how to taunt Ally and treat her with contempt in a painful way, serve as an example of every bullying act shown in this extract. Different tools are used in this extract starting with the first statement "Why would you give Mrs. Hall that card? That's, like, really mean." The concept of bullying is constructed through a variety of tools here. Representing Actions, Events, and States, Equating and Contrasting, Implying and Assuming, Hypothesizing and Representing Time, Space and Society. For the Representing Actions, Events, States tool, by using the verb "give" Shay uses the Material Action Process to convey her ideology. The use of the relational process is denoted by the intense verb "is". Ally's inability to read makes her act in an inappropriate way by accident. Equating is a powerful tool because it allows individuals to make sense of their surroundings via the use of the equivalent. This event illustrates the societal repercussions of Ally's dyslexia. Metaphorical equivalence is demonstrated in this sentence through the use of the simile "like". Moving to the tool of Implying and Assuming, Shay's statement conveys an existential presupposition that is manifested through using "that card" which implies the presence of a mutual notion that causes Ally to respond in a disoriented manner. Hypothesizing process is triggered through the modal adverb "really" as epistemic modality indicating Shay<unk>s certainty that Ally is not an intelligent person. Representing Time, Place, and Society, the last tool in the CS model, demonstrates how the world is shown. Shay refers to Ally with the personal pronoun "you" in this sentence as a person deixis. The demonstrative "that "is always referring to Ally's stupid behavior. This demonstrates that Shay intentionally chooses this pronoun to address everyone. In addition, "Mrs. Hall" presents the social title. Ally's behavior at Mrs. Hall's baby shower illustrates how her dyslexia prevents her from following the social norms properly such as presenting suitable cards at parties, which in turn makes everyone to be even more confused by her behavior. To put it another way, Ally's inability to read makes her seem dumb and, in this instance, like a mean person trying to get attention, despite the fact that her internal thoughts makes it clear that she really wanted to do something kind for Mrs. Hall. Another statement is used by Jessica "Has your mother always been a waitress?", Jessica employs a number of tools in her statement to demonstrate her ideology of bullying through belittling and humiliating Ally's mother. She looks up to Shay as a role model and aims to be just like her in each and every way. For the Naming and Describing tool, the word "waitress " as a choice of noun is used to refer to Ally's mother in a teasing way. Moving on to the Assuming and Implying tool, Jessica's utterance carries an existential presupposition of "your mother" referring to Ally's mother in a taunting manner. Jessica's insult about Ally's mother demonstrates that what Shay and her best friend Jessica prioritizes most is money, as being a waitress is traditionally a job that pays poorly. In addition, the process of hypothesizing is revealed by the use of the modal adverb "always" which indicates the epistemic modality. Jessica emphasizes her opinion that the job of Ally's mother is an unpleasant one. Some Other CS tools are integrated to show how Shay is acting in a bullying behavior in the following statements "Ally, maybe you can be a waitress when you grow up. But can you read the flavors of ice cream for me?" I'm having trouble. The first tool Naming and Describing is used by Shay when she changes the verb "flavor" into a noun "the flavors" just to describe it as a process. Jessica and Shay find Ally's mother works as a waitress absurd and laughable. Ally could work as a waiter, according to Shay, if she could read the ice cream flavor labels. Later, Ally discovers that her classmates are aware of her inability to read. With the tool Representing Actions, Events, and States, the conceptual meaning under investigation is shown according to the verb phrase. The verb "be" is an act of intensive relational process. The verbs "grow up" "read" indicate the material action process. While the possessive relation is realized through the verb "having". The tool of Prioritizing is also used by Shay to convey her ideology of bullying. She uses the subordinator "when" to emphasize the main clause "you can be a waitress''. For Equating and Contrasting tool, Contrasting is found through the conjunction "but". Shay expresses her ideology by making fun of Ally and telling her she cannot be anything, not even a waitress. In other words, Ally's inability to read makes her seem stupid and, in this situation, like a mean person looking for attention and an easy target to be bullied. The process of Hypothesizing is revealed via the epistemic modality verb "can"; Shay's idea that she is certain that Ally is unable to read is conveyed multiple times throughout the text. Concerning the tool of Representing Time, Space and Society, Shay makes many references to Ally by using the pronoun "you" as a person deixis. According to the findings of the analyses, Bullying is an ideology that is realized by mocking, taunting, and humiliating others. --- Extract 2 I hear, "Hey, Ally!" It's Shay. She is standing with Jessica and a few others. "Yeah?" I ask. --- "Do you want to sit with us for lunch?" Of course I don't want to sit with them. But I am getting tired of sitting alone. And having everyone else see me sit alone. --- Jessica points at Albert and they start laughing... Hey, Albert," she calls, "is that supposed to be a fashion statement?"... Shay hits me on the side of the arm and points down at his feet. The backs of his sneakers have been cut out. --- Shay calls him over and he comes. I don't know why everyone does what she says. Even me. Today, anyway. "What's the matter?" she asks him. "Don't you have any money for shoes?" --- Context of Bullying Act After lunch, Shay presents an invitation to Ally to join her and her friends at one table. Ally is skeptical about joining them, but she does so because she has a strong desire to be considered normal and to earn the respect of individuals like Shay. Albert, one of Ally's closest friends, is pointed out by Jessica at the same moment as everyone begins to laugh. --- Analysis For Ally and Albert, there is not any place on earth that is more terrifying than a school cafeteria. In this extract, both Ally and Albert faces a direct emotional bullying from Shay and Jessica. In the following statement "Do you want to sit with us for lunch?" again, this shows how Ally's learning disability isolates her from other students in her class. A number of tools are used together in these utterance: Naming and Describing, Representing Actions, Events, and States, Hypothesizing, and Representing Time, Space and Society. For Naming and Describing, Shay utilizes the term "lunch" that is pre-modified by the preposition "for" to show her ideology through sarcasm even at lunch, Ally is neglected and isolated since nobody likes to sit with her. Going on to the next tool of Representing Actions, Events, States tool, a material Action Intentional process is found through the verb "sit". Shay's invitation demonstrates that Ally's loneliness makes her open to Shay's bullying, even though it might seem that her request is innocent. The process of Hypothesizing can be identified via the lexical word "want" which functions as an epistemic modality. Here, Shay is certain that Ally will accept her invitation since she is ignored by others. Therefore, Ally examines her seat to ensure that it has not been booby-trapped. This is because Ally has seen that both Shay and Jessica are smiling in a flirty manner. The tool Representing Time, Space and Society is also used to reveal Shay<unk>s ideology of belongingness by using the person deixis "us". This is accomplished by demonstrating that Shay and the other individuals are a group of friends, however Ally is not a member of this group. After making fun of Ally, Shay and Jessica come over to Albert and make fun of him for being poor. They look at his slippers and say "is that supposed to be a fashion statement?". The ideology of bullying that Shay embodies is conveyed by her use of the expression "a fashion statement" as a choice of the noun that would represent the tool of Naming and Describing. Shay is making fun of the way Albert is dressed since he is wearing his proper uniform, which consists of pants and a t-shirt with the Flint logo on it. Through the tool of Representing Actions, Events, States, Shay highlights her ideology by taunting Ally through using the relational process verb " be" asking Albert if that what he wears is new or unusual and is meant to draw attention. As for Representing, Space, Time, Society in the same utterance, she utilizes the time deictic "that" as a demonstrative referring to Albert<unk>s illuniform. It is clear that bullying is embodied in Shay<unk>s character. She continues mocking Albert and ask him sarcastically "Don't you have any money for shoes?",. While Ally's class knows that Albert is exceptionally intelligent; nonetheless, they often find his fussy personality and his emphasis on certainty to be annoying. Shay makes fun of Albert not just for this, but also for the fact that his family is poor, which can often be seen in the clothing that Albert wears. A number of tools work together in Shay<unk>s utterance. As for the first tool Naming and Describing, it is realized through Shay<unk>s choice of nouns "money" and "shoes". Teasing Albert about his shoes reveals that Shay puts a significant amount of importance on a person's financial situation, which demonstrates that she is small-minded and has just one view of what success is. --- Moving on to the Representing Actions/Events/States tool, Shay expresses her ideology via the possessive relational process through the word "have". While Negation is found throughout the syntactic negation "Don't". Representing, Space, Time, Society tool is also used. Shay makes use of the person deixis "you". By employing this pronoun, Shay is insulting Albert and his family for their poverty. In this extract, the ideology of bullying is realized through insulting, taunting, and social isolation acts. --- Extract 3 --- Context of Bullying Act This extract takes place during the holiday concert backstage where Shay makes fun of Albert<unk>s ill-fitting clothes as usual. However, Keisha defends Albert. Keisha is a new student at the school. She is the only black hair girl and is quite confident in her skills and abilities. Because of this, she often challenges Shay and defends others. --- Analysis Shay is almost always commenting on her classmates for being different in some manner. While Albert has been subjected to direct emotional bullying, Keisha is trying to protect Albert and others from being teased, and she is also harassing Shay directly. In the following statement: What's with the pants, Albert?" she says. "Did you get that outfit in the third grade?", Shay's favorite method of bullying is criticizing her classmates' financial circumstances, which most of the time seem to be far worse than her own. Shay combines Naming and Describing, Representing Actions, Events, Implying and Assuming and Representing Time, Space and Society tool in her speech to bully Albert. The prepositions "with" and "in" are used as premodifiers for the two nouns "the pants" and "the third grade," which are two instances of noun modification used in Naming and Describing. In order to reveal her ideology, Shay employs noun modifications such as being sarcastic about Albert, underestimating him, and refusing to consider him as a real person. Representing Actions, Events, and States tool is clearly used to highlight the ideology of bullying through taunting. The material action intentional verb "get" is employed by Shay in her utterance. Shay is certain that there are some individuals who deserve their place at the bottom. Assuming and Implying tool is found through using the demonstrative "that" with the noun phrase "outfit" as existential presupposition; Shay assumes how nasty and unappealing his outfit is. For the last tool, Representing Time, Space and Society, in an arrogant and contempt manner, Shay refers to Albert by using the person deixis "you". As usual, Shay looks at her colleagues with arrogance and condescension Moving to the other utterance "You, on the other hand, are so low, you could play tennis against a curb." When Shay makes fun of Albert's illfitting clothing, Keisha defends Albert. Albert offers the helpful observation that people who are dragging someone else down are already below their victim. Keisha mocks Shay while laughing. Keisha makes use of a variety of tools, including insults directed to Shay, in order to reflect her ideology. She employs different tools like Naming and Describing, Representing Actions, Events, States, Equating and Contrasting, Hypothesizing, and Representing Space, Time and Society. As for the first tool, Naming and Describing in Keisha's speech, it is carried out through the noun "a crub" that is pre-modified by the preposition "against". This is a reflection of Keisha's inner state of mind, as well as her perspective regarding Shay's system and the way she interacts with her classmates. Representing Actions, Events, States appears in Keisha<unk>s utterance when she uses the word "play" as a Material Action verb to convey her ideology regarding Shay that she does not deserve anything more than to be outside playing with the sidewalk. In addition to that, the relational process is found through the relational verb "are". Turning to Equating and contrasting, equivalence is found through intensive relational equivalence in the utterance "You, on the other hand, are so low". Keisha demonstrates to Shay that she is lower than everyone else, and that she is not in any way on a higher level than the rest of them. In the case of Hypothesizing tool, epistemic modality is found through the lexical modality verb "could". Attempting to tell Shay that she would spend much of her life alone and that no one will like her. Finally, Representing Space, Time and Society tool is used through the person deixis "you" twice; both times referring to Shay. In this situation, Keisha shows her self-confidence and demonstrates that she is prepared to support the position of her colleague. In this extract, the ideology of bullying is performed by the acts of mocking and taunting which are revealed via Shay's language, while insulting, refusing and rejecting acts are exposed through Keisha's language. --- Extract 4 As soon as Mr. Daniels steps into the hallway to talk to another teacher, Shay says in her I'mbeing-loud-on-purpose-so-everyone-can-hear-my voice, "So, Jessica. Yesterday, I saw that Ally --- Context of Bullying Act In the extract above, Shay is waiting for Mr. Daniels to enter the hallway before she tells Jessica loudly that yesterday she saw Ally in a rundown car. Mr. Daniel, a new teacher who replaces Mrs. Hall. He is the first person who identifies Ally's dyslexia. --- Analysis In this extract, Ally faces another type of bullying in a direct way when Shay aims to embarrass Ally publicly which is a subtype of social bullying. The tools that are used in this extract are illustrated in the following discussion: Starting with first statement "So, Jessica. --- Yesterday, I saw that Ally riding in this disgusting green-colored car that I can't believe was even allowed on the road. Ally had to pull a rope to even get the windshield wipers to work." the bullying nature of Shay's character is shown in this extract. Her language clearly demonstrates her ideology. Shay's ideology of bullying is shown through humiliating and shaming Ally in front of her peers that is revealed via the utilization of the following CS tools: Naming and Describing, Equating and Contrasting, Implying and Assuming and Representing, Space, Time, and Society. The tool of Naming and Describing is found in the use of the noun modification in the utterance "in this disgusting green-colored car" where the head noun is pre-modified by the preposition "in" and the adjective "disgusting". Shay deliberately used a negative adjective to just be sarcastic towards Ally's status and family. In continuation with the other noun modifications, the head noun "the road" which is pre-modified by the prepositional phrase "on" is used. The practice of choice of noun, which is another practice located under the tool Naming and Describing, can be found in the phrase "a rope". Hence, Shay has decided to focus her discourse on the many processes that have been associated with the concept of bullying. Regarding the tool of Representing Actions, Events, States, many processes are combined in order to generate the concept that is being analyzed. The verbs "saw" and "believe" are forms of mental process, while the verbs "riding," "pull," and "work" are representations of material process. The verbs that are used in the utterances that are discussed above encode Shay's ideology of bullying by embarrassing and humiliating Ally in front of other. Using the tool of Equating and Contrasting, Shay emphasizes her contempt and insults by using two statements: "I saw that Ally riding in this disgusting green-colored car" and "that I can't believe was even allowed on the road." These two statements emphasize Shay<unk>s ideology. For the CS tool Negation, Shay uses "not" which indicates Syntactic Negation. In Negation, the reader is often given the opportunity to explore both the presence and absence of a thing. Shay expresses her ideology of bullying by employing the Hypothesizing tool through using the epistemic modal verb "had". Prioritizing is also used by Shay to emphasize the idea that she is making her speech in public to confront Ally and all of her classmates. She does this by using the subordinator "that" and elevating the main clause. Naming and Describing tool appears once again in the following utterance "Ally? What junkyard did you find that heap in?" To enhance her ideology of bullying, Shay begins with the term "junkyard" which is a location where scrap is gathered before being recycled or thrown. She uses this negative adjective to describe Ally's car. Representing Actions/Events/States tool is found through the verb "find" as an intentional material verb. By using this verb, Shay reveals her ideology concerning bullying. Implying and Assuming is shown by the existential presumption "that heap" which is defined as a collection of objects piled or tossed on top of one another. Waiting until Mr. Daniels finally leaves. Shay's behavior reveals that she places a high level of importance on bringing people down, since she obviously puts a lot of effort and preparation into the way that she achieves this goal. This is more evidence that her popularity and social position are dependent on bullying people in order to make herself seem more powerful. Bullying appears in other statements in this extracts. For example "I mean; what kind of loser would have a car like that? Probably the only thing your mother can afford." Although Ally here attempts to ignore them, she eventually gives in when they point out that this car is probably all what her mother could afford. Shay tries to insult Ally in every way. In this utterance, Naming and Describing is found through the word "loser" is, a noun that is used to insult someone in this speech and is chosen without much deliberation. Shay makes many attempts to belittle Ally and tries to insult her in every way. Naming and Describing is found through the choice of nouns "kind" and "loser" as derogatory term tossed out with little thought. The second tool of CS, Representing Actions, Events, States, which realizes the function of the verb phrase, appears in the verb "mean"; it represents a Mental process to highlight Shay's intent hurt and tease Ally all the time. Relational process is found by the relational verb "have" which describes the sense of attachment that is mixed by the Hypothesizing tool. Epistemic modal "would" shows that Shay is sure that this kind of car is sufficient for a family like Ally's. At last, the verb "afford" identifies the material action process. For Assuming and Implying, Shay's speech conveys an assuming process of existential presupposition via the utterance "the only thing your mother". Here, Shay is making an obvious attempt to mock Ally's mom by mentioning that she drives a cheap car since she works as a waitress in a restaurant. This is more evidence that Shay<unk>s popularity and social position are dependent on bullying others in order to make herself seem more powerful. The ideology of bullying is consistently related to the notion of humiliation, embarras

Language always conveys ideologies that represent an essential aspect of the world we live in. The beliefs and opinions of an individual or community can be organized, interacted with, and negotiated via the use of language. Recent researches have paid attention to bullying as a social issue. They have focused on the psychological aspect of bullying rather than the linguistic one. To bridge this gap, the current study is intended to investigate the ideology of bullying from a critical stylistic perspective. The researchers adopt Jeffries' ( 2010) critical stylistics model to analyze the data which is five extracts taken from Hunt's Fish in a Tree (2015). The analysis demonstrates that the critical stylistic tools contribute significantly to the linguistic formulation of the concept of bullying and account for a significant amount of the meaning of the text under consideration. The study concludes that the ideology of bullying is represented through using most of the stylistic tools but with different bullying acts.

CS, Representing Actions, Events, States, which realizes the function of the verb phrase, appears in the verb "mean"; it represents a Mental process to highlight Shay's intent hurt and tease Ally all the time. Relational process is found by the relational verb "have" which describes the sense of attachment that is mixed by the Hypothesizing tool. Epistemic modal "would" shows that Shay is sure that this kind of car is sufficient for a family like Ally's. At last, the verb "afford" identifies the material action process. For Assuming and Implying, Shay's speech conveys an assuming process of existential presupposition via the utterance "the only thing your mother". Here, Shay is making an obvious attempt to mock Ally's mom by mentioning that she drives a cheap car since she works as a waitress in a restaurant. This is more evidence that Shay<unk>s popularity and social position are dependent on bullying others in order to make herself seem more powerful. The ideology of bullying is consistently related to the notion of humiliation, embarrassment, and belittling, as seen in this extract. --- Extract --- Context of Bullying Act This conversation takes place in Mr. Daniels's class as he is assigning a writing project for the students in which they are required to write about a fictional character who they regard to be a hero. While Oliver lists every superhero in the world one after the other, he never stops talking and never gives anybody the --- Analysis For Shay, bullying in a variety of contexts is not only acceptable but also helpful to her own social position. She is able to keep her position as the dominant student in the class while ensuring that everyone is aware of this fact. This extract clearly shows another kind of direct emotional bullying which is revealed through the following utterances: "We don't need to hear every weird thought in your tiny little brain. We're trying to work.". Shay's ideology of bullying through the acts ridiculing and mocking others are expressed via the utilization of these tools: Naming and Describing, Representing Actions/Events/States Implying and Assuming, and Representing, Space, Time, Society. Starting with Naming and Describing, Shay chooses the derogatory adjective "freak" as a choice of noun to describe Oliver since it is often used in schools and everyone is aware of how much it hurts. To continue with another realization of Naming and Describing tool, the head noun "thought" that is pre-modified by the adjective "weird" as a Noun modification is utilized. Moreover, Shay<unk>s belief that Oliver is a mindless automaton is shown in her use of the noun phrase "tiny little brain" that is premodified by the preposition "in". She indicates her ideology toward Oliver; a man who never stops chattering about anything and everything. The Representing Actions, Events, States demonstrates one use of the mental process verb via the use of the verb "hear" which is combined with the syntactic negation "not". In a harsh tone, Shay tells Oliver that they do not need actually listen to his thoughts. In addition, a Material Action process is found via the use of the verb "work". These utterances demonstrate Shay's bullying ideology. Implying and Assuming tool is accomplished by combining the possessive pronoun "your" with the noun phrase "tiny little brain" as a form of existential presupposition. Here, Shay presupposes that Oliver's current behaviors are signs to bad acts. If Shay does not stop him, Oliver will certainly continue behaving improperly. For Representing Time, Space and Society, Shay uses "we" as a person deixis to refer to herself and her best friend Jessica just to give the sense of power. Oliver has troubles with his selfesteem, and all it takes is a glance of contempt from Jessica for him to shrink. While in the next bullying utterance "If. I. Were. Aquaman. I. Would. Summon. The piranhas. To take you away. You could be their queen.", Oliver refuses to be insulted by Shay therefore he decides to be sarcastic toward her directly. Oliver uses Naming and Describing tool to mock Shay. He uses the noun phrase "The piranhas" which refers to a kind of fish that has the ability to swim, breathe underwater, and talk with sea species. this is an attempt on Oliver's part to convey the feelings he has towards Shay. It is inappropriate to use since it is a negative term that demeans women and should be ignored completely. For the tool Representing Actions, Events, and States, Oliver uses the verbs "summon" and "take" as material action verbs. Oliver's use of these two verbs reveals his ideology of bullying, that could take the form of insulting or being contemptuous. Equating and Contrasting is also used in this utterance. The subject pronoun "you" and the noun phrase "their queen" are found on the opposite side of the intensive relational equivalence "be". As a result of this, Oliver considers Shay to be the queen of piranha, which is a derogatory term for a girl who engages in promiscuous behavior. The noun phrase "their queen" has an existential presupposition, which serves as a trigger for the Assuming and Implying tool. Oliver believes that Shay does not have great morals because of her childish behavior towards her classmates. This leads Oliver to believe that Shay does not have good judgment. The Hypothesizing process appears through the epistemic modality "would" and "could". Another form of modality is represented --- by the use of the modal adverb "away" which indicates boulomaic modality. In this utterance Oliver expresses his confidence and his desires to dismiss Shay. She also attacks classmates for being different or "freaks." After Mr. Daniels takes away Shay's recess for bullying Oliver, Shay becomes very sneaky about her bullying. This makes it harder for teachers to stop, though by that point, Mr. Daniels has already given his other students the abilities and resources that empower them to stand up to Shay themselves. Once more in this extract, Shay's ideology about bullying is linked to the acts of insulting and ridiculing, while Oliver's statements is linked to the act of sarcasm. --- Conclusions After analyzing the extracts from the novel Fish in a Tree, it is obvious that critical stylistic tools are used in the construction of the concept of bullying in order to uncover the ideology hidden in the language of the characters. The ideology of bullying is presented through Shay's character who is the most bully character in the novel. She presents the ideology of bullying through employing different acts of bullying such as insulting, ridiculing, disregarding, social isolation, ostracizing, underestimating, humiliation, and public embarrassment as the analysis of the extracts revealed. According to data analysis, it is clear that bullying is conveyed by using most of the critical stylistic tools. All previously chosen tools are recognized in the analysis which are Naming and Describing; Representing Actions, Events, States; Prioritizing; Negating; Equating and Contrasting; Assuming and Implying; Hypothesizing; and Representing Time, Space and Society.

Language always conveys ideologies that represent an essential aspect of the world we live in. The beliefs and opinions of an individual or community can be organized, interacted with, and negotiated via the use of language. Recent researches have paid attention to bullying as a social issue. They have focused on the psychological aspect of bullying rather than the linguistic one. To bridge this gap, the current study is intended to investigate the ideology of bullying from a critical stylistic perspective. The researchers adopt Jeffries' ( 2010) critical stylistics model to analyze the data which is five extracts taken from Hunt's Fish in a Tree (2015). The analysis demonstrates that the critical stylistic tools contribute significantly to the linguistic formulation of the concept of bullying and account for a significant amount of the meaning of the text under consideration. The study concludes that the ideology of bullying is represented through using most of the stylistic tools but with different bullying acts.

Background An ancient scholar, Aristotle, established the basis of predicate logic, which divides knowledge into the smallest units and expresses it by linking them together (Sung-ho H: Structure and emergence analyses of knowledge network based on the social network analysis (SNA) methods: Focused on chungcheong strategic industries, unpublished) [1]. Recent studies have begun to use social network analysis as a means to analyze the trends of studies and understand the knowledge systems of each field by analyzing previously researched results. Generally, the purpose of research trend analysis in a particular academic field is to comprehend the current state of research by examining the existing results and to present future research directions [2]. Research trend analysis has been conducted for articles published in representative journals in medical education (ME), and its results serve as fundamental measures for securing academic identity [3,4]. Analysis is being conducted from multiple angles to confirm this identity from a holistic perspective, and research methods analyzing the relationship through the application of SNA in research trend analysis are steadily increasing in the social studies field. The study of trends in medical education analyzes the entire academic field or the subject of a particular academic field. There are studies taking quantitative approaches such as those analyzing the frequency of medical training in medical education [4][5][6][7][8]. Other examples include studies that a) focused on the main subjects studied in medical education by analyzing common research topics in medical education from six journals [4], b) analyzed the co-topics occurring frequently in ME articles and the differences among journals' publication of co-topics [9], c) focused on top-cited articles identified by keyword search [10], and d) focused on network analysis of the researchers in medical education [11]. In addition, analysis of unit subjects in specific academic fields, such as an analysis of the trends in research topics including a study on the geographical distribution of researchers whose works have published in major journals of medical education [12] and a study on the social relationships of medical students and the dispersion of their attitudes [13], have been conducted steadily each year. These studies are meaningful in that they analyze the trends of medical education subjects from a macro perspective or study specific research topics from a micro perspective, thus enabling the analysis of the trends in medical education and its knowledge system. However, this method requires the collection and analysis of vast amounts of data, demanding considerable time and manpower for interpretation. In addition, it is highly likely that researchers rely on the knowledge, experience, and insight of experts during analysis [14,15]. In addition, the analysis has to be conducted by sorting the impactful keywords based on frequency [9,11] or citation factors [10] or through keyword analysis by topics [4]. However, such methods are limited in their ability to identify historical changes in the relationships between specific topics. SNA is a commonly accepted method for quantitatively and visually obtaining the overall structures of network connections. As studies analyzing the networks and relational structures of research topics in academic fields emerge, studies that apply methods of network and relationship analysis, such as SNA, are drawing more attention [16]. General methods of analyzing research trends include using co-word analysis on keywords extracted from databases [10,11], co-citation analysis using the citation information of articles [12]. And there have also been studies on topics network analysis [13,[16][17][18]. SNA is an actively utilized method that recognizes and interprets complex phenomena under micro units as an issue of order [17]. Exploring the interactions and qualitative changes in research topics in medical education according to the framework of complex systems theory will provide new answers regarding the knowledge network of medical education. Unlike previous quantitative studies on the issues in medical education, this paper aims to identify the phases of medical education distinguished by changing topics and explore the topics that emerge during the phases. Therefore, the study utilizes SNA to investigate the interaction patterns among the issues in medical education by applying the framework of complex systems theory [18] and realistically contemplating the abstract knowledge network of medical education. --- Methods In order to grasp the features of research trends in the field of medical education, the study extracted social-network keywords connected to terms from the title and abstract of available articles in Medline. Mesh terms were used during the process of retrieving articles from Pubmed, and the keyword extraction was conducted through text analysis. The information used for the analysis in this paper includes the title, abstract, and publication year of the paper. Since MeSH terms are not attached to all of the papers to be analyzed in this study, the authors extracted the keywords using the TextRank algorithm from the text consisting of the title and abstract. The TextRank algorithm is advantageous in that it provides high performance without being influenced by the linguistic characteristics of the text to be analyzed (Mihalcea R, Tarau P: TextRank -bringing order into texts. In: Proceedings of the Conference on Empirical Methods in Natural Language Processing, unpublished). A more detailed analysis was conducted by collecting the articles for analysis. This analysis included 1) category-setting through analysis of keyword similarity, 2) performing content analysis on the keywords, 3) analyzing the resulting network, and 4) conducting a trend analysis. In June 2015, we searched PubMed for articles indexed under the "medical" major topic whose titles or abstracts included the term "medical education." Our query terms included related terms such as "medical learner," "medical teacher," "medical teaching," "medical training," "medical learning," and "medical education." In this stage, two researchers reviewed and evaluated the list of keywords. For all of the papers, the extracted keywords with the use of the TextRank Algorithm underwent a refining process by two researchers. During the refining process, in order to refine the keywords, we looked at the whole list, checked and summarized the thesaurus, exception list, and defined words that needed refinement, and conducted a re-analysis of keywords. For instance, the research team deleted numbers or keywords such as "the", "% +/", "% <unk>", "% ci -0/3", "(99 m) tc" which make it difficult to draw out the meaning of a keyword before data analysis. They also considered singular and plural keywords, such as "cardiac problem" and "cardiac problems," as synonyms. Moreover, abbreviations were normalized by controlling them with a list of synonyms. Then, as the first stage in the data analysis, the team generated a frequency matrix sized 3,030X53 that consisted of the yearly frequency of all the terms and the year of publication of each article. Next, to sort out the terms, the team calculated the weighted value of the terms by applying the Term Frequency-Inverse Document Frequency (TF-IDF) formula used in the field of information search [19]. The weighted value W t,D was calculated using the formula below. W t;D 1<unk>4 normalized tf t; D <unk> <unk> log Y j j y<unk>Y : f t appears in yg j j The tf(t,D) refers to the adjusted value of the sum of the frequencies of t of terms used in data collection using yearly frequency, and N from log<unk> jY j jfy<unk>Y :t appears in ygj <unk> refers to the yearly range 53 <unk>y<unk>Y: t appears in y<unk>. TF-IDF is a weighted value used in text mining, and it indicates how many times a certain word appears in a given document. The higher the value of TF-IDF, the greater its importance; this also means that the word appears often. Therefore, the value multiplies DF (Document Frequency) with IDF (Inverse Document Frequency), a reciprocal number. Since this value increases with the frequency of a specific word and decreases with the number of documents containing the word out of the total number of documents, it filters the words that appear often in most documents [20]. In order to quantitatively calculate the relationship between MeSH terms, the research team calculated the Weighted Jaccard Similarity [20]. That is, the relationship between the terms and t was calculated with the formula below, using the yearly frequency information from the frequency matrix. Distributional Hypothesis [21] is the result of a study showing that when two words are used in the same context, these two words tend to have a similar meaning, and we assumed that there is a higher correlation between the two words if two keywords were used many times in the same year compared to the case where they were not. The science mapping principle dictates that the more related two elements are, the closer to each other they are positioned in a map [22]. This study based on the approach of distribution hypothesis and the science mapping principle for the correlation between words, the frequency value of each word's annual appearance was used. The calculation method used in this study is a Weighted Jaccard similarity that used the appearance frequency of keywords. When using a Weighted Jaccard similarity, if two words are used together with high frequency in multiple years, they return a high similarity value. --- Relatedness(S, T) = Clustering of keywords was calculated using the Markov Cluster(MCL) Algorithm [23], which is widely applied to weight graphs in the computer science field, after constructing a graph with the keyword as the node of the graph and the similarity between the keywords as the weight of the edge between the nodes. The MCL algorithm is a simple yet useful algorithm that is used for sequence data clustering in the biotechnology field which can be expressed as a weight graph. Therefore, it can be understood that the keywords with a high frequency of simultaneous appearance are used in the same context and have a higher correlation than other words in the same year. That is to say, they return a high similarity value. --- Data analysis and interpretation In order to analyze the process of change in research topics in the medical education field, the study used the Frequency Matrix and the Weighted Jaccard Similarity and marked the times at which clear changes occurred, such as when new keywords rapidly emerged or diminished, using yearly similarities as cut-off points. The entire data collection process was separated into five phases based on the emergence of keywords, and each phase was analyzed using SNA. In order to conduct the network analysis, the input file for Gephi, a tool used in network analysis, was generated by calculating the relevance of terms for each phase using the methods mentioned above and representing the values as the relevance between nodes. The size of each node was expressed as the authority score obtained by the HITS (Hypertext Induced Topic Selection) algorithm of Gephi [24]. The authority score enabled the extraction of main research topics by using the mutual information between the nodes that comprised the network. Here, the authority score refers to the frequency of the reception of links [25]. --- Results The study used PubMed articles that were available for electronic search using MeSH terms in October 2015. From 1963, the year of the first publication related to medical education, to 2015, a total of 9,379 articles (with 162,866 keywords) on medical education were published in PubMed, with a slow increase over time and a rapid increase since the 2000s. --- Category-setting through analysis of keyword similarity Figure 1 shows the results of the analysis of keywords by year, arranged in three-year sections. In the graph, points at which similarity begins to increase after decreasing indicate a great increase in change in keywords; these were set as phase cut-off points. On the basis of the similarity analysis by year, phase 1 was set to range from 1963 to 1975; phase 2 from 1976 to 1990; phase 3 from 1991 to 1996; phase 4 from 1997 to 2005; and phase 5 from 2006 to 2015. The next subsection characterizes these phases by keyword (and the keywords by phase). --- Content analysis in the key words Figure 2 shows increases and decreases in the top 20 keywords newly appearing in each phase. Keywords newly emerging as research topics were as follows for each phase: From phase 1 to 2, "Internship and Residency," "Medical Staff, Hospital," and "Psychiatry;" from phase 2 to 3, "Problem-Based Learning," "Program Development," and "Health Care Reform;" from phase 3 to 4, "Internet," "Evidence-Based Medicine," and "Education, Distance;" and from phase 4 to 5, "Young Adult," "Quality Improvement," "General Practice," "Patient Safety," "Cultural Competency," and "Self-Efficacy." --- Analysis of the resulting network To systematically understand research trends and changes in knowledge structure in medical education over time, this study analyzed connections between keywords using social network analysis. Figure 3 shows a schematization of the network resulting from extraction of keywords with high connectivity and high weighted value for each phase. In all, 20 clusters were schematized. Topics in cluster 1, the largest group (comprising 19 nodes), are as follows: "Education, Medical, Graduate," "Questionnaires," "Clinical Competence," and "Internship and Residency." Cluster 2 is made up of eight nodes, under the following topics: "Middle Aged," "Data Collection," "Accreditation," and "Problem-Based Learning." Cluster 3 has seven nodes, under the following topics: "Communication," "Career Choice," and "Computer-Assisted Instruction." Topics in cluster 4 are gathered around "Computer Simulation," "Leadership," and "User-Computer Interface." In cluster 5, "Competency--Based Education" and "Professional Competence" are the topics, and cluster 6 mainly deals with "Adolescents," "Fellowships and Scholarships," and "Interview as Topic." --- Trend-watching: All five phases Figure 4 shows the SNA over all five phases, with detailed topic networks for each phase given in the Additional files 1, 2, 3, 4 and 5: Figures S1-S5. Phase 1 (1963Phase 1 ( -1975) ) showed lower connectedness among research topics compared to other phases, due to the difference in scale of article publication. Central keywords included "Education, Medical, Undergraduate," "Curriculum," "Male," "Female," and "Adult." On the basis of these keywords, a subnetwork emerged, continuing up to phase 5. In phase 2 (1976-1990), connections between central keywords grew tighter, and new keywords appeared, including "Professional Competence," "Attitude of Health Personnel," and "Peer Review." In phase 3 (1991-1996), connections among keywords such as "Clinical Competency," "Educational Measurement," and "Physician-Patient Relations" were enhanced. In phase 4 (1997-2005), the association of keywords with high connectedness became dual, and connections among keywords such as "Data Collection," "Problem-Based Learning," and "Health Knowledge, Attitudes, Practice" were enhanced. In phase 5 (2006-2015), the number and connectedness of keywords increased, and new keywords, such as "Computer-Assisted Instruction," "Personal Staffing and Scheduling," "User-Computer Interface," "Professional Competency," "Accreditation," "Program Evaluation," and "Educational Measurement," appeared. --- Discussion The study realistically contemplated the abstract knowledge network of medical education by identifying the network trends in medical education research topics through the use of SNA and investigating the use patterns in interactions by time. The study contains articles from the year when PubMed made it possible to electronically search for MeSH term in medical education articles, and coincidentally, this is consistent with Norman's suggestion that a new generation of medical education has emerged [25]. The study identified five phases based on the changes in time indicated by clear differences in keyword similarities and identified newly derived keywords and networks in each phase. The clustering was conducted by deriving the keywords with high similarity using the appearance frequency values of the two keywords and constructing a weighted graph based on the similarity between the keywords. This can be observed by clustering the sequences of the main keywords overall. When the trend of the newly emerged keywords from five phases was analyzed, the keywords with the highest increase rates in all the phases, such as "Education," "Medical," "Humans," "Curriculum," "Continuing Medical Education," and "Internship and Residency," were similar to the keywords from a previous study by Lee K. [9]. Such repetition of research topics, as noted in the study by Eva K. W., probably occurs because studies in medical education are mostly observational [26]. In a similar study, Lee K. also analyzed the historical trends in medical publications in the field of medical education [9]. Even though the general trend appears similar, it did not distinguish the semantic unit that grasps the variations in the emergence of new keywords. Therefore, the study is meaningful in that it distinguishes between the phases by analyzing the interactions between medical education keywords using the complex systems framework. --- Fig. 3 Topic clusters in medical education Research in medical education has mostly been dominated by a positivist approach [26], and the emergence of new keywords with time represents the extent of the efforts being made to reflect social needs using the educational paradigm [27]. When the contents of topics that increased in a certain period or had newly emerged were analyzed, the first phase was characterized by important keywords being continuously mentioned in medical education, and new keywords such as "competency" or "accreditation" began to appear in the second phase. This could be due to the fact that the authentication program was formally declared in 1975 in order to improve the quality of medical education [28]. Considering that the top-cited articles in medical education began to contain reviews and research on competency since then, the studies seem to have been accumulated from this time [10]. Keywords that emerged in the third phase, such as "problem-based learning" and "computer communication networks" imply an increased interest in new education methods [4]. Keywords such as "competency-based assessments" and "outcome-based education," which emerged in the fourth phase, represent the extension of research topics during the time period in which medical education became a topic of conversation [28]. Finally, the fifth phase is characterized by the emergence of keywords such as "quality improvement," "patient safety," "cultural competency," and "self-efficacy," which confirms that more research reflecting the trend is being conducted and realistic demands of medical education are being made. This period is also marked by increased interest in medical education and emphasis on the importance of evaluation, and thus, qualitative analysis and program evaluation were among the most important research topics (Fligstein N: Theoretical perspectives in medical education: past experience and future possibilities, unpublished). It appears that interest in quality improvement increased as social requirements for doctors gradually influenced educational institutions [27,29,30]. Therefore, various educational programs should be developed and evaluated with a focus on the effectiveness of medical education [31][32][33][34]. After exploring the keywords used in medical education research using SNA from a macro perspective, the research team analyzed the research trends of each phase by historical flow. When a network is considered to be one ecosystem, it corresponds with the principle of complex systems, and from the perspective of interpreting the flow of the network, the complex systems logic is presented as a new alternative [35]. Recently, there have been a number of discussions on the need to explore the nature of knowledge networks using complex systems theory [17]. The study was able to identify the process of improving the academic field in medical education by analyzing keywords in separate phases. This effort can be considered as a method of knowledge formation clearly distinguished from those used in previous studies. An emergency refers to a disorderly situation that arises as a result of complex network structures and patterns, and the system of such an emergency can be referred to as a complex system [18]. Unlike the analysis of keyword emergence, the flow of the phases studied by SNA is quite similar to the changing trend in human societies or networks [36]. This implies that the research topics in medical education resemble the emergence phenomena, as used in the complex phenomena. In other words, when examining the timely flow of keywords related to medical education, it can be noted that the newly emerged keywords form a network by interacting with each other. This, like the coevolution phenomena presented by complex systems theory, shows a similar phenomenon in which keywords evolve as they interact. As such, it seems like the trend in topics by phases derived through medical education keyword analysis is a part of the change process suggested by complex systems theory. At the same time, a cycle in which new research topics emerge, interact, and evolve should be formed [30,37]. As the research team examined the research trends by phase, the features of each phase could be analyzed on the basis of complex systems theory: the waking phase (1963)(1964)(1965)(1966)(1967)(1968)(1969)(1970)(1971)(1972)(1973)(1974)(1975), the birth phase (1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989)(1990), the growth phase (1991)(1992)(1993)(1994)(1995)(1996), the maturity phase (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005), and the expansion phase (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015). And each name contained one the following meanings. The first period (1963)(1964)(1965)(1966)(1967)(1968)(1969)(1970)(1971)(1972)(1973)(1974)(1975) is when keywords that served as central nodes for all the phases, such as "Education, Medical, Undergraduate" "Curriculum," "Male," "Female," and "Adult," appeared. This period forms the backbone of research in medical education, and shows the networks of basic levels. The second phase (1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989)(1990) is the period of the birth of medical education. The major keywords in the first phase focused on the subjects; however, the second phase is characterized by a focus on the keywords of properties, such as "Professional Competence," "Attitudes of Health Personnel," and "Peer Review." In order for the subjects of medical education research to connect and be studied, it seems like the keywords representing the properties or characteristics should emerge and connect the subjects and foster the research. The third phase (1991)(1992)(1993)(1994)(1995)(1996) was a period of growth for medical education, which is marked by the emergence of keywords in research methodology such as "Educational Measurement," "Evaluation as Topic," and "Questionnaire." It appears that various methodologies have been tried in order to achieve qualitative improvement in subjects and properties. Ultimately, this seems to reflect the purpose of solving various problems in medical education, and it has been confirmed that suggested alternatives influenced and improved the academic field of medical education. The fourth phase (1997-2005) was a period of maturity, when keywords such as "Health Knowledge, Attitudes, and Practice," "Ethics and Medicine," and "Physician-Patient Relations" emerged. These keywords reflect an increasing interest in selecting physician candidates with high morality, with an emphasis on ethical responsibilities in medical education. At the same time, the trend represents the extension of research topics from analysis of general education to quality management [27]. From this perspective, various educational keywords in performance and competency are being connected in this phase. This trend could imply that the influence of general citizens' requirements of physicians could have had effects on the education sector as well. The fifth phase (2006-2015) was a period of expansion, and major keywords such as "Computer Assisted Instruction," "Personal Staffing and Scheduling," "User-Computer Interface," "Professional Competency," "Accreditation," and "Program Evaluation" emerged. Unlike other keywords, medical education keywords have larger network connectivity from the fifth phase, forming true network structures. While the first three phases are marked by the emergence of new keywords, the fourth phase is characterized by network formation. The fifth phase is called the period of expansion because networks are becoming highly concentrated and forming new networks. However, the study has some limitations. First of all, since it is a quantitative study using SNA, it focused on terms related to medical education in Medline without taking into consideration the articles published in medical education journals such as JAMA(Journal of the American Medical Association), BMJ(British Medical Journal), JAMA internal medicine, etc. Thus, compared to the studies conducted by Rotgans JI, Wolf E Hautz et al., and Tutarel O, some articles are not reflected in this study [4,11,12]. Secondly, as in many other studies, the research team could only search for articles published in English. Thirdly, co-word analysis, co-citation analysis, and bibliographic coupling are among the most commonly used content analysis methods in the field of bibliometrics [38]. Co-word analysis used in this study is a method of analyzing a pattern in which a pair of terms (phrases) used in text in a specific field are analyzed at the same time to reveal the knowledge structure of the field. In this paper, the corelation between two words is used by frequency of use of words in common by year using the approach of distribution hypothesis. However, in order to better comply with the context-based distribution hypothesis, a new method is needed to calculate semantic relations between two words in the future. Fourthly, since this is a quantitative study, there is a need for interdisciplinary research focusing on issues in sociology, economics, or ecology. At the same time, future studies could focus on the establishment of new theories from current effectiveness verification studies. Lastly, a great amount of time and manpower was required for data collection, classification, and interpretation, because of which the study could not implement additional keyword analysis within the last one year. This calls for the development of a new research methodology that can readily analyze recent trends through SNA. --- Conclusions As this shows, medical education research has focused not only on medical knowledge and practice (content) but also on research topics related to education theory as a social science (pedagogy) [31,39]. Hence, for the development of medical education, a relevant community of work in related social science fields is also needed, and this work, from all disciplines, needs to be pursued in an integrated, interdisciplinary fashion, with fields and studies reflecting each other's requirements and assumptions. In this way, a new and unique kind of medical education will develop, which will be crucial for the future of the field. The study reinterpreted the changes in medical education using the complex systems theory, a mechanism in which various factors influence each other and collide into an order while forming a causal relationship. This confirmed that a unique legitimacy of medical education is being formed. Research in medical education is continuously improving and keeping pace with numerous social changes. Therefore, as educational and sociological theories integrate in the field of medicine, the medical education sector is expected to achieve independent development in the future. --- Availability of data and materials The datasets used in this study are stored at the College of Nursing, Keimyung University and the Center for Innovative Dental Education Korea. They are available from the corresponding author on reasonable request. --- Additional files Additional file 1: Authors' contributions YJ substantial contributed to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work. SN contributed to the design of the work and analze big data for the work. HK contributed to the approval of the version to be published. JL contributed to the interpretation of data and drafting the work or revising it critically for importatnt intellectual content. SL contributed to the agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work. All authors read and approved the final manuscript. Ethics approval and consent to participate Not applicable. --- Consent for publication Not applicable. --- Competing interests The authors declare that they have no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: As studies analyzing the networks and relational structures of research topics in academic fields emerge, studies that apply methods of network and relationship analysis, such as social network analysis (SNA), are drawing more attention. The purpose of this study is to explore the interaction of medical education subjects in the framework of complex systems theory using SNA and to analyze the trends in medical education. Methods: The authors extracted keywords using Medical Subject Headings terms from 9,379 research articles (162,866 keywords) published in 1963-2015 in PubMed. They generated an occurrence frequency matrix, calculated relatedness using Weighted Jaccard Similarity, and analyzed and visualized the networks with Gephi software. Results: Newly emerging topics by period units were identified as historical trends, and 20 global-level topic clusters were obtained through network analysis. A time-series analysis led to the definition of five historical periods: the waking phase (1963)(1964)(1965)(1966)(1967)(1968)(1969)(1970)(1971)(1972)(1973)(1974)(1975), the birth phase (1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989)(1990), the growth phase (1991)(1992)(1993)(1994)(1995)(1996), the maturity phase (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005), and the expansion phase (2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015).The study analyzed the trends in medical education research using SNA and analyzed their meaning using complex systems theory. During the 53-year period studied, medical education research has been subdivided and has expanded, improved, and changed along with shifts in society's needs. By analyzing the trends in medical education using the conceptual framework of complex systems theory, the research team determined that medical education is forming a sense of the voluntary order within the field of medicine by interacting with social studies, philosophy, etc., and establishing legitimacy and originality.

Introduction Mobile communication has become a taken for granted condition of young people's everyday lives (Ling, 2012), and early research on the adoption of smartphones suggests that mobile, ubiquitous internet access may soon become as constitutive of their social and media ecologies as mobile phones. Therefore, empirical evidence on smartphone ownership and use among young people revives new hopes regarding the potential leapfrogging effect of mobile telephony (Castells et al., 2007), especially in less advantaged social groups: by providing a cheaper and more accessible route to the internet, it is argued, smartphones with data plans may reduce inequalities in access. However, prior research (Donner et al., 2011) has concluded that different devices do not lead to the same internet experience. Therefore, while mobile-based internet use reduces the access divide, it may actually produce new inequalities in terms of usage patterns and skills. Drawing on the findings of the Net Children Go Mobile project, this article contributes to existing research on mobile digital divides by investigating what influences the adoption of smartphones among children, and whether going online from a smartphone is associated with specific usage patterns, thus bridging or widening usage gaps. --- Literature review --- Divides in ownership and usage of mobile phones Research examining mobile telephony in terms of digital divides has been sparse compared to the body of writing on digital and social inequalities associated with internet access and use. In the field of internet studies, research has moved past an initial understanding of the digital divide as a binary opposition between those who have access to online technologies and those who do not, towards a focus on inequalities that lie in differential online experienceswhat has been defined as the'second-level digital divide' (Hargittai, 2002). The refined approach to the digital divide conceptualises the issue of digital exclusion as a continuum of divides, whereby a variety of factorsdivides in access, differential uses and motivations to use, unequal skills, inequalities in the ability to benefit from online opportunitiescombine and concur to differential gradations of digital inclusion (Hargittai and Hinnant, 2008;Livingstone and Helsper, 2007;van Dijk, 2005;Warschauer, 2004). Moreover, digital inequalities have been recognised as strongly related to inequalities in the access to economic, cultural and social capital (Helsper, 2012a): opportunities and limitations of the use of ICTs are differentiated in intersection with social inclusion and exclusion, whereby 'those who are already in more privileged positions are more likely to use the medium for activities from which they may benefit' (Hargittai and Hinnant, 2008: 615). Research on mobile telephony from a digital divide perspective has followed a similar evolutionfrom access to inequalities. One of the first studies addressing the mobile digital divide investigated the impact of socio-demographic factors on the adoption of the internet and mobile telephony (Katz and Rice, 2003). The study showed that adoption patterns of the internet and mobile phone were quite similar, with income and education being the most influential factors shaping the use of both technologies. Moreover, though respondents who were internet users were also more likely to use mobile phones, the authors concluded that mobile phone and internet users were not necessarily the same sets of population, and that among both, differences persisted between early and late adopters. This pointed to a variety of patterns of adoption against mere opposition among users and non-users. With an ever-increasing penetration of mobile telephony on a global level (ITU, 2013), income and other measures of socioeconomic status are now less important predictors of mobile phone ownership, though they are still associated with diverse patterns of usage that reproduce differences among information-haves, information-have less and information-have nots (Castells et al., 2007). Another socio-demographic factor that has attracted a number of studies on variations in ownership and use of mobile phones is gender. Generally, research focused on gender divides in mobile communication concluded that, while there are no significant gender differences regarding access to mobile phones and engagement in traditional communicative practices, specific patterns of use emerged in relation to gender, with recreational and non-communicative uses (such as gaming) being the domain of boys (Cotten et al., 2009), and with girls engaged in producing distinctive mobile phone cultures (Castells et al., 2007;Hjorth, 2009). Finally, other research focused primarily on differences in specific communicative practices. For example, Ling and colleagues examined how texting is shaped by age and gender: based on the analysis of nearly 400 million texts, they found great variations by age in the volume of SMS exchanged, thus concluding that 'texting is a teen phenomenon' (Ling et al., 2012: 294). Despite a not inconsiderable number of works, we can nonetheless conclude that issues of digital inequalities have not been the primary concern of mobile communication studies, which have generally privileged other topics and approaches, such as the study of the domestication of mobile phones into individuals and groups' everyday lives, the investigation of communication and social practices developed around mobile telephony and their social implications, the analysis of youth mobile cultures, or the reconfiguration of private and public spaces (Green and Haddon, 2009;Ling, 2004Ling,, 2012)). --- Divides in usage of smartphones and mobile internet With the diffusion of smartphones, mobile phones have turned into an 'online, networked media device' (Hjorth et al., 2012), which supports an ever-growing repertoire of communication practices and online activities. Therefore, the once independent research agendas of mobile communication studies and internet studies have increasingly converged. As a consequence, the number of studies addressing mobile communication in terms of digital inequalities is likely to grow. A few noteworthy studies have already been published. Among these, Hargittai and Kim (2010) examined how a user's background characteristics and internet experience informed different smartphone usage patterns among a group of young adults. They found considerable variation in both the availability of, and the effective use of advanced phone functionalities: while gender, parental education and ethnic group are important factors which partially explain this variation, regular engagement with advanced mobile phone functionalities was more strongly correlated with internet experience, measured by both 'autonomy of use' -that is free, unrestricted access to use the internet 'when and where one wants' (Hargittai and Hinnant, 2008: 606) -and digital skills. 'People who have more Internet access points are more likely to possess higher levels of online skill and have more opportunities to explore a wide range of mobile phone features', Hargittai and Kim conclude (2010: 25). This conclusion suggests caution regarding the potential leapfrogging effect of mobile internet devices: instead of bridging digital inequalities, smartphone use is rather dependent on, and reproduces the so-called'second-level digital divide' (Hargittai, 2002), that is, skills divides and usage gaps that relate to a user's background characteristics. That access to the internet through mobile devices may lead to a diverse and less capital-enhancing internet experience is also suggested in a study conducted in Armenia (Pearce and Rice, 2013): through a comparison of PC-based and mobile-based internet users, Pearce and Rice found pervasive differential divides for internet access and online activities. Mobile internet use is more common among lower socio-economic levels of the population: mobile phones, then, provide less advantaged social groups with a viable alternative to online resources. However, mobile-based users engage in less advantageous and beneficial uses of the internet: digital inequalities such as differential online activities may therefore result in strengthened offline social inequalities, leading to an entrenched digital exclusion of the most disadvantaged citizens (see also Helsper, 2012a). When it comes to younger generations, digital exclusion, some argue, is no longer an issue since children are growing up in a convergent media ecology (Prensky, 2001). On the contrary, research indicates that inequalities in access, usage, skills and motivations to use the internet persist, even among the so-called 'digital natives'. Studies show how age, gender and socio-economic background are correlated with where and how children gain access to the internet (Livingstone and Helsper, 2007;Helsper, 2012b), and how socio-demographic factors combined with autonomy of use influence frequency of use and number of online activities taken up, thus shaping the progression onto the 'ladder of opportunities' from basic activities to more interactive, creative and capital-enhancing uses (Livingstone and Helsper, 2007). Research on inequalities in smartphone ownership and use among young people has just started. A recent report by the Pew Research Center (Madden et al., 2013) shows that the mobile internet has become pervasive among young Americans aged 12-17: half of the respondents own a smartphone, and one in four report using the internet mostly from their smartphones. The Pew report also highlights divides in the use of the internet and smartphones based on socio-economic status: teens from disadvantaged families are less likely to use the internet overall; however, teenagers living in lowerincome and lower-educated households are just as likely or, in some cases, more likely than peers from higher socio-economic households to use smartphones as their primary means of internet access. The implications of this finding in terms of children's digital inclusion needs to be further explored: while it is certain that smartphones provide children with greater autonomy of use (Hargittai and Hinnant, 2008;Park, 2014), when smartphones are the only connection point available, the issue of usage patterns associated with specific devices becomes crucial, as the risk that mobile internet use further reinforces social exclusions cannot be underestimated. In this regard, a recently published article (Park, 2014) investigates the second-level digital divide in mobile communication, and concludes that the benefits of mobile telephony are not uniformly accessible across different youth populations. More specifically, the study shows that variations in teens' social engagement are associated with different socialisation patterns, and that mobile internet use may represent a source of social inequalities: a combination of socio-demographics, parental background, and mobile skills and use results in lower or greater engagement in'socially productive' activities. --- Cross-national comparisons The diffusion of mobile phones has been uneven across the world due to economic, regional, industrial (such as technological standards and pricing systems) factors, sociocultural variations and different media regulation; moreover, there is evidence of differential rates of diffusion, not only across different regions, but also within wealthier economies (Castells et al., 2007). While European countries have been at the forefront of the adoption of mobile communication, inequalities persist across countries, and also among children, especially regarding internet use. The EU Kids Online country classification (Helsper et al., 2013), for example, distinguishes European countries on the basis of daily internet use among children, online activities, incidence of online risks and parental mediation strategies. This suggests that the context in which young people domesticate smartphones is far from uniform. We therefore assume cross-national variations as important factors influencing the adoption and use of smartphones. In undertaking comparative research, researchers can rely on different models and aim at different theoretical goals. In this article we focus on countries as the 'context of study' (Kohn, 1989;Livingstone and Hasebrink, 2010); in other words, we aim to assess hypotheses concerning social inequalities in mobile internet access and use by testing their applicability in different national contexts. --- Hypotheses As we have seen, research on mobile internet use among adults and young adults points to differential gradations in digital inclusion and to the interplay between digital and social inequalities: socio-demographic factors, internet experience and range of available devices to access the internet are all influential factors explaining the secondlevel digital divide and the usage gap (Hargittai and Hinnant, 2008;Hargittai and Kim, 2010;van Deursen and van Dijk, 2014). While in Western societies it is especially internet users who benefit from greater autonomy of use (Hargittai and Hinnant, 2008), in less advantaged social contexts smartphones may represent the primary means of internet access (Pearce and Rice, 2013). On the other hand, studies of children and the internet have emphasised persisting inequalities based on gender, age and socioeconomic background, at least on the quality of access (Livingstone and Helsper, 2007;Helsper, 2012b). Furthermore, there are indications that teenagers' mobile internet use is related to social inequalities (Madden et al., 2013), and to the process of socialisation (Park, 2014). Differential engagement in online opportunities is a better measure of digital inclusion compared to access to devices per se. However, as smartphones are currently being domesticated among the youngest, we are first of all interested in understanding what influences adoption. Moreover, since differences in children's online experiences persist across Europe (Helsper et al., 2013), we aim to explore country variations in the domestication of smartphones in this age group. Based on these reflections, we propose two hypotheses concerning children's access to smartphones: H1: Ownership of smartphones will vary by age, gender, country, socioeconomic background, parental ownership and use of mobile devices, and child's internet experience. H2: Accordingly, the daily use of smartphones will also vary by age, gender, country, socio-economic status, parental ownership and use of mobile devices, and child's internet experience, and also by ownership of smartphones. Beyond the question of access, we are also interested in differences in usage that may be related to mobile internet access. As outlined in the 'Literature review' section, empirical evidence so far has indicated large variations in online activities among adult PC-based and mobile internet users (Donner et al., 2011;Pearce and Rice, 2013), as well as among mobile internet users (Hargittai and Kim, 2010;Park, 2014). Among children, autonomy of use seems to reduce inequalities in online activities; moreover, research has shown that the wider the range of online activities pursued, the more the child progresses along the 'ladder of opportunities' (Livingstone and Helsper, 2007). Despite potential constraints deriving from parental or school regulation (Mascheroni and <unk>lafsson, 2014), smartphones provide children with greater autonomy of internet use (Park, 2014). Based on this, the following hypothesis concerning online activities is formed: H3: Access to smartphones broadens the number and type of online activities children engage in, thus shaping children's progression on the 'ladder of opportunities'. More specifically, we hypothesise that the number and type of online activities children engage in on a weekly basis varies by age, gender, smartphone ownership and daily use, child's experience with the internet and parents' ownership and use of mobile devices. --- Methods --- Data and sampling This article draws on data collected in 2013-14 in a sample of internet-using children aged 9-16 in Belgium, Denmark, Ireland, Italy, Portugal, Romania and the UK as part of the Net Children Go Mobile project. In each country a stratified sample of approximately 500 children was drawn through a random methodologyrandom walk route based on prior random selection of sampling points in all countries except Denmark, where households were randomly selected based on national residents listsresulting in a total of 3,565 respondents. Using a very conservative approach, the response rate ranged from 21% in Denmark to 56% in Romania. Similar to the 2010 EU Kids Online survey on the same age group (Görzig, 2012), questionnaires were administered face to face at home, and self-completed for sensitive questions on risky experiences, lasting 40 minutes on average. The selection of this particular age-group is based on methodological and theoretical considerations: 9-16 years old offer an insight on the early process of encountering and coping with online risks, while also being amenable to parental mediation. The questionnaire included many of the questions already asked in the EU Kids Online projectto facilitate comparison over timeand new questions on smartphones and tablets; it underwent cognitive testing in all countries in order to ensure the highest possible comprehension by children, and to evaluate the validity of translations in national languages. Validation of translations also relied on the process of translation and back-translation already completed during the EU Kids Online II project (Görzig, 2012). --- Measures: independent variables User background: parents were asked about socio-demographics. The parent who answered the questionnaire was to be 'the parent/carer in the household who is likely to know most about selected child's use of the internet'. Interviewers also noted if the parent was in the role of mother (73%), father (23%) or another carer (4%). Socioeconomic status was measured as a combination of the household income and the educational attainment of the main income earner in the household. With respect to children's demographic variables, interviewers were asked to indicate the age and gender of all children eligible to take part in the survey (respondents were then selected on the basis of the last birthday method). Parents' experiences with the mobile internet: parents were also asked to indicate whether both (in the case of two parent households) were internet users, and whether they owned a smartphone or a tablet that they used to go online. Prior research suggests that use of the internet by parents shapes the social context of internet use: more specifically, a parent's domestication of the internet is associated with quality of access and frequency of internet use among children (Mascheroni et al., 2012). Since the use of the internet among sampled parents is almost universal in all countries (89-99%), except in Romania (57%), including it as a predictor is of limited value in the analysis. Thus, we focus on parents' ownership of mobile devices. Child's internet experience: since research has shown that the quality and number of online opportunities varies by age and number of years the child has used the internet for (Livingstone et al., 2011;Livingstone and Helsper, 2007), we collected information on the age of first internet use. More specifically, children were asked how old they were when they first used the internet. They were also asked how old they were when they had their first mobile phone and first smartphone. However, since mobile internet use seems more influenced by internet experience than traditional mobile communicative practices (Hargittai and Kim, 2010), we focus on the number of years a child has been online for. Country: as anticipated, we use the country as the 'context of study' (Kohn, 1989;Livingstone and Hasebrink, 2010), to assess how patterns of access and use are differentiated across countries. --- Measures: dependent variables Smartphone ownership: children were asked the following question: 'Do you personally own or have for your private use any of these devices? By private use of a device we mean a device that only you use.' Overall, 46% of children say that they own a smartphone, though smartphone ownership varies consistently by age and country (Figure 1). Daily use of smartphones: we asked children how often they used different devices at different places to access the internet. Forty-one per cent of the respondents reported using smartphones several times per day or at least daily to go online, with great variations by age and country (Figure 1). Figure 1 here Type and number of online activities: children were asked how often (several times each day, daily, at least every week, never or almost never) they engaged in a number of online activities from any of the devices they use to go online. We collected information regarding 25 activities (for a detailed list of online activities, see Mascheroni and <unk>lafsson, 2014). Here, we focus on watching videos as a measure of leisure online activities, on social network sites as an indicator of communication practices, and using the internet for schoolwork as a proxy for academic and information usage (Kalmus et al., 2011). Since we hypothesised that children who use smartphones are on average more likely than those who do not use smartphones to engage in more complex types of activities and to be higher up on the 'ladder of opportunities' (Hasebrink et al., 2011;Livingstone and Helsper, 2007), we also look at those children who engage in at least two activities associated with levels 4 and 5 as defined by Hasebrink et al. (2011: 27-28), namely: playing games with other people on the internet; publish photos, videos or music to share with others; use file sharing sites; download music or films; post a message on a website or a blog; create a pet or an avatar; using a webcam; visiting a chatroom; spending time in a virtual world. --- Results --- Access and use H1: A logistic regression model was used to estimate the effect of age, gender, country, years online, parental education and parent's ownership and use of mobile devices on children's likelihood of owning a smartphone (see Table 1). Model 1 includes only the main effects of these variables, and indicates that age, country and use of mobile devices by parents are strongly correlated with children's smartphone ownership. Together these variables account for around a third of the variability in smartphone ownership. Table 1 about Model 2 tests for interaction between age and country (adding variables which are the multiplication of age and the dummy variable for each country). The possibility of an interaction between age and gender was also explored but was not significant: boys and girls seem to acquire smartphones at a similar age. There is, however, an interaction effect between age and country and between age of first internet use and country. These interaction effects are explored in Figures 2 and3. Adding the interaction terms to the model does not improve the overall model fit in terms of the explained variance, but offers a more accurate assessment of the effect of individual variables. Figures 2 and3 Figure 2 shows the predicted probabilities of a child owning a smartphone by age and country for girls (the boys are much the same) who began to use the internet when they were of an average age (seven years), in households with average socioeconomic status (mode = 35%), and where their parents have a mobile device (mode = 64%). The results show that the reason why fewer children in Romania own smartphones is partly because older children in this country are less likely to own smartphones than older children elsewhere, while in Belgium and Portugal younger children are less likely to own a smartphone compared to their peers in other countries. If we then look at the age of first internet use, the main effect is that as children start using the internet at an older age, they are less likely to own a smartphone. If we add an interaction term by country, then this effect is statistically significant just for Italy, where the decrease in smartphone ownership has a stronger correlation with age of first internet use than in the other countries. If we calculate the predicted probabilities of owning a smartphone and look at this by country and as beginning age of internet use runs from 4 to 11 years for a 12-year-old girl (the boys are much the same), where the child lives in an average socio-economic status household, and where parents have a mobile device, we see clearly how the higher age of first internet use has a bigger effect in Italy. H2: If we use the model for smartphone ownership (Table 1, Model 1) as a starting point in examining daily use of smartphones we can observe similar patterns (Table 2, Model 1) in terms of age, gender, country and socio-economic status differences. However, daily use would seem unlikely unless the child owns a smartphone, and indeed, around 60% of the variability in daily use of smartphones can be explained by smartphone ownership. On the other side, this finding also suggests that smartphone use is not simply a question of ownership. If we compare the coefficients in Models 1 and 2, we can note that age still has an important effect. And differences in country effects between the two models suggest potential country interactions that are worth exploring. The third model in Table 2 adds interaction with age and ownership of smartphones, gender and ownership (adding variables that are a multiplication of the original variables), as well as countries and ownership. The gender and ownership interaction is not relevant, while the importance of ownership seems to increase with age. In Ireland and Denmark, ownership seems to be less important in terms of explaining daily use than in the other countries, while it is more important in explaining daily use in Portugal. --- Table 2 about here The interaction effects again are best explored by looking at them graphically. Figures 4 and5 show the predicted probability of a child using a smartphone daily at any location. Figure 4 shows this for children who own a smartphone, but Figure 4 for children who do not have a smartphone for private use. The analysis suggests again that the main reason why children do not access the internet on a smartphone is because they do not own one. But it also indicates a very important age effect. Thus, even if a 9-yearold child owns a smartphone, the probability that she will use it to access the internet is as low as 39% in Belgium; however, if 16-year-old teenagers own a smartphone, then there is about a 80-90% likelihood of them using it to go online. Figure 5 Table 3 shows two linear regression models for the log-number of online activities. Table 3 Model 1 includes the same independent variables as previous models for ownership and daily use of smartphones. Here we can see that with each year a child grows older, the number of online activities they engage in increases by 19%, and that girls engage in slightly fewer activities than boys (around 6% fewer). Children in Romania, Italy, Denmark and Portugal pursue on average more online activities than their UK counterparts. Higher age of first internet use is related to a smaller number of online activities, with each year a child grows older before starting to use the internet being related to a 7% reduction in the number of online activities. Socio-economic status and parents' use of mobile devices is not correlated with number of activities engaged in by children. Conversely, using a smartphone to access the internet at least daily is associated with a substantial increase (70%) in the number of online activities. Model 2 adds interaction terms for age and daily smartphone use as well as gender and daily smartphone use. These indicate that using smartphones to access the internet on a daily basis has a slightly bigger effect on the number of online activities for younger children. The question of types of activities can be approached both from the viewpoint of different kinds of activities (e.g., leisure, communication and information, as in Kalmus et al., 2011) and from the viewpoint of different complexitiesthe so-called 'ladder of opportunities', whereby children tend to progress from basic to participatory uses of the internet (Livingstone and Helsper, 2007). Table 4 shows four logistic regression models using the same independent variables used in Table 3. However, the focus here is rather on the extent to which smartphone use might be related to different types of activities. The first three models explore the probability of using the internet at least weekly for schoolwork, watching video clips and visiting profiles on social network sites. The fourth model shows the probability of engaging in at least three activities associated with levels 4 and 5 in the ladder of opportunities (Hasebrink et al., 2011;Livingstone and Helsper, 2007). Table 4 Looking across the four models, age has a similar effect on all activities, with the likelihood of children engaging in these activities increasing by 30-85% for each year they grow older. The effect of gender is smaller, but highest when considering use of the internet for schoolwork and use of social network sites, with girls being 26% more likely than boys to do both at least weekly. Country effects are, however, more diverse, with children in Italy, Portugal and Romania being considerably more likely to use social network sites than their peers in the UK. While parents' use of mobile devices has a low effect on leisure and communication activities, socio-economic status has a diverse effect across the activities examined, with children from medium socioeconomic status homes 36% more likely to use the internet for schoolwork than lower socio-economic status children, and children from higher socio-economic status households 69% less likely to use social network sites. Smartphone users are more likely to engage in entertainment and communication activities -but smartphone daily use is not correlated with use of the internet for schoolwork -and they are between three and four times more likely than those who do not use smartphones to reach at least level 4 in the ladder of opportunities. Pursuing activities in the creative sphere also increases among older children, children in Denmark, Ireland, Italy and, especially, Romania, and children whose parents also use smartphones or tablets to go online. By contrast, the likelihood of reaching level 4 and 5 on the ladder of opportunities increases by age (49% for each year a child grows older) but decreases by 11% each year a child grows older before starting to use the internet; there is, however, no gender difference. Figures 6 and7 Figure 6 shows the interaction between age and smartphone use in the third model in Table 4 by looking at the predicted probability of girls in the UK visiting social networking sites by age and smartphone use: daily use of smartphones makes less of a difference for teenagers aged 16. Figure 7 shows the interaction between age and smartphone use in the fourth model (in Table 4) by looking at the predicted probability of girls in the UK reaching level 4 or 5 on the ladder of opportunities by age and smartphone use. In this case, the divide between children using a smartphone daily to go online and those who do not becomes narrower by age, but is still noteworthy. --- Discussion and conclusions In this article we have examined variations in the ownership and use of smartphones among children aged 9-16 in order to understand what socio-demographic factors influence the adoption and regular use of smartphones, and whether smartphone use is associated with specific patterns of online activities and with children's progression from basic to more advantageous uses of the internet. These research questions have guided the analysis. Concerning ownership, the most influential factor explaining variations in the adoption of smartphones is whether parents themselves use a smartphone or a tablet to go online. There are also large variations by country, age and children's experience with the internet, while gender and parents' socio-economic status show little or no effect on smartphone ownership. These findings have some implications for the access digital divide among children: first, we can conclude that socio-economic background does not seem to have a simple and direct effect on children's adoption of smartphones. Rather, it is mediated by the domestication of smart mobile devices, both at a family level and at a country level. In households and countries with a higher domestication of the mobile internet, smartphones are also more diffused among children. Second, since children who start to use the internet later are less likely to own a smartphone, we can conclude that smartphones do not provide alternative access to the internet for children who haven't had any opportunity to go online regularly before. If we consider the interaction between age in general and age of first internet use more specifically, these findings are, instead, consistent with prior studies on inequalities in internet use among children in showing that autonomy of usehere measured by access to the internet by means of a private mobile deviceincreases with age and online experience (Livingstone and Helsper, 2007). In other words, and in accordance with studies on young adults (Hargittai and Hinnant, 2008;Hargittai and Kim, 2010;Park, 2014), children with more internet experience also benefit from greater autonomy of use. Therefore, this suggests caution regarding the leapfrogging effect of mobile devices: not only is the potential of smartphones to bridge the access digital divide weaker among children than it is among adults (Pearce and Rice, 2013), but as autonomy of use is associated with the take-up of more online activities, including more beneficial activities, then divides in access result in differential uses and activities. Second, we investigated how daily use of smartphones varies by age, gender, country, parental education, parental ownership and use of mobile devices, child's internet experience and ownership of smartphones. If daily use is mainly predicted by ownership, we observed a significant interaction of age and country, whereby younger children in general, and younger children in Belgium, Ireland and Romania more specifically, are less likely to use a smartphone to go online on a daily basis. This finding suggests that the access divide cannot simply be reduced to material access to devices: the availability and cost of connectivity also matter, as well as parental mediation strategies (e.g., the choice not to provide younger children with an internet plan in order to limit their unsupervised internet use). Indeed, younger children are less likely to be provided with an internet plan on their smartphones: 36% of children aged 9-10 use only wifi networks to go online from their smartphones, 14% use either a wifi connection or a mobile internet plan, and just 9% access the internet using only an internet plan (Mascheroni & <unk>lafsson, 2014). This suggests further caution against easy assumptions on the potential of smartphones to reduce digital inequalities in access. We were also interested in understanding whether the use of smartphones is associated with variations in the number and type of online activities children undertake, and more specifically, whether smartphone use is associated with less or more capital-enhancing uses of the internet. Consistent with prior studies on children and the internet (Livingstone and Helsper, 2007;Livingstone et al., 2011), we found that the number of online activities varies by age, gender, and internet experience: older children, boys and those who have started to use the internet at a younger age are more likely to engage in a wider range of online activities. Country of residence also matters, while a household's socio-economic status or parents' ownership and use of mobile devices is not influential. However, the greatest variation in the number of online activities is explained by daily use of smartphones: as observed among adults (Hargittai and Hinnant, 2008), users who benefit from more autonomous access to the internet engage in a wider range of online activities. Regarding the type of activities children undertake, beyond persisting differences by age, gender and child's internet experience, we found that smartphone use is associated with a consistent increase in social networking and entertainment activities, but is not correlated with use of the internet for schoolwork. Moreover, we also observed a significant correlation between daily use of smartphones to go online and children's progression on the ladder of opportunities: children who access the internet from their smartphones on a daily basis, and especially younger children, are more likely to pursue activities included in stages 4 and 5 of the ladder of online opportunities. Therefore, the findings of research on the adult population showing that smartphones are associated with less capital-enhancing activities, thus reducing the access divide while widening the usage gap (Pearce and Rice, 2013), are not supported by the empirical evidence presented here. However, the findings are at least partially supportive of the'second-level digital divide' (Hargittai, 2002;Hargittai and Hinnant, 2008): indeed, gaining participatory activities is correlated with autonomy of use and with the number of years a child has been using the internet for, suggesting that both technological platforms and different family backgrounds still function as sources of online disparities that are mirrored in, and entrench, offline inequalities. Moreover, there are indications that children from medium or higher socioeconomic status households engage in more productive uses of the internet compared to peers from lower socio-economic backgrounds, which is consistent with studies on adults (van Deursen and van Dijk, 2014). We have observed a general pattern, whereby access to smartphones is influenced by parental domestication of the mobile internet, child's age and internet experience, and country; moreover, daily use of smartphones is strongly, but not exclusively, predicted by ownership; and, finally, more capital-enhancing uses of the internet are strongly associated with autonomy of use, which, in turn, is associated with smartphone ownership, parents' use of mobile devices and age of first internet use. While this pattern is valid throughout Europe, some variations across countries are noteworthy. In terms of access to smartphones, children in Romania, Portugal and Belgium are generally less likely to own a smartphone, but Portuguese children who own a smartphone are the most likely to use it daily to go online, together with Italian children, who, at the same time, are the least likely to own a smartphone if they start using the internet late. These findings suggest that, despite being mediated by family's domestication of the internet, socio-economic and cultural inequalities across and within European countries can still influence autonomy of use. On the other hand, crossnational comparison also shows that beneficial uses of the internet vary largely across countries, despite being strongly predicted

and a visiting fellow at the Department of Media and Communications, LSE. She is the project director of Net Children Go Mobile, and the national contact of the EU Kids Online. She is also involved in the comparative project "Building Inclusive Societies and a Global Europe Online" (webpoleu.net). Her research examines the use of the internet and mobile devices by children and young people, its opportunities and risks. Kjartan Ólafsson is a lecturer at the University of Akureyri where he teaches research methods and quantitative data analysis. He is also a visiting researcher at the Masaryk University in Brno. He has extensive experience in survey research and has played a key role in the design and implementation of a number of cross national research projects on children's media use. Amongst these are the 2010 EU Kids Online study, which has been a landmark project in the field of media studies in Europe, and the Net Children Go Mobile survey.

). We have observed a general pattern, whereby access to smartphones is influenced by parental domestication of the mobile internet, child's age and internet experience, and country; moreover, daily use of smartphones is strongly, but not exclusively, predicted by ownership; and, finally, more capital-enhancing uses of the internet are strongly associated with autonomy of use, which, in turn, is associated with smartphone ownership, parents' use of mobile devices and age of first internet use. While this pattern is valid throughout Europe, some variations across countries are noteworthy. In terms of access to smartphones, children in Romania, Portugal and Belgium are generally less likely to own a smartphone, but Portuguese children who own a smartphone are the most likely to use it daily to go online, together with Italian children, who, at the same time, are the least likely to own a smartphone if they start using the internet late. These findings suggest that, despite being mediated by family's domestication of the internet, socio-economic and cultural inequalities across and within European countries can still influence autonomy of use. On the other hand, crossnational comparison also shows that beneficial uses of the internet vary largely across countries, despite being strongly predicted by autonomy of use (measured by daily use of smartphones), child's age, and parents' use of mobile devices: here, inequalities may also be the product of different parental mediation strategies, with restrictive approaches in the so-called 'protected by restrictions' countries (Helsper et al., 2013) restricting opportunities as well as reducing risks, the UK being a paradigmatic example (Mascheroni and <unk>lafsson, 2014). To conclude, this study aimed at showing the resilience of digital inequalities among a segment of the populationchildrenwho are usually assumed to be on the 'right' side of the digital divide. It has also shown how social inequalities intersect with divides in access and result in disparities in online activities, with children who benefit from a greater autonomy of use and a longer online experience also engaging in more productive and capital-enhancing uses of the internet. However, this study has some limitations that may make findings about differential access and use of the internet among children less generalisable. First, the relatively low response rate registered in some countries limits the extent to which we can draw generalisable conclusions from the sample. Nonetheless, the study offers unique comparative data on children's ownership and use of smartphones. Second, the research was conducted in Europe, in a context where digital inequalities persist, but where both the number of internet users and mobile telephony subscriptions is above the world average (ITU, 2013). As a consequence, we didn't have the opportunity to examine a significant number of internet users who access the Another divide that has not been addressed in this article, and that could instead help grasp the potential of mobile devices, is digital skills. Despite having measured a number of self-reported online skills, including instrumental, informational, safety skills and communicative abilities, at this stage we have limited our analysis to access and use. Future analysis on the dataset may, then, provide further confirmation for these conclusions. --- Funding Net Children Go Mobile (www.netchildrengomobile.eu) was co-funded by the EC's Better Internet for Kids Programme (SI-2012-KEP-411201).

and a visiting fellow at the Department of Media and Communications, LSE. She is the project director of Net Children Go Mobile, and the national contact of the EU Kids Online. She is also involved in the comparative project "Building Inclusive Societies and a Global Europe Online" (webpoleu.net). Her research examines the use of the internet and mobile devices by children and young people, its opportunities and risks. Kjartan Ólafsson is a lecturer at the University of Akureyri where he teaches research methods and quantitative data analysis. He is also a visiting researcher at the Masaryk University in Brno. He has extensive experience in survey research and has played a key role in the design and implementation of a number of cross national research projects on children's media use. Amongst these are the 2010 EU Kids Online study, which has been a landmark project in the field of media studies in Europe, and the Net Children Go Mobile survey.

I ndia is home to many native people who are still untouched by the modern world's lifestyle practices. The tribal culture of India and their traditions and practices pervade almost all aspects of Indian culture and civilisation (Patro et al, 2012). Cultural practices, beliefs, and taboos are often implicated in determining the care received by mothers during pregnancy and child birth which are important determinants of maternal mortality (Chandra et al, 2016). India has made extensive efforts to reduce maternal mortality and to increase access to reproductive health care. However, the progress made has been uneven and inequitable. Remoteness and lack of modern amenities in tribal areas lead to less utilisation of maternal health care services which ultimately causes maternal and child mortality (Govt of India, 2011). According to Census 2011, the tribal population of India is 10.43 crore, constituting 8.6 percent of the total population. Out of total population residing in the Indian Himalayan range, a little more than 51 percent belongs to a tribal community (Chaudhary, 2012). As one of the Member States at the United Nations General Assembly Summit in September 2015, India committed to the 17 Sustainable Development Goals (SDGs). The goals stand at the three pillars of overall developmenteconomic, social and environment. Of the targets laid down under SGD-3 "Ensure healthy lives and promote well-being for all at all ages"; 4 out of 9 targets specifically concern maternal and reproductive health (Babu et al, 2012). Tribal culture and their belief in certain things make the concept of health and illness very interesting and a matter of great concern and priority. Their close relationship with the environment probably makes them believe in the supernatural power or God and Goddesses. The mother and children have been the most vulnerable group in tribal community. However, some issues pertaining to their reproductive, maternal and child health continue. To tackle these, adequate MCH care & services should be provided through Health Care personnel (Dubey, 1982). --- Need of Study: According to a UNICEF study (2009), 61 percent of maternal deaths occur in tribal communities in India. The target of Sustainable Key words: Cultural practices, Maternal and Child Health Care, Tribal women Development Goals (SDG) set by United Nations aim at reducing the global maternal mortality ratio to less than 70 per 100,000 live births. About 99 percent of maternal deaths occur in developing countries and India accounts for the largest number. In the North Zone, the tribes of Jammu & Kashmir, Himachal Pradesh, Punjab, Uttrakhand, and Bihar come under this zone. Most of them need to focus on mother and children because they have high rate of infant, child and maternal mortality in the tribal areas (Registrar General of India, 2009). In Himachal Pradesh, people of the Gujjar tribe live in district Sirmour. They still follow the custom of early marriage where girls are married at 14-15 years and boys at 17-18 years (Govt of Himachal Pradesh, 2016; Ministry of Tribal Affairs, 2013-14). In terms of health indicators, children and women are more vulnerable than men. Baseline information about traditional new-born feeding practices and care during pregnancy of tribal communities is of importance in planning culturally sensitive care. Some cultural beliefs had a good impact on mother and child's health outcomes, whereas some were responsible for maternal and child morbidity and mortality (Shah & Dwivedi, 2013). Healthcare providers should enhance their knowledge of the area-specific cultural practices to provide better maternal and child health services to promote their health status. This study aimed to explore the existing cultural health practices in tribal areas and its impact on MCH care. --- Review of Literature Contractor et al. Sana (2019) explored their experiences with pregnancy and childbirth among mothers of Rayagada district of Odisha. Methods included in-depth interviews with women, traditional healers and formal health care providers and outreach workers, observations in the community and health. Traditional health providers who are important stakeholders have not been integrated into the health system. Despite the immense difficulties that women face, they do access health facilities, but barriers of distance, language, cultural inappropriateness of services, and experiences of gross violations have further compounded their distrust. Omer et al (2021) revealed that the delay in seeking care and the potentially resulting maternal mortality is more likely to occur in South Punjab, Pakistan. Data was collected through FGDs and thematic analysis was done. Poor socioeconomic status, limited knowledge about maternal care, early marriages and lack of family planning and financial constraints among rural people were the main barriers to seeking care. The preference for traditional birth attendants results in maternal deaths. --- Objective The study sought to explore the existing cultural health practices in tribal areas and its impact on MCH care among tribal women of Himachal Pradesh. --- Methodology A qualitative research approach and ethnographic research design was used to explore the impact of the cultural practices on MCH care among women of reproductive age group (18-49 years) residing in tribal areas of district Sirmour (Himachal Pradesh) during year 2020-21. Majority of tribal population were residing in Nahan and Paonta Sahib blocks of district Sirmour (DLHS-4) (Ministry of Health & Family Welfare, 2017). Participants belonged to Gujjar tribe having Hindi as their local language. They were selected through a probability stratified sampling technique from each stratum (10 villages) till data saturation. Total sample size was 84. --- Inclusion criteria 1. Women of reproductive age group between 18-49 years who were residing in the selected tribal areas. 2. Women who were willing to participate in the study. 3. Women who were able to understand Hindi language. Exclusion Criteria 1. Women who were mentally retarded or mentally ill. 2. Women who were not available at the time of data collection. Ethical consideration was maintained during data collection i.e., formal permission was obtained from concerned authority and written informed consent was taken from the participants. Secondary data was taken from previous literature, books, policy document, records & reports, online databases & websites, journals, etc. Primary data was collected from the beneficiaries, i.e., women of reproductive age group (18-49 years). Ten focused group discussions (FGDs) were conducted with 8-10 participants from each village for 30-40 minutes. ASHAs and Anganwadi workers were present during the discussions in order to make the beneficiaries more comfortable. Primary data were analysed with Colaizzi procedural stepsand N-Vivo software. The different issues affecting MCH services utilisation have emerged as significant themes from the data (FGD transcripts, notes, field observations). Finally, both the predetermined and emerged themes were pooled together to address the research question. --- Results & Discussion Socio-demographic variables of women are shown in Table -1. --- Malpractices in Child Health Care Inadequate exclusive breastfeeding: Exclusive breastfeeding means the infant will receive only breast milk; no other liquid or solid is given. Beneficiaries reported that they have given salty water, honey and Janma-ghutti (Ayurvedic tonic) to their children immediately after birth rather than first feed of colostrum. For the management of diarrhea, they used to prepare a solution with Ajwain (ajwan caraway, bishop's weed), Harar (Terminaliachebula), and Tulsi leaves (Holy Basil) for the drinking by the children instead of using ORS. Traditional practices: There are numerous practices based on the theories, beliefs, and experiences indigenous to different cultures and traditions. Beneficiaries reported some traditional child care practices which are followed by Muslim religion only. Hazaan ceremony: In Muslim culture, Hazaan practice was followed for children, i.e., piercing in both ears after seven days of birth during hospital delivery and after 3-day in home delivery, which has no significant relation to health deteriorating conditions. --- Wearing of Taweez (magical ornament): A Taweez is a locket that is generally associated with Islam, although wore by Hindus also. It usually contains verses from the Quran or other prayers and symbols inscribed on the metal portion of the Taweez. Beneficiaries reported that Taweez is mandatory to be put in the neck of the child to be prevent them from diseases. Circumcision practice: In Muslim culture, they follow the aseptic technique of circumcision in which children under the age of 3-5 years has to undergo Sunnat (circumcision), i.e., removal of the foreskin from human penis using aseptic techniques without sterilised blades and then applying cow dung on the wound, etc. which is causing infection and delay wound healing. --- Myths related to Antenatal Care Antenatal beliefs: Women are isolated for 11 days in a room during the religious event (Pooja) and her presence considered as Sutak (bad) for the village during Pooja. In Muslim culture, during Roza time, they have to keep fasting continuously for days. Some of them have omitted vaccination during fast because of fear of Allah's (God) punishment in the form of illness. Inadequate dietary practices: Primitive practices of the tribal population to be discarded and necessary health education should be imparted. There is no specific attention given to the food during pregnancy. They are eating less quantity of fruits because of cost and unavailability. Unhealthy practices: In some areas, women smoke tobacco smoking during pregnancy because of their habitual and ancestral practices (Fig 2). They smoke tobacco through a pipe that brings smoke through a container of water before it is breathed in (known as Hukka). Smoking, chewing tobacco and alcohol consumption is high among tribal population. It was noticed that most of women had not accepted antenatal care during their pregnancy due to their misperception of 'not necessary' and 'customary'. "We are smoking (Hukka) during pregnancy time also, now we are habitual, cannot change our habit". or smoking tobacco) for females. ices: During home delivery, immediately after birth, the new-born baby is n and cotton cloth. After giving honey or Jamangutti, the baby is put on the whereas the mother is also given hot tea with Jaggery. After six days of and placenta were buried underground. It is usual for them to migrate to their r delivery. Among Hindus, most prefer hospital delivery by trained health care s Muslim beneficiaries prefer home delivery. Post-natal care: Respondents reported that during post-natal period, they rtain specific practices regarding diet, hygiene, and rest to keep herself and --- Intranatal practices: During home delivery, immediately after birth, the new-born baby is wiped with clean cotton cloth. After giving honey or Janamgutti, the baby is put on the mother's breast, whereas the mother is also given hot tea with Jaggery. After six days of delivery, the cord and placenta were buried underground. It is usual for them to migrate to their mother's house for delivery. Among Hindus, most prefer hospital delivery by trained health care personnel whereas Muslim beneficiaries prefer home delivery. --- Myths related to Post-natal Care: Respondents reported that during post-natal period, they have to follow certain specific practices regarding diet, hygiene, and rest to keep herself and her baby healthy. Less exposure to sunlight: Beneficiaries reported that there was no exposure of mother and child to sunlight (outside room) at least for 1 month & 15 days, i.e., they are isolated in a room for six weeks. --- Inadequate dietary practices: In the post-natal diet, they have eaten moong daal and chapatti for one month and Desi ghee Halwa for 3 days. Boiled water was given to the mother with ajwain, Ghee, and Jaggery for a drink. Only one-time, chapatis in food were given to them because they believe that if they eat more chapatis, it will increase the size of abdomen. Intake of rice, buttermilk, milk, curd, and chillies is avoided during the post-natal period. Personal hygiene: Inadequate personal hygiene practices related to bathing and teeth cleaning etc. due to cultural beliefs. "After 40 days, we use to take a body bath with warm water & neem leaves with our children, and changed clothes. In our Muslim culture, mother and child bath is allowed after 1 week or 1 month." --- Post-natal superstitions: Superstitions are the cultural beliefs for prevention of mother and children from supernatural powers and diseases. "After the birth of a child, if you want to see mother and child, you have to stand in front of Rakh (sand) kept outside their room, and then you can enter inside so that we can prevent a child from supernatural [evil] powers. We are keeping one vessel with wheat, knife, and onion under mother & child's bed to prevent supernatural powers responsible for child mortality (Fig 3 &4). --- Myths related to Family Planning Services Inadequate utilisation of Family Planning methods: Muslim women reported that males are not adopting vasectomy because they believe it will cause physical weakness and reduce energy to work in fields. Few of them are not using any family planning methods because they think children are God's gifts. Beneficiaries reported that if they undergo surgery, then they will be deprived of God's blessing. "Zanat nhi milte, Namaz nhi lagegi, Operation karwana Gunah hota hai." --- Miscellaneous Practices Quack treatment: Cultural belief sand traditions are followed for the management of infertility & fibroid uterus which is responsible for the non-acceptance of modern medicine. "During infertility and fibroid uterus development, we are going to local Baba for Jhada or Muslim Elaaz, not preferring medical treatment." Gender issues: There was under-utilisation of obstetrical and gynaecological services from Govt hospital due to gender issues of health care personnel (physician). In Muslim culture, the family does not allow females to visit male gynaecologist and obstetrician. --- Discussion Child Health Care Practices The malpractice of inadequate exclusive breastfeeding has increased child morbidity and mortality. The irrational practice of, squeezing out the mother's first milk deprives the new-born baby from nutrient-rich colostrum milk, which leads to risk for malnutrition. Children should be given Oral Rehydration Solution (ORS) during diarrhoea instead of the home prepared solution to maintain fluid and electrolyte balance for immediate effect. Application of Kajal in the eyes of children can cause minor eye problems such as irritation, discharge, and infections. The use of a non-sterilised blade and application of cow dung on the wound (after circumcision) has bad impact on children's health in the form of infection, bleeding, etc. Consistent to our findings, Contractor et al (2018) conducted a study and found similar results related to tribal women experiences with MCH services in Odisha (India). --- Antenatal Health Care Practices --- Post-natal Health Care Practices Exposure to sunlight is essential for mother and child to maintain the intake of vitamin D inside body. They are not used to expose the mother and child to sunlight after delivery for 7 days, which leads to the development of nutritional deficiency diseases. Inadequate dietary practices can cause poor health outcomes for the mother and adversely impact the health of the breastfeeding baby. Boiled water with neem leaves with antibiotic/anti-infective properties used for bathing of mother and child may have good impact on health. However, they should maintain their hygiene regularly, not after a long period of time, to prevent infections. --- Family Planning Services Underutilisation of family planning methods and frequent childbirths can cause poor maternal health in terms of blood loss, anaemia, malnutrition, low birth weight babies, etc. Similar findings were found in a study conducted by Dehury Ranjit, Pati, Dehury Ashalata Parthsarathi (2018) regarding traditional practices and beliefs in post-partum care among tribal women in Maharashtra. --- Implications 1. For provision of comprehensive services in community area, health care personnel have to provide transcultural care based on their traditional values and customs for effective usage of MCH services. These measures will reduce maternal and child morbidity and mortality for achievement of SDGs. 2. There is intensive need to involve community people in village health meetings and awareness campaigns in order to enhance their knowledge regarding impact of cultural practices on health of mother and child which is causing poor maternal and child health outcome. Gender issues: There was under-utilisation of obstetrical and gynaecological serv hospital due to gender issues of health care personnel (physician). In Muslim cul does not allow females to visit male gynaecologist and obstetrician. --- Discussion Child Health Care Practices augmented by nurse practitioners in place of physician to provide essential drugs and basic diagnostic free of cost. 4. Targeted awareness campaigns should be organised which can be more fruitful in comparison with general campaigns. For effective communication, different audio-visual aids can be used. --- Recommendations • Qualitative study can be conducted to explore the tribal Govt initiative for promotion of tribal maternal and child health in India. • Multicomponent interventional research can be performed on selected culturally impacted health problems of mother and child residing in tribal areas. --- Conclusion Tribal populations live in areas having scarcity of resources, inaccessible health care facilities. They follow traditional norms, are socially and economically weak and conventional in nature. This study was related to various myths, beliefs, and malpractices concerned with mother and child health care during the perinatal period. There should be awareness campaigns regarding exclusive breastfeeding practices, adequate personal hygiene, usage of ORS, healthy dietary habits, prohibition of smoking, preference to institutional deliveries, usage of family planning methods etc. to improve maternal and child health outcome. Religious leaders are great motivators for their community. So, they should be involved by health care personnel during distribution of MCH services to enhance its utilisation and to promote safe motherhood which will ultimately help in achievement of Sustainable Development Goals.

Maternal and Child Health Care (MCH) is essential for achievement of Sustainable Development Goals. Delivering quality primary care to tribal populations is always challenging, which is the case in India. Cultural practices are often implicated in determining MCH care. This study aimed to explore the existing cultural health practices in tribal areas and its impact on MCH care among tribal women of Himachal Pradesh. In this exploratory study qualitative research approach was adopted. Women of reproductive age group (18-49 years) were selected through stratified sampling techniques from selected tribal areas of district Sirmour (Himachal Pradesh). Data was collected through Focused Group Discussion (FGDs) and Colaizzi method was used for data analysis. The study findings revealed inadequate exclusive breastfeeding, antenatal beliefs, faulty dietary habits, unhealthy practices, less exposure to sunlight, quack treatment and trans cultural issues. In addition, early marriages and inadequate usage of family planning deeply entrenched in cultural values and influence of traditional or spiritual healers etc. refrain them from adequately availing provisions of MCH. Maternal and child mortality is firmly related to certain cultural practices, which create constraints for women seeking maternal and child care. Hence, it is imperative to create awareness regarding impact of cultural practices on MCH care and need to address the health concerns among tribal women to reduce maternal & child mortality rate.

Introduction Internally Displaced Persons (IDP) are groups who have been forced to leave their homes, but remain within the borders of their own country. 1 According to a new report from a 2018 Internal Displacement Monitoring Center (IDMC) and Norwegian refugee council (NRC), globally a total of 30.6 million people were internally displaced due to conflict and disaster. 2 Most of them live in low-income countries which are sometimes affected by internal conflict and violence. 3 In 2016, the total number of displaced people due to conflict in Africa was almost 12.6 million. 4 Ethiopia saw the highest number of internal displacements in the first half of 2018. According to the IDMC report, 1.4 million people experienced internal displacement. 2 In Gede'o zone (Southern Nation Nationality Region) and west Guji (Oromo region) more than a million people were displaced due to intercommunal conflict. 2 Generally people with displacement were exposed to different kinds of trauma, violence, and injuries, making them more vulnerable for psychological disorders, particularly post-traumatic stress disorder (PTSD). 5 PTSD is one of the psychological disorders which can be experienced following exposure to a traumatic or stressful event. it is characterized by symptoms of intrusion, avoidance, changes in mood and cognition, and hyperarousal, all of which can last for more than a month after the traumatic event. [6][7][8] PTSD can occur due to witnessing and being exposed to terrible events such as murder, threats, kidnap, loss of relatives or friends, loss of house, and starvation. 5 Several systematic reviews indicated that IDP who stay within their own country experience worse mental health outcomes than refugees. 9,10 PTSD symptoms have been described as one of the most prevalent mental health conditions in IDP. 11 In post-conflict and conflict-ridden societies, the prevalence rates in the general population can be much higher. 12 In a study looking at the lifetime prevalence of PTSD, mood, and anxiety disorders in four post-conflict societies the researchers reported a PTSD prevalence ranging from 15.8% to 37.4%. 13 Statistical estimates showed that PTSD is between 1% and 5% in a range of general population studies 14,15 and between 3% and 58% for high-risk groups such as displaced people. 16,17 The global economic burden of stress-related mental illness is expected to rise in the coming decade. The World Health Organization's (WHO) global disease of burden survey estimates that mental illness, including stress-related disorders, will be the second leading cause of disability by the year 2020. 18 A systematic review conducted in 40 countries showed that the prevalence of PTSD among IDP was 30.6%. Another systematic review undertaken revealed that PTSD among IDP ranges 3% to 88%. 19,20 Studies undertaken in Africa show that PTSD can still be a public health concern several years after the civil conflict. [21][22][23] In East Africa, like Uganda, the prevalence of PTSD ranges from 11.8% to 54%. [24][25][26][27][28][29] The prevalence of PTSD among IDP ranges from 3.6% to 88% in different studies from different countries. [30][31][32][33][34][35] Mental illness, and specifically PTSD, is documented as a key public health issue of a conflict-affected population; war and armed conflicts contribute to poverty, lack of employment, community violence, insecure living circumstances, and changes in the social dynamic. This makes PTSD highly associated with a lower quality of life, even after the end of the actual hostilities in a post-disaster setting. 34,35 Factors that contribute to the development of PTSD have been classified into four groups: pre-existing factors like family history of mental illness and substance abuse history, the traumatic event itself, the level of exposure, and post-trauma factors such as social support. [36][37][38] Most psychiatric findings are limited to other African countries, such as Nigeria or Uganda, where studies have shown that exposure to psycho-trauma among IDP leads to PTSD. 32,39,40 Even though the prevalence of PTSD is high among IDP, as far as we know there is no specific published study on Ethiopia. --- Materials and Methods --- Study Design, Period and Setting A community-based cross-sectional study was conducted from 1 to 30 April 2019. The study was conducted in Gede'o zone, Southern Nations, Nationalities, and Peoples' Region (SNNPR) of Ethiopia. The assessment site was affected by internal displacement due to intercommunal violence along the borders of the Gede'o (SNNPR) and West Guji (Oromo region) zones, which led to large-scale displacement, loss of life, and damage to property. IDP lived in temporary camps at different sites. --- Study Participants and Sampling Procedure A simple random sampling technique was used to select 636 participants. Since IDP were included from three sites (Gedeb, Yirgacheffe, and Dilla), to assure representativeness of the sample, proportional allocation was done to the number of IDPs located in each site. The lists of persons were obtained from the leaders of each site, and participants were selected using a computer-generated random method. For an eligible participant who was not found at their assigned camp, the interviewers revisited the area at another time during the data collection period. The study included all displaced people residing in the Gede'o zone who were aged 15 years and above and were living in collective sites. About 88% were under 45 years of age and those who were severely ill or had difficultycommunicating were excluded from the study. --- Sample Size Determination We determined the sample size by using a single population proportion formula with the assumptions of 36% prevalence of PTSD from studies conducted in South Sudan; 41 0.36= P, 1.96 =Z (standard normal distribution), 95% CI, margin of error 0.04 and after using 10% nonresponse rate total sample size was 636. --- Data Collection Instruments Data was collected using interviewer administered structured and pretested questionnaires. It was collected by six BSc nurses and regularly supervised by two psychiatry professionals. The questionnaire was designed in English and translated to Amharic and back to English to maintain consistency. Data collectors were trained on how to interview participants and explain unclear questions and the purpose of the study. PTSD was measured using the Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5). The PCL-5 is standardized instrument and is a self-report rating scale for assessing the 20 DSM-5 symptoms of PTSD. 43 A total score was computed by adding the 20 items, so that possible scores range from 0 to 80 with a 5-point Likert scale (0 = Not at all, 1 = A little bit, 2 = moderately, 3 = Quite a bit, 4 = extremely) with a cut off point of <unk>33. 43 Validity and reliability of the PCL-5 have been tested and proven on displaced people and refugees in a number of countries, for example, in Iraq (Cronbach's alpha =0.85), 44 and Zimbabwe (Cronbach's alpha =0.92). 45 Depression was measured using the Hopkins' Symptom Checklist-25 (HSCL-25) in which scores for symptom criteria of depression was measured using the 15 depression items from the HSCL-25. 46 This also had a 4-point severity scale 1 = Not at all, 2 = A little, 3 = Quite a bit, and 4 = Extremely. Mean depression scores <unk>1.75 were considered significant for meeting symptom criteria of depression based upon the instrument standards. 46 The reliability and validity of the HSCL-25 have been tested and proven for use with displaced persons in a number of countries. 47 Social support was measured according to the Oslo-3 social support scale which ranges from 3 to 14, those respondents who score between 3 and 8 are considered to have poor social support, a score of 9-11 is considered as having moderate social support, and a score of 12-14 is considered as having strong social support. 48 Other stressful life events are measured by the presence of one or more item from the list of stressful life event questionnaires over an entire life. 49 Socio-demographic factors, substance use history, clinical factors, trauma-and displacement-related factors were used on "yes/no" response questionnaires and were operationalized according to different literature. --- Statistical Analysis Data was entered into the computer using EPI Data version 4.2 and exported to statistical package for social science (SPSS) version 24 for analysis. Descriptive data was summarized using tables. Binary logistic regression was used to identify factors associated with outcome variable. Variables with a P value of less than 0.2 in bivariate regression were included for multivariate logistic regression. Finally, P-value <unk> 0.05 in multivariate logistic regression was considered as statistically significant and the strength of associations was determined using adjusted odds ratio (AOR) at 95% CI. --- Ethical Approval and Consent to Participation All procedures undertaken during data collection were in accordance with the ethical review board of the University of Gondar, Amanuel mental specialized hospital, with the ethical approval number AM/146/4/106 and the Helsinki Declaration. The study was approved by the ethical review board of the University of Gondar and Amanuel mental specialized hospital. The participants were informed about the aim of the study and no identification or names were recorded so as to maintain confidentiality. The study participants were informed of their right to refuse or stop participating at any time during the interview. Finally, data were collected after obtaining written informed consent from the participants. For participants who were found to have PTSD during the study, further assessment of their condition was carried out at a nearby psychiatric clinic. --- Results --- Socio-Demographic Characteristics of the Respondents A total of 625 participants were included in the study with a response rate of 98.3%. The mean age (<unk>SD) of the respondents was 32.98 (<unk>11.22) years, with age ranging from 18 to 79 years. Among the respondents 194 (31.04%) were in the age range of 25-34 years, 328 (52.48%) were male, 345 (55.2%) were married and 292 (46.7%) were attended primary school. Regarding occupation, about 252 (40.3%) were farmers, while 176 (28.2%) were merchants (Table 1). --- Clinical, Psychosocial, Substance and Displacement-Related Factors of Respondents With regard to the the clinical characteristics of the respondents, more than half of the participants (333; 53.3%) had depression, 31 (4.96%) had a family history of mental illness, 36 (5.76%) were ever treated for mental illness and 168 (26.9%) had co-morbid medical illness. Of the total study participants, more than half of the participants (364; 58.2%) had never been previously displaced and 261 (41.76%) had been displaced more than once. About three-quarters of the respondents (480; 76.8%) spent between 9 and 12 months in displacement areas. Regarding the psychosocial characteristics of respondents, more than half of the participants with PTSD (336; 53.76%) had poor social support and most (550; 88%) of the respondents had experienced other stressful life events. With respect to substance use, more than one-third of respondents (194; 31.04%) were lifetime alcohol users, and 133 (21.28%) were current alcohol users (Table 2). --- Trauma-Related Factors Regarding individual trauma type, the most frequent type of trauma experienced by the IDP was the destruction of personal property (422; 67.52%) and a lack of food and water (382; 61.12%). More than half (348; 55.68%) had experienced or witnessed the murder of family or friends. With regard to cumulative trauma events, nearly half (308; 49.28%) of respondents had experienced between 0 and 3 traumatic events and around half (51.8%) of respondents had experienced <unk> 4 of the 16 traumatic events covered by questionnaire. Generally males reported 328 (52.48%) cumulative trauma events and female reported 297 (47.52%). In addition, 157 (25.12%) of the participants had experienced physical abuse in childhood (Table 3). --- Prevalence of Post-Traumatic Stress Disorder Among Internally Displaced People In this study, the estimated prevalence of PTSD was 58.4% with a 95% CI of 55%-61.9%. The estimated prevalence rate was higher among females (60.8%) compared to males (39.2%). --- Independent Variables Associated with Post-Traumatic Stress Disorder Supplementary Table1 shows that variables with a P-value of less than 0.2 in bivariate regression were included for multivariable logistic regression. In the multivariate logistic regression being female, those displaced more than once, depression, witnessing the murder of a family member/friend, destruction of personal property, and cumulative trauma were statistically significant with PTSD at p-value<unk>0.05. Females were 2.35 times more likely to develop PTSD than males (AOR=2.35, 95% CI 1.61 to 3.44). Those who had experienced the destruction of personal property were 1.58 times more likely to develop PTSD than those who The odds of developing PTSD among those with depression were 2.6 times higher as compared to those without depression (AOR=2.6, 95% CI 1.18 to3.78). Participants who had been displaced more than once were 3.69 times more likely to develop PTSD than respondents who had never been displaced (AOR=3.69, 95% CI 2.35 to 5.82). Respondents who had experienced 4 or more of the 16 trauma events included in the questionnaire were more likely to have PTSD (1.9 times more likely for 4-7 traumatic events, 2.9 times more likely for 8-11 traumatic events, and 4 times more likely for 12 or more traumatic events) than participants who had experienced 0-3 traumatic events of the 16 trauma events (AOR=1.9, 95% CI 1.1 to 3.4), (AOR=2.9, 95% CI 2. 3 to 4.1), (AOR=4.1, 95% CI 1.7 to 9.7) (Table 4). --- Discussion The findings from the current study revealed that the estimated prevalence of PTSD was 58.4% with 95% CI 55 to 61.9) among IDP. The prevalence of this study was in line with the study carried out in Sri Lanka (56%). 50 On the other hand, the finding of the current study was lower than study done in Medellin Colombia (88%), 33 and North Uganda (74%). 51 The discrepancy might be due to exposure to different trauma types, in which being abducted was the most frequently reported type in Colombia, 47 and it might be more stressful than destruction of personal property, which was most frequently reported in the current study. 51 Variation in study type and sampling technique might be another difference in the qualitative study and convenience sampling technique used in Colombia, 33 and its result might be more biased --- DovePress and subjective than probability sampling, which was used in current study. The difference in the instrument might be another reason for this variation, PTSD was assessed by using a culturally-validated 24-item PTSD-check list in Colombia, 33 PCL-C for DSM-IV in Nigeria, but PCL-5 with LEC-5 and extended criteria A was used in the current study. 49 It might be also due to a difference in sample size and study setting in which IDPs living in a camp and in the host community was included and a larger sample size was used in northern Uganda, 51 but in this study participants living in the host community were excluded. Contrarily, the estimated prevalence of the current study was higher than the studies carried out in Nigeria (42%), 32 Darfur (54%), 36 Sri Lanka (2.3%), 29 Georgia (23.3%), 52 Iraq (20.8%), 53 Central Sudan (12.3%), 31 and Sindh (9%). 54 The possible explanation for the observed differences could be the difference in tools, in which Nigeria and Iraq's studies used the Harvard trauma questionnaire (HTQ), 32,52 structured interview using DSM-IV-TR was used in Sindh, 54 and the k-section of the Composite International Diagnostic Interview (CIDI) was used in Sri Lanka, 29 but the current study used PCL-5 with LEC-5 and extended criteria A which was modified with a better internal consistent to measure PTSD. 49 An other reason might be duration of displacement; the study in Sri Lanka was conducted after 20 years of forced displacement, 29 after 10 years in Georgia, 52 after 2 years in Nigeria, 32 but the current study was conducted less than 2 years after forced displacement. 2 Hence, the increased duration of displacement was more likely to reduce the magnitude due to recall bias. Variations in type of exposure to trauma, sampling techniques and socio-cultural factors might be another reason. 29,36,53 Females were 2.4 times more likely to have PTSD compared to males. This may be because females have a higher risk of developing PTSD due to a lower threshold from exposure to psycho-trauma compared to males. 33 It might be also due to a direct psychological consequence of rape or sexual abuse, the violent loss of partner, children and of becoming single parent or widow. 36,51 In fact the exposure to traumatic events had high impact among females when compared with males. 36,42 Another reason could be that females tend to show a more emotional and ruminative response to stress. 50,55 This could increase the risk of developing PTSD. Another factor strongly associated with PTSD was depression; participants with depression were 2.6 times more likely to have PTSD when compared to respondents without depression. This could be because participants with depression are more likely to have suffered traumatic experiences than respondents without depression, 55 which in turn increases the likelihood of PTSD development. PTSD was more common among depressed patients than those without depression. Having previous depression and another psychological disorders might be another reason for the increased risk of developing PTSD. 32,50 Regarding frequency of displacement, participants who were displaced more than once were 3.7 times more likely --- DovePress to have PTSD than respondents who were only displaced once. This might be because respondents with repeated displacement were more likely to be exposed to trauma and violence than participants only displaced once, hence repeated exposure to displacement-related trauma might increase the risk of developing PTSD. 56,57 In addition, the destruction of personal property was significantly associated with PTSD in this study. Those who had experienced this event were 1.58 times more likely to have PTSD than those who had not experienced it. This might be because participants feel that those type of losses will be difficult, if not impossible, to replace, resulting in increased psychological distress. 32 Also, following traumatic events like destruction of personal property, acute stress is a typical response, if this problem persists it may increase the risk of developing PTSD. 32 Participants who had witnessed or experienced the murder of family or friends were twice as likely to have PTSD than those who had not experienced this event. This could be because the effect of losing a loved one may resemble the experiences of other types trauma victims, including reminders of the event, negative intrusive thoughts like thoughts of revenge and it may have a significant impact on emotional well-being. 32,58 Those who have witnessed the violent death of a family member might be at an increased risk of developing PTSD. 59,60 Respondents who had experienced 4 or more of the 16 trauma events included in the questionnaire were more likely to have PTSD (1.9 times more likely for 4-7 traumatic events, 2.9 times more likely for 8-11 traumatic events and 4 times more likely for 12 or more traumatic events) than participants who had experienced 0-3 traumatic events of the 16 trauma events. This could be because when an individual is exposed to several traumatic events they have a greater negative influence on mental health than a single, discrete trauma. 56,57,61 Greater exposure to multiple types of traumatic events may predict greater PTSD severity. 51,62 --- Conclusion A high rate of PTSD was found among internally displaced people. Depression, sex, frequency of displacement, witnessing the murder of family or friends, destruction of personal property, and cumulative trauma were found to be significant predictors of PTSD. Therefore, the Ministry of Health should do on-site screening and provide treatment for all IDPs suffering from for PTSD and depression, establishing a referral system for mental health problems is recommended. --- Strength and Limitation of the Study The study has several strengths. First, it included important variables which were not included in previous studies. Second, it used updated standardized instrument for measuring PTSD. Third, validated and standardized tools were used to assess independent variables such as stressful life events and depression. Whereas, including participants or IDPs from a single place (zone), excluding IDPs hosted by relatives or friends or living in unregistered camps, mean there was an inability to consistently match the gender of interviewers and respondents to minimize under reporting of certain sensitive traumatic events, like rape or sexual abuse, and the majority of the study participants were adults; these this could be considered as some of the limitations of the study. --- Data Sharing Statement The data sets used and analyzed during the current study are available from the corresponding author on reasonable request. --- Author Contributions All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, 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 agree to be accountable for all aspects of the work. --- Disclosure The authors declare that they have no competing interests.

Background: Displaced people experience different traumatic events. This can have serious and long-lasting consequences in terms of physical and mental health outcome. Posttraumatic stress disorder (PTSD) is the most frequent mental disorder following traumatic exposure. In 2018 Ethiopia saw the highest number of internal displacement, despite this, less attention has been given to mental health among internally displaced people in the country. This study aims to determine the estimated prevalence and associated factors of PTSD among internally displaced people in the Gede'o zone, south Ethiopia. Participants and Methods: A community-based cross-sectional study was conducted between 1 and 30, May 2019 among 636 participants, who were selected using a simple random sampling technique. PTSD was measured by the Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5). The association between outcome and independent variables was identified by bi-variable and multivariate logistic regression. Finally, variables with P-value less than 0.05 were considered statistically significant at 95% CI. Results: A total of 625 participants were interviewed with a response rate of 98.3%. The estimated prevalence of PTSD was 58.4% with 95% CI 55 to 61.9. In the multivariate logistic regression, being female (AOR=2.4, 95% CI 1.6 to 3.4), depression (AOR=2.6, 95% CI 1.2 to 3.9), displaced more than once (AOR=3.7, 95% CI 2.4 to 5.8), destruction of personal property (AOR=1.6, 95% CI 1.04 to 2.44), witness the murder of family (AOR=2, 95% CI 1.2, 3.9), and cumulative trauma (AOR=4, 95% CI 1.7 to 9.6) were significantly associated factors.In the current study, the estimated prevalence of PTSD was high. Ministry of health should plan routine screening and management of PTSD, depression and linking with available mental health service is recommended.

INTRODUCTION Previous studies examining the grief of parents who lose their child have primarily addressed two aspects. First, the grief expressed by them has been studied. For example, Michon et al. (2003) used a scale to measure the intensity of grief, whereas Olivas (2013) used a form of textual data to illustrate their state of grief through qualitative research. Second, researchers have continuously attempted to explore the factors that influence the grieving process among them. For example, Rando (1983) found that a previous loss tended to be associated with poorer bereavement outcomes among those who lose their child to cancer, whereas Ronen et al. (2010) interviewed parents who lose their child and found that continuing bonds could promote their grief adjustment. Because of language differences and other barriers, however, the state of grief among Chinese shiduers has rarely received scholarly attention. Losing a child causes the most painful and lasting grief (Gorer, 1965). China's One-Child Policy was maintained for approximately 30 years to control the population. This policy ended only recently in 2015. During the several decades of the One-Child Policy, losing an only child became a unique social phenomenon in China. Parents who lose their only child are called'shiduers.' Using census data from 1990, 2000, and 2010 as a basis, Wang estimated that as of 2010, the cumulative number of deceased only children exceeded one million, which corresponds to more than one million families that lost their only child (Wang, 2013). Wang also noted that although the One-Child Policy has ended, the number of future families that will lose an only child will continue to increase for a considerable period of time (Wang, 2016). The results of several studies have suggested that the state of grief of Chinese shiduers is more severe than that of other parents who lose their child. A survey of 226 Chinese women who became shiduers due to earthquakes found that the state of prolonged grief amongst the 116 women who did not give birth again was more severe than that amongst the 110 women who had given birth again (Xu et al., 2014). Furthermore, a cross-cultural study of shiduers in China and parents who lost their child in Switzerland found that those in China scored significantly higher on the prolonged grief scale (Xiu et al., 2016). Therefore, the grief state of shiduers is deserving of research. A Chinese saying states that 'losing one's parent(s) in one's youth, losing one's spouse in middle-age, and losing one's child in old age' are the three great tragedies in life. The shiduers population undoubtedly experiences an unforgettable grieving process. Grief refers to 'a primarily emotional reaction to the loss of a loved one through death. It incorporates diverse psychological (cognitive, socialbehavioral) and physical (physiological-somatic) manifestations' (Stroebe et al., 2001). Qualitative studies have found that most shiduers develop an intense grief response in terms of cognition, emotion, behavior, and physiology (He et al., 2014). If this type of intense grief response persists in the long term, prolonged grief can easily develop. Prolonged grief is also called complicated grief, which is a long-lasting and permeating grief response characterized by longing for or persistent preoccupation with the deceased and accompanied by intense emotional pain (World Health Organisation, 2017). According to another survey, the proportion of shiduers who suffered from prolonged grief was approximately 30% (Shang, 2016). Many factors affect shiduers with regard to the suffering they experience from prolonged grief or from the slow recovery process. The effect of culture on this grieving process has been stressed by scholars. For example, the well-known grief research scholar Neimeyer (2012) argued that 'exporting' the grief model primarily generated in the United States to other cultures might be inappropriate and that grief research should consider the role of different cultures in the grieving process. Studies on the relation between the grief of shiduers and their culture are rare because shidu is a unique social phenomenon in China. Recently, relevant studies have discussed the effect of culture. For example, in Chinese culture, participants in funeral rites are usually a group formed by ties of blood and geography (Jia, 2010). The grieving process for shiduers is affected by the negative influence of'stigmatization' from traditional Chinese culture (Xu, 2014;Zheng and Lawson, 2014). The ritualistic behavior of grieving for shiduers has unique Chinese cultural connotations. For example, according to traditional Chinese customs, some shiduers hold a sacrificial ceremony for the child every 7 days for 49 days after the child's passing (He et al., 2017). However, the objectives of these studies were not to systematically examine the effect of culture. These studies provided only partial information to understand the grief of shiduers from a cultural perspective and lacked in-depth studies of a particular effect of culture. Therefore, the question remains: for shiduers in China, which type of traditional Chinese culture has the most profound effect on their grieving process? China is a country deeply affected by the collectivist culture. Among the numerous types of collectivist cultures, familism culture has an especially profound effect on Chinese society. Familism culture refers to a type of 'ingroup collectivism' in which family members attach primary importance to the family (Schwartz, 1990). In China, however, the word 'family' refers not only to close relatives, such as parents, spouses, and children, but also to a social organization formed by ties of blood or marriage that encompasses nephews, aunts, and other relatives (Chinese Academy of Social Sciences, 2012). The famous Chinese social psychologist Guoshu Yang generalized the social orientation of Chinese people into four characteristics: family orientation (the most important characteristic), relationship orientation, authority orientation, and other orientation (Yang, 2004). In his book The Essentials of Chinese Culture, the famous Chinese thinker Liang (2011) noted, 'Everyone knows that the family is a particularly important relationship in the lives of Chinese people; Chinese people value such relationships much more than Westerners.' The formation of this type of culture is attributed to the family having served as the basic unit of social structure and function in China's traditional agrarian society for several 1000 years. The core of familism culture is a set of relationships of rights and obligations that attach primary importance to the interests of the family in all things, including at the three levels of cognition, emotion, and behavioral tendency. An example at the cognitive level is the importance placed on the continuance, solidarity, and reputation of the family. Examples at the emotional level are a sense of belonging, a sense of responsibility, and a sense of security. Examples at the behavioral tendency level are reproducing one's offspring, interdependence, and striving for the family (Yang, 2004). Bowen (1978) proposed the family systems theory, which considers the family as a functional organic whole. Subsequently, scholars argued that grief is not an individualized experience, and the family, as the most important social organization for an individual, exerts important influences on the grieving process (Detmer and Lamberti, 1991;Kissane and Bloch, 1994). Within the familism culture of China, many grieving activities are shared with family members. For example, making sacrifices and cleaning tombs with the whole family during the Qingming Festival is a way for the family to connect with lost loved ones (Jia, 2005). Thus, against the cultural backdrop of familism, how might the grieving process of shiduers in China be affected? There are many expressions in familism culture regarding carrying on the familial line. All are directly related to shiduers, such as, 'There are three unfilial acts, of which having no posterity is the greatest' and'more children will bring more happiness.' Therefore, for Chinese shiduers,'shidu' means more than just losing their only child. It means losing the hope of having descendants and carrying on the family line, and the continuity of the family line in familism culture is seen as a duty to the ancestors. This unrealized and unfulfilled duty may have negative effects on the grief process of shiduers. In the grieving process of shiduers, familism culture may play an important role. For example, psychoanalysts emphasize the positive role of a container in the grieving process and suggest that other people can facilitate the completion of meaning making and the integration of the life narrative by containing the grieving person's emotions (Rolls, 2007). Familism culture advocates mutual support and help among family members. Does this support allow the family to become a large container for the grief of shiduers? Another survey found that 85.8% of shiduers felt inferior (Fang, 2015). Is this feeling caused by the enormous psychological burden experienced by shiduers due to the importance that familism culture places on reproducing offspring? From a more optimistic perspective, however, the bond and harmony among relatives in familism culture may be beneficial for the grief process of shiduers. To summarize the above research, the present study poses the following questions. How does familism culture play a role in the grieving process of shiduers? Specifically, through which channels does it play a positive role, through which channels does it play a negative role, through which channels does it play both positive and negative roles, and how are these roles played? This study seeks answers to these questions to increase understanding of the grief of shiduers in China from a cultural perspective, both for the enrichment and development of theories on grief and in the hope of providing useful suggestions to psychological and social services aimed at helping shiduers. --- MATERIALS AND METHODS --- Study Context and Design This study is part of the project 'Research on the Effect of Familism Culture on the Grief and Mental Health of Shiduers.' The data for this report came from the qualitative study portion of that project, which was based on a phenomenological perspective and used the semi-structured interview method to survey seven shiduers individually in hopes of understanding the impact of familism culture on their grief. The implementation of this study was approved by the Ethics Committee of the School of Humanities and Social Sciences at Beijing Institute of Technology. All interviewees in this study signed a written informed consent form. --- Study Population, Sampling, and Recruitment We first performed volunteer service at multiple service agencies that help shiduers in Beijing, China, including the 'Homestead for the Psyche' for shiduers established in three subdistricts (a subdistrict is the most basic level of government in Chinese cities) and a self-service organization for shiduers. The subdistrict 'Homestead for the Psyche' had full-time government staff and specialized venues, was open only to shiduers within the area of jurisdiction, and held activities such as singing, dancing, handicrafts, and culinary arts on workdays. The self-service organization for shiduers existed in the form of a WeChat (an instant messaging app) group. The members were shiduers from all areas of Beijing, and the group leader organized occasional gatherings and activities or organized group members to help shiduers who were having difficulties. Based on the objective of this study, we used a non-probability purposive sampling approach. That is, by participating in activities, we observed which of the shiduers were most likely to provide abundant information for the research project and then individually sent invitations to these shiduers to participate in the study. When sending invitations for the study, we explained to the invitees the study's objective, content, possible risks, and the rights of the participants. During the interviews, we continually summarized the themes of the interview content. When every theme had reached saturation, no new invitations for the study were issued. At this time, a total of seven interviewees had participated. --- Participants We sent 12 individual interview invitations; five people refused, and seven people accepted. These seven participants included two males and five females ranging in age from 51 to 74 years with a mean age of 62.7 years. The deceased children of three participants were boys, and the deceased children of the other four participants were girls. The age at which the children passed away was between 6 and 33 years, with a mean age of 24.3 years. The duration since the children had died was between 0.5 and 25 years, with a mean duration of 11.6 years. See Table 1 for more details on the corresponding relations among this information. --- Data Collection The interviews were conducted between June and September 2017. In accordance with the wishes of the interviewees, three people were interviewed at their homes, and four people were interviewed in a quiet room at the activity venue for shiduers. We used semi-structured interviews in which a summarized interview outline was prepared in advance, and detailed inquiries were made depending on the interviewee's answers in the course of the interview. In the first step, a detailed explanation was given to the interviewee on the study's objective, content, possible risks, and the rights of the participants, including the information that the interviewer was about to begin recording. If the interviewee agreed to be recorded, a written informed consent form needed to be signed. In step two, it was inadvisable to begin directly with the themes because the interview themes could easily trigger negative emotions. Therefore, the interviewer first exchanged pleasantries with the interviewee and chatted about topics that were easier to discuss, such as the participant's hobbies. In step three, after exchanging pleasantries and obtaining the consent of the interviewee, the interviewer formally began the interview with four summarized questions in the interview outline: (1) After you lost your child, how do you feel your family influenced you in various aspects, including favorable or unfavorable aspects? (2) Do you feel that the influence you just mentioned was related to traditional Chinese culture, especially traditional culture involving family? (3) In the process of mourning your child and slowly processing the pain in your heart, do you feel that some things in traditional Chinese culture hindered you? If so, what were they? Do you feel that some things in traditional culture helped you? If so, what were they? (4) Is there anything else you want to tell me? In step four, the formal interview ended, and the interviewer observed the interviewee's emotions, asked whether help was needed, and informed the interviewee that relevant resources could be recommended if professional assistance was required. The interviewer paid the interviewee 100 Renminbi (RMB; approximately 16 USD) as remuneration for participating in the study and as an expression of gratitude. The interview duration was 63-120 min, and the total interview duration for the seven people was 585 min. --- Data Analyses In this study, thematic analysis was used to analyze the data. The analyst in the following text refers to the first author of this study, YZ. First, the analyst performed a verbatim transcription of the audio recordings obtained from the interviews. Transcription is an important means of controlling the quality of qualitative research (Steinke, 2004). During transcription, the analyst strived to maintain the original meaning by completely and accurately recording the words spoken by the interviewees, the pauses, and the tone. After the transcription was complete, a transcription text with a total count of 86,696 Chinese characters was obtained. Then, referring to the suggestions of Braun andClarke (2006, 2012), the analyst took the following steps to analyze the data. (1) A full-text reading of the verbatim transcription text was conducted. While reading, the analyst recorded initial thoughts with regard to coding. (2) The analyst generated initial codes based on the text and obtained 1,440 codes. (3) The analyst wrote the name of each code on separate pieces of paper and attempted to organize them into candidate themes. Five candidate themes were created:'relationship with ancestors,''relationship with the deceased child,''relationship with loved ones,''relationship with Tong Ming Ren,'and'relationship with the country.' (4) The analyst discussed the candidate themes with XJ, another author of this study who is a psychologist and has been engaged for many years in research related to the loss and grief of shiduers. The authors agreed that it was appropriate to divide the theme of'relationship with loved ones' into'relationship with spouse' and'relationship with relatives.' In Chinese culture, the spouse and relatives are both considered loved ones, but further discussion between the two authors concerning the text and coding clearly differentiated the shiduers' relationships with their spouses from those with their relatives. Therefore, these groups were divided into different themes. The two authors reached a high degree of consensus after dividing this theme based on multiple discussions. ( 5) The themes obtained from this study as well as the definition and description of the themes were sent to two participants of this study with a request to assess whether the division of themes was appropriate. Both participants expressed a high degree of approval regarding the division of the themes. ( 6) The study report was written based on the developed themes. --- RESULTS Starting from the perspective of familism, this study found that the grief of the shiduers was primarily embodied in various relationships, including those within the following six themes: relationship with ancestors, relationship with the deceased child, relationship with spouse, relationship with relatives, relationship with Tong Ming Ren, and relationship with the country. --- Theme 1: Relationship With Ancestors In familism culture, producing an offspring is an important responsibility, 'continuing the ancestral line' is an obligation to the ancestors, and having no posterity is seen as unfilial. The interviewees who lost their only child were deeply affected by the traditional culture of familism and could elaborate on their understanding of this culture by citing idioms or traditional art forms, with examples provided from Interviewees B and E. Interviewee B called these idioms 'auspicious sayings,'indicating that in his understanding, the opposite situation was 'inauspicious.' Ah,'more children will bring more happiness' is what old people used to say in the past. For example, someone says (asks), 'Why did you give birth to so many children?' (He answers) 'who knows which cloud bears rain?' He is saying that I have many children, so one is bound to be successful....If you do not have children...it means it is a misfortune of a family. 'There are three unfilial acts, of which having no posterity is the greatest'...there are three unfilial acts, and 'having no posterity' means you do not have descendants; it is the greatest unfilial act. (Interviewee B, woman, age 74, child age 29). Look at that little decoration; so many children are climbing on the body of the big Maitreya Buddha. There are many auspicious sayings, like'more children will bring more happiness.' A 100 children painting depicts a lot of children dressed in ancient costumes playing all kinds of games...then, there's that other auspicious Chinese saying that is included on buildings, 'get a pomegranate.' Does a pomegranate actually look good? It just has symbolic meaning because it has many seeds (in Chinese,'seed' sounds the same as'son'), so more children will bring more happiness. (Interviewee E, man, age 68, child age 22). Although shiduers expressed their understandings, changes occurred over time in ideas related to producing offspring. The people of this generation who had lost their only child could clearly understand the connotations of the concept of 'continuing the ancestral line,'but they did not necessarily personally uphold such concepts. In the interviews of this study, Interviewees B, E, and G expressed disagreement with this type of traditional culture and indicated they could feel changes occurring in the culture over time. 'There are three unfilial acts, of which having no posterity is the greatest'; this was for the generation before me. They obviously believe in that saying. As for me, I received a new education, so I do not believe this idea. I feel it is fine that (this concept is) changing (with the times) and has become weaker. In the generation after me, there are dual-income, no kid (DINK) households. (Interviewee B, woman, age 74, child age 29). Like, in this type of situation where there is only one (child), once she was gone-we were originally particular about having a boy or a girl-only a boy can continue the ancestral line. Now, there is only one; since there is no choice, it doesn't matter if it is a boy or a girl....I do not put much stock in this so-called idea of continuing the ancestral line. It is your only child, in any case. (Interviewee E, man, age 68, child age 22). (Speaking of 'there are three unfilial acts, of which having no posterity is the greatest') this thing is basically nonsense...perhaps the last generation was a bit more traditional, and we may be slightly better at not sticking to the saying. In terms of this thing of descendants, I am not particularly concerned with having descendants. (Interviewee G, woman, age 51, child age 25). --- Theme 2: Relationship With the Deceased Child The approach to mourning and burial is an important part of familism culture (Yang, 1992). With regard to the place of mourning and burial, a strong relationship between life and death is achieved among family members through burial at the same or a nearby place. Many shiduers buried the child next to their own parents (that is, the child's grandparents) or their own spouse, as Interviewee C did. Some shiduers also chose or attempted to choose a cemetery with multiple plots in preparation for the shiduer's burial at the same gravesite as the child, as Interviewees D and G did. In addition, the things left behind by the child (such as photographs) served as symbols of the child. Shiduers such as Interviewee C put the left-behind things in their own home and sometimes evoked emotional attachment with the child through the left-behind items. I go (to the cemetery) to visit every year during Qingming Festival. I go once a year and visit my spouse also; they are together. (Interviewee C, woman, age 64, child age 33). After she left, I insisted on having it...it is so expensive here! (Referring to a local cemetery that charged very high fees.) I must put my daughter here even though I have to spend my entire fortune. Since my parents are here, we are very close...she has a double plot, and I will surely be beside her! She is waiting for me. I feel I have no regrets, and I still want to be with her. (Interviewee D, woman, age 57, child age 26). At the time, I originally planned to have all three of us buried together. I said, let us buy a site with three plots, but the site was not available, so we could only let her have a single plot. (Interviewee G, woman, age 51, child age 25). I look at photographs to find the feelings when he was a small child and recall the memories. (Interviewee C, woman, age 64, child age 33). Prior to the rise of research on continuing bonds, Western culture tended to deem communication with the dead through dreams and visual or auditory experiences a psychiatric symptom (Olivas, 2013). However, Chinese familism culture holds a completely different view. For example, a saying exists in familism culture concerning the'spirit in heaven' (Yang, 2000), which can communicate with family members who are still living so that the influence of the deceased individual does not disappear. This'spirit in heaven' mostly refers to one's ancestors; however, this study found that the spirit in heaven of a child had a major influence on the shiduers. Interviewee A felt that his motivation to live was to be worthy of the deceased child. Interviewee B thought that she had to pull herself together because only by being alive and well would there be a person in this world who missed the child. Interviewee G believed the child went to 'another world,'one not completely separated from the real world in which the shiduers lived, and the two worlds were linked through some sort of mysterious channel; therefore, the child communicated with her through dreams, hallucinations, and other activities. Interviewee D believed that after she dies, she will go to the world where her child is and meet her. I have to live and be strong. The most important reason is that I (must) be worthy of my dead child. (Interviewee A, man, age 67, child age 29). How did I come around at the time? I thought that if we were both in good health, then even in this world, there would still be people who cherished his memory, who still thought about him. If our health was bad and we die, then it would be completely over; there would be no one to think about him. In this way, we both came around later. I had to pull myself together. (Interviewee B, woman, age 74, child age 29). On the second day, she returned in a dream...later that night, she embraced me, and the two of us slept for a night. It was equal to saying a kind of goodbye; it seemed similar to saying goodbye. (Interviewee G, woman, age 51, child age 25). I was on an outbound flight and reached the skies over Montreal. I was sitting next to the porthole on the airplane and suddenly heard my daughter calling me, calling with vigor, 'Mom! Mom!' I was a bit stunned at the time when I heard the first sound. Afterward, she called two more times. It was unlike her usual (soft) calling, 'Mama, Mama.' Hers was a very loud shout, 'Mom!', as if afraid I could not hear. I slowly turned toward the porthole and looked outside. I said,'Are you calling for me? Are you calling for Mama?' (The interviewee cried and became silent for 40 s) I said, 'Mama has come. I will bring you back.' Then she did not call out anymore. (Interviewee G, woman, age 51, child age 25). In the future, I will be with my daughter. We will meet each other there. She is definitely waiting for me. She thinks that the later I come the better. She is fine there. I do not need to rush there. (Interviewee D, woman, age 57, child age 26). --- Theme 3: Relationship With Spouse This study found that the obligation to produce offspring and family unity proposed by familism culture generated conflict in the shiduers. After the child passed away, the shiduers faced choices in terms of how to handle their relationships with their spouses. Should they maintain a good relationship with their spouses in accordance with the obligation of family unity, or should they vent emotions in the home because of their inability to satisfy the obligation to produce offspring? Should they go so far as to continue to produce offspring through divorce and remarriage? The spousal relationships of different shiduers may go in different directions. Some people are affected by the grief of losing an only child and become irritable and prone to conflicts with their spouse, particularly soon after losing an only child, as in the situation mentioned by Interviewee A. None of the interviewees in this study divorced due to the death of the child, but Interviewee F lashed out when speaking of the phenomenon of men who lost their only child divorcing and remarrying to produce another offspring. Shiduer spouses who supported each other and helped each other in simple ways were not lacking. Interviewee F talked about the feeling of 'depending on each other for survival' with her husband. Interviewee C's husband passed away a dozen years ago; she personally witnessed the situation of people with spouses who had each other when they lost their only child, and she sighed with heartfelt emotion and with some envy. After losing an only child, the first obstacle for the young parent is marital crisis. Once the child dies, both people feel miserable. People lose their reason when they are miserable. Sometimes, you may not find me as pleasing to the eye, and I also may not find you as pleasing to the eye. There is no other place to vent, so one takes things out on the other. (Interviewee A, man, age 67, child age 29). You don't want your spouse, right? You trade her in for a younger one to give birth to a child for you. How old are you now? Speaking based on my age, over 50. You want another one. You live another 30, can you live for 30 more years? In the end, you get a widow and a child. Just when (you) are needed, you are gone. Are you not cheating others? I disapprove of this. I feel there is no need for this! Having gone through thick and thin together for so many years, this is the time when you are needed; you have no conscience! (Interviewee F, woman, age 58, child age 6). No matter how you look at it, having a spouse is having someone to rely on. You lay there and can't move; he cooks for you and talks with you. You don't feel well, so let's go to the hospital to be seen. At least there is someone who cares about you. --- Theme 4: Relationship With Relatives The relatives discussed here refer to family members other than ancestors, the deceased child, and the spouse. Relationships with relatives are established through ties of blood or marriage. Under the influence of the concept advocated by familism culture that 'family members must stick together,'the relatives of shiduers often gave the shiduers some support but were also subject to the influence of the concept in familism culture that 'having more children and grandchildren is lucky; having no descendant is inauspicious.' Relatives often believe that shidu is extremely unlucky; it cannot be mentioned to avoid upsetting the shiduers. Thus, on the surface, the support of relatives is often not at an emotional level. For example, they may provide material help or help with activities or they may visit the child's grave together, but the motivation and emotions for providing these types of support often were not expressed, as described by Interviewees A, B, and E. (With relatives) sometimes we visit each other; sometimes they come over to see us. For example, if I were sick and hospitalized, they would all come to the hospital to visit me. This is care, right? (Interviewee A, man, age 67, child age 29). Although they didn't say it clearly, I can understand (their meaning): 'although your family is incomplete, you still have an intact big family.' I feel it is this way. For example, my birthday, in the past, they have never celebrated my birthday, and also my husband's birthday. (After the child passed away,) they organized a birthday celebration for us...They said to me, 'Tell us right away if you have anything going on! You have to tell us!" Don't hold out and keep it to yourself, especially things you need help with. Don't treat us like outsiders'....This issue is not discussed at all in interactions with relatives...Everyone talks about his/her work, life, family life, not about this event in our family. No one talks about it...I feel the way everyone treats us is a type of respect. They don't want to open your scar. (Interviewee B, woman, age 74, child age 29). The child is buried in Wanan (name of a cemetery). I must go every year, and the relatives also go. Sometimes we go together; sometimes they go on their own. I'm the eldest in my family...at the time, the effect was deeper because I was the first among several brothers to have a second generation. Afterward, it lessened, and now I'm also less affected. The relatives don't bring up this matter, and it's slowly fading. (Interviewee E, man, age 68, child age 22). Theme 5: Relationship With Tong Ming Ren 'Tong Ming Ren' in this study refers to other shiduers. Most shiduers like to be with Tong Ming Ren and are able to feel family like comfort from this type of togetherness. Although Tong Ming Ren are not each other's family members, the mode by which they get along is very similar to that of family members. In Beijing, the government provides shiduers with specialized activity venues, most of which are titled with the name 'XX Homestead.' In the narratives of shiduers, 'homestead' and 'loved ones' were words that appeared often, suggesting that the Tong Ming Ren were quasi-family members without ties of blood or marriage, as indicated by the narratives of Interviewees C, D, and F. To us, these people who lost the only child, having a homestead seems to evoke a kind of feeling like being at home. (Interviewee C, woman, age 64, child age 33). I am now consciously increasing the frequency (of interactions with Tong Ming Ren). Why? I feel comforted. (Interviewee D, woman, age 57, child age 26). All of us voluntarily joined this group. After joining, everybody helps each other if anything happens. It is just like being a volunteer. If something happens, everybody would especially remember with concern. After all, since our hearts have suffered trauma, we can understand each other. Perhaps at the time when she was irritable, she would say something we didn't like to hear, but we could all understand it was due to being troubled by the wounds. We could understand feeling some irritability, but people in general didn't understand. When all was said and done, because she saw her own loved ones after coming here, that is, seeing us come, these Tong Ming Ren, it was just like her loved ones, she naturally...could not help it. But after it was over, she knew...after getting under control, she would apologize on her own, knowing that, 'I did something wrong.' Some people could not stand it; 'You have mental problems.' No! It was because she had wounds for many years that troubled her. In actually seeing loved ones, she could vent her temper a bit; this was the case... (Speaking of the name 'homestead, ') yes, I treat it as my parents' home. (Interviewee F, woman, age 58, child age 6). --- Theme 6: Relationship With the Country In Chinese, 'country' is pronounced 'guo ji

Shidu is the Chinese transliteration for 'losing an only child,' which indicates the death of the only child in the family. Shidu is a unique social phenomenon resulting from the One-Child Policy implemented in China for several decades. Shiduers are parents who have lost their only child. The grief research scholar Neimeyer (2012) argued that grief research should consider the role of different cultures in the grieving process. Familism culture is a collectivist culture that has a profound effect on Chinese society and is likely to produce a significant effect on the grieving process of shiduers; however, this effect has not yet received systematic attention in research. To explore the effect of familism culture on the grief of shiduers, we conducted semi-structured personal interviews in Beijing, China, with seven shiduers. The study results show that the effect of familism culture on the grief of shiduers includes three levels: cognition, emotion, and behavior. These levels are reflected in a variety of relationships, including relationships with ancestors, the deceased child, the spouse, relatives, Tong Ming Ren (the Chinese transliteration of 'people who share the same fate'), and the country. The first four types of relationships are reflections of 'direct familism culture,' and the latter two types of relationships are reflections of 'extended familism culture'. The relationships with the deceased child, relatives, and Tong Ming Ren are mainly supportive; the relationship with ancestors is mainly stressful; the relationship with the spouse has a dual nature; and the relationship with the country is contradictory. Over time, shiduers have abandoned the concept of familism culture and have moved toward reducing stress and increasing supportiveness. Psychological professionals, social workers, and government staff may refer to the results of this study to help shiduers obtain support and reduce stress from the described relationships. Specific suggestions are provided in the text.

to hear, but we could all understand it was due to being troubled by the wounds. We could understand feeling some irritability, but people in general didn't understand. When all was said and done, because she saw her own loved ones after coming here, that is, seeing us come, these Tong Ming Ren, it was just like her loved ones, she naturally...could not help it. But after it was over, she knew...after getting under control, she would apologize on her own, knowing that, 'I did something wrong.' Some people could not stand it; 'You have mental problems.' No! It was because she had wounds for many years that troubled her. In actually seeing loved ones, she could vent her temper a bit; this was the case... (Speaking of the name 'homestead, ') yes, I treat it as my parents' home. (Interviewee F, woman, age 58, child age 6). --- Theme 6: Relationship With the Country In Chinese, 'country' is pronounced 'guo jia'; 'jia' means 'family.' Chinese people often speak of the relationships with their own families and the country as relationships with the'small family' and the 'big family,'respectively. Therefore, the country also has a cultural connotation of family to Chinese people. The loss of the only child is related to the state policy; therefore, the feelings of shiduers toward the country were relatively conflicted. On the one hand, resentment and loss were expressed; on the other hand, reliance on the country was very much desired, similar to children at home who want to rely on their parents, as stated by Interviewees F and G. For this generation of shiduers, obedience to the state had been taught since childhood, and the shiduers were similar to children who were afraid to disobey their parents, as stated by Interviewee C. When government staff organized group activities for shiduers, the shiduers were proud of showing 'conscientiousness' and not being'mischievous,'as stated by Interviewee F. In my time, having one was being advocated already. They said it was good to give birth to one. You had resentment...that was the system set by the state. We dared not have it, and what could you do if you had it? In any case, at the time we just listened to the leader on everything, listened to the state. (Interviewee C, woman, age 64, child age 33). In general, like in our case, if the subdistrict organizes activities or something where we can move around in most conditions, we would participate. Because, after all, to put it plainly, the party and the government are quite concerned about this, so everyone is willing to go. Also, after going, these people are very conscientious. If you say, let's gather, they would all return at the appointed time, unlike those mischievous types who don't return at the appointed time. No, they are very obedient and very willing to participate in this activity. (Interviewee F, woman, age 58, child age 6). (Speaking of the lack of assistance) People like us have a sense of loss; he is not complaining, he is lost. At the outset, people said, I will make a contribution to the country; if the country doesn't let us have it (a second child), then we are willing to not having a second child; it is fine either way. Except now, when we need the country to manage us, there is no one. We are old and need someone to take care of us, but there is no one. He has a special sense of loss. Once the sense of loss is great, why can't he complain? (Interviewee F, woman, age 58, child age 6). There is hate, but there is also a desire for reliance because, how to say it after all, I am certain that in the end we still have to rely on the government. Personal power is still nothing...state policy, to the entire group that lost an only child, is truly beneficial to the whole group. (Interviewee G, woman, age 51, child age 25). In general, if you say you question the country's policies, then it is a bit. --- DISCUSSION --- Presence of Familism Culture in the Relationships of Shiduers Xiaotong Fei, a well-known Chinese sociologist, used the following analogy to describe the closeness of interpersonal relationships among Chinese people: when a stone is thrown into water and the entry point is used as the center, rings of ripples are generated from the inside to the outside; the distance from the ripple to the center of the entry point represents the closeness of the relationship (Fei, 2012). To many Chinese people, family members are the ripple closest to the entry point. This is the deep influence of several thousand years of China's agrarian society. In traditional Chinese society, the family is the basic unit of structure and function. This understanding differs from Western society, in which the individual is the basic unit (Yang, 2000). In this study, familism culture was embodied in the lives of the shiduers in a variety of relationships, including relationships with ancestors, with the deceased child, with the spouse, with relatives, with Tong Ming Ren, and with the country. These relationships reflected the grief of the shiduers from different angles. Losing an only child is a traumatic event resulting in the loss of an important relationship, which can damage an individual's sense of security, sense of control, self-esteem, and sense of trust in the environment (Herman, 1992). 'Relating to others' was found to be an important indicator of post-traumatic growth (Tedeschi and Calhoun, 2004), suggesting that grief caused by the loss of a relationship needs to be rehabilitated with other relationships. In the relationships of the shiduers with their ancestors, the deceased child, the spouse, the relatives, Tong Ming Ren, and the country, the first four types of relationships are relationships with living or dead family members. In familism culture, death does not affect an individual's position as a family member; the saying goes, 'born as a member of a certain family, die as the ghost of a certain family' (Wu, 2011). Additionally, death does not affect continued concern for the family, as indicated by the common Chinese saying, 'the spirits of the ancestors in heaven' (Yang, 2007), which suggests that the'spirit in heaven' sees whether the behavior of the living is appropriate and may both protect and punish living family members. These four types of relationships do not exceed the connotations of familism culture and may be called 'direct familism culture'. In the past, discussions on the connotations of familism culture were usually within the scope of 'direct familism culture.' For example, Guoshu Yang stated that the connotations of familism culture included unity and harmony, reproducing for the family, and making the family financial situation prosperous (Yang, 2004). This understanding contrasts with the results of the present study in which unity and harmony are the focus for relationships with relatives, whereas reproducing for the family and making the family financial situation prosperous are mainly obligations to the ancestors. In addition, although the relationships with Tong Ming Ren and with the country cannot be covered in a strict definition of familism culture, the nature and the emotions contained in these two types of relationships are quite similar to the first four types of relationships and may be considered an 'extended familism culture.' One case study argued that the relationship between shiduers and Tong Ming Ren can act as a partial substitute for the deceased child's affections (Chen, 2014). In this study, interviewee F directly called Tong Ming Ren 'loved ones,'which is a vivid statement. With regard to the relationship with the country, due to the influence of 1000s of years of 'loyalty and filial piety culture' in China, a type of conflict is reflected in the emotions of the shiduers toward the country. On the one hand, the One-Child Policy is one of the reasons for shidu, and shiduers may harbor resentment. On the other hand, shiduers have often received patriotic education since they were young and see 'having utmost loyalty to the country' as their obligation. Although 'having no descendant' is a type of unfilial act against the ancestors, in the same vein, a saying exists in the Book of Filial Piety linking'substitute filial piety with loyalty to the country'; the saying unites being loyal to the country with being filial to parents. Because the country is the 'big family' and the individual family is the'small family,''giving up the small family for the big family' is an act praised by Chinese culture. At this level, the unfilial act of shiduers against the ancestors can find a basis for forgiveness in the culture. Because China is a society that places importance on relationships, Chinese people often have an interdependent self-construct in which the self is defined through relationships with important objects (Markus and Kitayama, 1991). Therefore, understanding the described relationships is conducive to a deep understanding of the grief of shiduers and to understanding how shiduers view themselves after their loss. --- Support and Pressure of Familism Culture on the Grief of Shiduers Research has shown that shiduers not only need to handle the pain of loss but also face pressure imposed by the social context (Wang et al., 2017). However, this research did not indicate how pressure from the different areas differs. A study found that social support and the subjective sense of well-being in shiduers showed a significant positive correlation (Yao et al., 2016), but that study did not indicate how support from the different areas differed. The effect of the six types of relationships on the grief of shiduers found in this study is mainly reflected in two aspects: support and pressure. The relationships with the deceased child, with relatives, and with Tong Ming Ren are mainly supportive. Shiduers gain strength by staying connected with the child; for example, an interviewee in this study mentioned burying the child beside her future gravesite. Furthermore, making funeral arrangements according to the interviewees' own beliefs helped them gain a sense of control over life (Jia, 2010). Relatives provided some material or transactional support. Tong Ming Ren can provide emotional support on the basis of mutual understanding. Therefore, the deceased child, relatives, and Tong Ming Ren provide support to shiduers from different angles. In the introduction portion of this paper, we posed a question: familism culture advocates mutual support and help among family members; does this support allow the family to become a large container for the grief of the shiduers? The results of this study suggest that support from the first three types of relationships may provide a huge container. For example, the results section presented Interviewee F's mention of a person who lost her only child and vented her temper on the Tong Ming Ren, but the Tong Ming Ren assumed a very tolerant attitude. According to psychoanalytic theory, such a container is conducive to shiduers, allowing them to rebuild a sense of security and a sense of trust in the environment (Symington and Symington, 1996). Another example is Interviewee G's mention of communication with the deceased child through her own dreams and auditory experiences. One study found that after-death communication (i.e., communication with the deceased child through visual, auditory, or dream experiences) played a positive role in the grieving process of shiduers (Olivas, 2013). In another example, Interviewee B mentioned that her relatives repeatedly reminded her to ask for any help that she needed; this situation increased the availability of her social support. One study showed that the availability of social support amongst the elderly positively predicts their social functioning (Guo et al., 2017). Furthermore, according to the Selah grieving model of Cacciatore (2012), providing community service, helping others go through the grieving process smoothly, and other acts that require social functioning are behavioral indicators of the adaptability of the grieving person. A study found that Chinese people experienced stronger grief and worse health than Americans did in the initial grieving period, but the feeling of pain and self-reported health conditions of Chinese people were better than those of Americans after 18 months (Bonanno et al., 2005). This finding may be due to the positive effect of these supportive relationships. The relationship with ancestors is mainly stressful. This type of pressure originates from the emphasis in familism culture that posterity must fulfill obligations to the ancestors by'reproducing offspring.' If the obligation is not fulfilled, those who fail to continue the lineage feel ashamed, thereby causing a decrease in the level of self-esteem in shiduers (Hou, 2015). The relationship with the spouse has a dual nature. On the one hand, some shiduer spouses provided each other with concern and care in accordance with the requirement for family unity and harmony requirement within familism culture, especially spouses who became shidu for longer periods of time. On the other hand, the propensity for familism culture to condemn a lack of offspring prevented the shiduers from recovering from their deep sorrow and made it easy for contradictions to arise between certain shiduers and their spouses, especially those who had not been shidu for long. The relationship with the country is contradictory because support and pressure coexist. On the one hand, the concern of the country for shiduers makes them feel warmth and a desire for reliance on the country, similar to a child's reliance on adults at home. On the other hand, most shiduers feel this type of support is insufficient. Therefore, although they may feel the country's assistance is inadequate, pressure comes from concerns about how to live well in the future. In addition, because of the emphasis that familism culture places on parental authority, most shiduers have difficulty expressing dissatisfaction with the government (the 'big parent'). For example, Interviewee G discussed the continuation of the One-Child Policy for several decades, which was associated with numerous shidu families. Emotions of dissatisfaction were present, but she did not directly criticize the government; rather, she spoke through euphemisms. This question was also raised in the introduction portion. For example, one survey found that 85.8% of shiduers felt inferior (Fang, 2015). Thus, the question arises: is this feeling caused by the enormous psychological baggage placed on to shiduers by the importance familism culture attaches to producing offspring? No obvious'stigmatization' components were found in this study in this stressful relationship with the country. This type of situation may be due to the self-stigmatization of shiduers; however, because the interviewees of this study all lived in a relatively inclusive and open major city, specific causes require further study. The study results suggest that shiduers and their family members are abandoning some aspects of familism culture. For example, although the interviewees in this study were very clear on the obligations required by familism culture to ancestors, such as 'continuing the ancestral line,'these shiduers no longer upheld all of these concepts and were therefore subject to less pressure in this respect. Additionally, in this study, many of the interviewees reported support from relatives, and no interviewees reported discrimination from relatives. This finding suggests that over time, the stigmatization experienced from 'having no descendant' has decreased. --- Recommendations for Psychological and Social Professionals and the Government Psychological and social professionals and the government may refer to the results of this study to help shiduers obtain support and reduce stress from the described relationships. For example, the cultural connotations of continuing the ancestral line can be discussed with shiduers, who can be encouraged to abandon this type of cultural expectation. They can be helped to establish a positive connection with the deceased child that allows them to hold the child in their hearts and to bravely face a new life. When necessary, counseling or family therapy for partners who lost their only child can be provided to improve the interpersonal skills of the partners to make the relationship between them more supportive. They can be counseled in communication skills that help them in relationships with relatives and that encourage them to ask for help from relatives to resolve difficult issues in their lives. The shiduer population can be helped by the establishment and improvement of self-service organizations, that is, the group of 'Tong Ming Ren.' The government needs to increase assistance efforts and care for shiduers, thereby allowing shiduers to truly feel warmth from their 'big family,'the country. --- Limitations All interviewees in this study came from Beijing, a mega-city with an inclusive and open cultural atmosphere. The support and pressure that shiduers in Beijing experienced might differ from that in small cities and rural areas. Therefore, caution is needed in interpreting the results of this study, especially with regard to the support and pressure experienced in the six described types of relationships. Chinese familism culture views the status of men as more important and emphasizes the man's authority in the household (Yang, 2000). Because of the cultural value of this role, men are often ashamed to place themselves in a position of weakness and seek help. As such, far fewer male shiduers than female shiduers were willing to participate in the activities of the service agencies. Based on the observation of this researcher (no accurate count was made), the number of male shiduers who participated in activities was approximately one-fifth that of female shiduers. The sampling location of this study was a service agency for shiduers; therefore, finding male shiduers as subjects presented some difficulties. In fact, only two of the seven participants of this study were men. In addition to this gender imbalance, another limitation of this study was the heterogeneity of the age range for the deceased children of the participants in this study (6-33 years) and the length of time since the child's passing (0.5-25 years). --- CONCLUSION In this study, six important relationships were identified in the grieving process of shiduers: relationships with ancestors, with the deceased child, with the spouse, with relatives, with Tong Ming Ren, and with the country. The first four types of relationships are relationships with family members, embodying the effect of 'direct familism culture' on the grief of shiduers. Although the latter two types are not relationships with family members, they have characteristics of the relationships with family members, embodying the effect of 'extended familism culture' on the grief of shiduers. Among these relationships, the relationships with the deceased child, with relatives, and with Tong Ming Ren are mainly supportive; the relationship with ancestors is mainly stressful; the relationship with the spouse has a dual nature; and the relationship with the country is contradictory. Over time, shiduers have gradually abandoned the influence of familism culture, causing the effect of familism culture on the grief of shiduers to be mainly positive. Understanding these relationships of shiduers is useful to psychological and social professionals and to the government to help shiduers obtain support and reduce stress, thereby enhancing their quality of life. --- ETHICS STATEMENT This study was carried out in accordance with the recommendations of the Ethics Committee of the School of Humanities and Social Sciences at Beijing Institute of Technology with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Ethics Committee of the School of Humanities and Social Sciences at Beijing Institute of Technology. --- AUTHOR CONTRIBUTIONS XJ designed the study. YZ performed the interviews, analyzed the data, and wrote the manuscript. --- Conflict of Interest Statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Shidu is the Chinese transliteration for 'losing an only child,' which indicates the death of the only child in the family. Shidu is a unique social phenomenon resulting from the One-Child Policy implemented in China for several decades. Shiduers are parents who have lost their only child. The grief research scholar Neimeyer (2012) argued that grief research should consider the role of different cultures in the grieving process. Familism culture is a collectivist culture that has a profound effect on Chinese society and is likely to produce a significant effect on the grieving process of shiduers; however, this effect has not yet received systematic attention in research. To explore the effect of familism culture on the grief of shiduers, we conducted semi-structured personal interviews in Beijing, China, with seven shiduers. The study results show that the effect of familism culture on the grief of shiduers includes three levels: cognition, emotion, and behavior. These levels are reflected in a variety of relationships, including relationships with ancestors, the deceased child, the spouse, relatives, Tong Ming Ren (the Chinese transliteration of 'people who share the same fate'), and the country. The first four types of relationships are reflections of 'direct familism culture,' and the latter two types of relationships are reflections of 'extended familism culture'. The relationships with the deceased child, relatives, and Tong Ming Ren are mainly supportive; the relationship with ancestors is mainly stressful; the relationship with the spouse has a dual nature; and the relationship with the country is contradictory. Over time, shiduers have abandoned the concept of familism culture and have moved toward reducing stress and increasing supportiveness. Psychological professionals, social workers, and government staff may refer to the results of this study to help shiduers obtain support and reduce stress from the described relationships. Specific suggestions are provided in the text.

Background Alcohol consumption is an integral part of many cultural, religious, and social practices worldwide [1,2]. However, in recent years, the volume and risky pattern of consumption pose a significant public health threat to the consumer, family, friends, and the larger society [3][4][5]. Harmful alcohol consumption results in health, social, and economic burden on both the individual and others in both immediate and distal environments [4]. Alcohol is a commonly used substance among the youth in tertiary institutions [5,6]. In many instances, alcohol serves as a gateway to the usage of other psychoactive substances [6]. Tertiary education is a transitional period characterized by autonomy or independence from family control, and self-decision making, academic pressures, forming social groups, and sharing living quarters with new students with diverse cultural values [5,[7][8][9], and peer influence [9][10][11][12][13]. Other factors shown by researchers to predispose students to alcohol consumption include; ease of availability and accessibility of alcohol [14], academic pressures [12,15], family member use of alcohol [8], and psychological distress [3,16]. These features of tertiary institutions' environment elsewhere are synonymous with those in the Ghanaian setting [17]. Globally, alcohol consumption is the leading causal factor for the overall morbidity and mortality burden [18,19]. Harmful alcohol consumption serves as a risk factor in over 200 diseases and injuries [4]. These diseases and injuries contribute to about 3million deaths annually, representing 5.3% of all mortality globally and 132.6 million (5.1%) disability-adjusted life years (DALYs) [2,4]. About 13.5% of all mortality cases in young people aged 20-39 years were attributed to excessive alcohol consumption [2]. However, the association between alcohol consumption and its negative health implications remains complex and inconclusive given the protective effects of moderate alcohol consumption on the human body [19]. Alcohol consumption during the early years is associated with negative consequences such as alterations in attention, verbal learning, and memory, along with altered development of major parts of the brain [20]. These negative consequences subsequently lead to behavioural, emotional, social, and academic problems in later life [21]. Researchers have shown that harmful alcohol consumption leads to the development of cardiovascular diseases [18], cancer [22], liver diseases [23], hepatitis [24], risky sexual behaviours and sexually transmitted diseases [25,26], mental and behavioural disorders, injuries, violence [2], and poor academic performance [27][28][29]. Most countries in sub-Saharan Africa are experiencing rapid economic, social, and cultural transitions which have created an avenue for increased and socially disruptive use of alcohol [30]. Ferreira-Borges et al. [31] asserted that alcohol consumption and disease burden in Africa are expected to increase, but that policymakers have paid little or no attention to the issue of increasing alcohol consumption. Studies conducted in various parts of Africa reported a significant prevalence of alcohol consumption among tertiary students. For instance, reported lifetime and current prevalence of alcohol consumption ranged from 16.9 to 34.5% in Ethiopia [8,9,32], 31.1 to 78.4% in Nigeria [33,34], 31.9% in Botswana [5], 50.7-63.2% in Kenya [35,36], and 2.7% in Sudan [37]. Limited studies (example [17,38]) have been conducted on alcohol consumption among tertiary students in Ghana. This makes it difficult to implement effective interventions due to the dearth of literature on the magnitude of alcohol consumption and its contributory factors. In Ghana, recent evidence showed that there has been an increase in the promotion, competition, and popularity of alcohol beverages in both the media and non-media sources [38]. These alcoholic beverages are considerably cheaper than soft drinks. As a result, young people (majority of which are students) tend to consume alcoholic beverages due to its accessibility and low cost [38]. Anecdotally, there has been an increased proliferation of drinking spots, night clubs, and alcoholic vending sites in the Hohoe Municpality. This has also resulted in easy accessibility to alcoholic beverages by students in the Hohoe Municipality. Hence, the present study sought to determine the prevalence of alcohol consumption and its associated factors among tertiary students in the Hohoe Municipality of Ghana. The findings are likely to inform the development of school-based programmes and interventions aimed at reducing alcohol consumption and promoting healthy lifestyles among students. --- Methods --- Study setting We conducted the study in the Hohoe Municipality, which is one of the seventeen (17) administrative municipalities/districts in the Volta region. It shares borders with the Republic of Togo on the East, Afadjato district on the Southeast, south by Ho Municipality, Southwest by Kpando Municipality, Northwest by Biakoye district, and on the North with Jasikan district [39]. According to the 2010 Population and Housing Census, the municipality has a population of 167, 016 with a growth rate of 2.5%. Females make up 52.1% of the entire district population whilst males represent 47.9% [39]. The district has a total land area of 1172 km 2. In terms of education, 0.8% of the inhabitants in the municipality are in tertiary institutions [39] --- Study design Institutional-based cross-sectional study was conducted among tertiary students in the Hohoe Municipality using the quantitative technique. Tertiary students from three (3) institutions were recruited for the study. Students on short courses or sandwich programmes, absent on the day of data collection, and sick or had difficulty to communicate were excluded from the study. We relied on the strengthening the reporting of observational studies in epidemiology statement writing the manuscript. --- Sample size determination and sampling procedure The sample size for the study was determined using the Cochran formula; n = z 2 x p <unk>1-p<unk> d 2 [40]. Where n = required sample size, z = reliability coefficient (z-score) of 1.96 at 95% confidence level, p = estimated proportion who use alcohol, and d = margin of error of 5% (0.05). With a 44.9% prevalence of alcohol consumption among students in Cape Coast Metropolis [41] and a 10% nonresponse rate, the estimated sample size for the study was 418 tertiary students. A two-stage sampling technique was used to recruit the 418 tertiary students. A simple random technique was first used to select three tertiary institutions using ballotery without replacement method. The three schools that were randomly selected were UHAS, MTS, and FRANCO. In the second phase, we employed a proportionate stratified sampling method to apportion the sample size per each institution based on the students' population size. We calculated the sample size for each school as the product of the total students' population in a selected school and the total sample size for the study divided by the total students' population in the three schools. With a total students population of 2001 from the three selected schools as at the time of the study, the calculated sample size per each selected school was UHAS (125), MTS (65), and FRANCO (228). At the school level, a simple random sampling technique using the lottery method was used to recruit the students to include in the study. Pieces of paper with inscription "YES" or "NO" written on them were used and the students were asked to pick one each. Any student who picked "YES" was given a consent form and both parental/guardian consent and assent forms to those below 18 years for their voluntary approval to take part in the study. We repeated the procedure in all selected schools until we obtained the required sample size. --- Data collection procedure A self-administered structured questionnaire was used to collect data from the students. We developed the questionnaire from a review of pertinent literature on the subject [34][35][36]. Detailed questionnaire has been attached as a supplementary file. We pretested the developed questionnaire among 42 tertiary students who were not part of the actual study in the Hohoe Municipality. We then administered the pretested questionnaire to the students with the aid of five ( 5) trained data collectors. We structured the questionnaire into four (4) sections. These sections comprised the sociodemographic characteristics, the pattern of alcohol consumption, psychosocial factors of alcohol consumption, and perceived effects of alcohol consumption. We included students aged 18 years and above who signed the written informed consent. For those below 18 years, we sought written informed consent from their parents or guardians and child assent form from the student. Both written parental or guardian informed consent and child assent forms were required before the students aged below 18 years were included in the study and given a questionnaire to complete. --- Statistical analyses Data collected from the respondents were entered into EpiData 3.1 and exported into Stata version 16.0 for the analysis. The exported data were cleaned, validated, and coded for analysis. We presented categorical variables using frequencies and percentages in tables and charts. A Chi-square test was first performed to determine the relationship between lifetime alcohol consumption and the explanatory variables. We performed a binary logistic regression analysis to determine the strength of association between lifetime alcohol consumption and the explanatory variables. All the variables that showed statistical significance were placed in the regression model. We presented the results of the regression analysis using crude odds ratio (COR) and adjusted odds ratio (AOR) with their corresponding confidence interval (CIs) and p-value. A p <unk> 0.05 was considered statistically significant, showing the level of precision. --- Ethical issues We obtained ethical approval for the study from the Ghana Health Service Ethics Review Committee (GHS-ERC) with a reference number (GHS-ERC:92/10/16). We strictly adhered to the ethical guidelines and protocols put forth by the GHS-REC throughout the study. We also sought institutional approval from the Ghana Education Service and Municipal Health Directorate, Hohoe, and Heads of the various institutions. Before the commencement of data collection, written informed consent was sought from students aged 18 years and above before inclusion in the study. For students aged below 18 years, written informed consent was obtained from each student's parents or guardian before participating in the study. Additionally, written parental or guardian consent and child assent were sought from each student before inclusion in the study. All ethical issues concerning research among humans were strictly followed. Respondents' rights to withdraw from the study, confidentiality, participants' privacy, risk, and benefits involved in the study were duly explained to the students after which interested respondents voluntarily signed the written consent or assent forms. --- Results --- Sociodemographic characteristics of the tertiary students Of the 418 tertiary students, 51.4% were males. The majority (65.3%) of the students were aged 21-25 years with the mean age of 22.4 <unk> 3.1 years. Almost all the students (95.0%) were single. Most of the students were Christians (87.1%) and residents on school campuses (64.6%). In the year of study, 39.0% were in the first year as shown in Table 1. --- Pattern of alcohol consumption among the tertiary students The lifetime prevalence of alcohol consumption was 39.5%. Out of them, 49.1% were still using alcohol, translating to an overall current prevalence of 19.4% among the tertiary students. The majority (83.0%) of alcohol consumers started between the ages of 16-20 years. The mean age of alcohol initiation was 18.9 <unk> 2.7 years. Seventy-two (43.6%) of the students consume alcohol yearly. Beer (37.6%) was the most consumed alcoholic beverage followed by wine (35.2%). On a typical day, 41.2% of the students consume alcohol 1-2 times. Also, 28.5% of the students drunk alcohol at least once in the past week prior to the study as presented in Table 2. --- Psychosocial factors of alcohol consumption Two hundred and twelve respondents (50.7%) attributed alcohol consumption among students to peer influence. Regarding curiosity/imitation, 35.2% of the respondents reported curiosity/imitation to influence students' alcohol consumption. Also, psychological issues (29.9%), family influence (21.8%), and academic adjustment problems (18.9%) were some of the key reasons influencing alcohol consumption among tertiary students as presented in Fig. 1. --- Factors influencing alcohol consumption among tertiary students Results from the bivariate analysis (chi-square analysis) showed that age group (<unk> 2 = 13.16, p <unk> 0.001), sex (<unk> 2 = 10.43, p <unk> 0.001), religion (<unk> 2 = 27.90, p <unk> 0.001), peer influence (<unk> 2 = 47.17, p <unk> 0.001), and academic adjustment problems (<unk> 2 = 28.31, p <unk> 0.001) were significantly associated with alcohol consumption among tertiary students (Table 3). --- Predictors of alcohol consumption among tertiary students --- Results of the regression analysis of predictors of alcohol consumption among tertiary students has been shown in --- Perceived effects of alcohol consumption Commonly reported effects attributed to alcohol consumption among the students were loss of valuable items (60.6%), and excessive vomiting (53.9%) as shown in Table 5. --- Discussion This study sought to determine the prevalence of alcohol consumption among tertiary students in the Hohoe Municipality of Ghana. We also assessed the factors associated with alcohol consumption and the perceived effects of alcohol among the consumers. We found that the overall lifetime and current prevalence of alcohol consumption among the students were 39.5% and 19.4% respectively. These findings are similar to that of Gebremariam et al. [32] who reported the lifetime and current alcohol consumption prevalence of 36.3% and 16.9% respectively among university students in Ethiopia. However, our prevalence rates were lower than some studies from Kenya [35], Nigeria [6,33], and Ghana [17,38]. For instance, the study conducted in Ghana reported an ever alcohol consumption prevalence of 56.3%, whiles current consumers were 25.8% [17]. Also, Hassan [36] found in Kenya that lifetime alcohol consumption was prevalent among 63.2% of tertiary students. The observed differences in prevalence could be because of the inclusion of two health tertiary institutions in the current study. These students from health institutions might be knowledgeable about the health implications of alcohol consumption hence the less consumption rate. Our findings showed that the odds of alcohol consumption among the students increased with increasing age. Students aged 26 years and above were more likely to consume alcohol. This finding is consistent with results from a cross-sectional study conducted in China [42] and Nigeria [33]. The finding also confirms the association between older age and alcohol consumption found in a study that used data from 24 different countries [43]. The plausible explanation of the finding could be that older students were more likely to access alcohol because they have passed the legal age of alcohol consumption [33]. Also, older age is associated with societal pressure, stress, and increased quest to achieve success and this could have increased their likelihood of resorting to consuming alcohol as a way of coping [33]. Consistent with previous literature from Ethiopia [7,9] and Ghana [38], this study found that being a Muslim was associated with lower odds of alcohol consumption. This finding is not surprising as alcohol consumption is prohibited in the Islamic religion. It is against the religious doctrines as a Muslim to consume alcohol. Also, the study found that peer influence was associated with higher odds of alcohol consumption. This finding corroborates studies from South Africa [13], Ethiopia [8,9,12,15,44] where peer influence was a significant predictor of alcohol consumption among tertiary students. Studies conducted in Ghana also reported similar findings [10,11]. The social learning principle which emphasizes that individuals can learn bad behaviours from watching their peers [14] could explain the findings in the study. Also, as peers are important sources of social support and therefore, their pressure can be an enforcer for good and bad behaviour [14]. We found academic adjustment problems to be a significant predictor of alcohol consumption among the students. This finding is in line with previous studies which reported significant associations between students' academic adjustment problems and alcohol consumption [12,15,45]. That is, the rate of alcohol consumption was higher among students with academic problems or those dissatisfied with their academic performance. Plausible factors that could explain the observed association include; difficulties in balancing academics with social life, low level of commitment towards the field of study, and course and assignment overload which could have predispose the students to consume alcohol. --- Limitations of the study The cross-sectional nature of the study did not allow for inferences of causality between alcohol consumption and the risk factors to be made. Second, the self-reported pattern of alcohol consumption and the perceived effects of alcohol use are often prone to recall and social Fig. 1 Psychosocial factors influencing alcohol consumption desirability biases. Also, the study cannot be generalized to the general population because of the involvement of only tertiary students. Additionally, we did not perform rigorous statistical analysis for the perceived effects of alcohol consumption among the students. Furthermore, sample weights were not used in the present study and this limits it's generalizability to other tertiary students. The use of simple random sampling technique in selecting study schools is another limitation of the study given the varying students population in the selected schools. --- Conclusion Our study found a relatively high prevalence of alcohol consumption among tertiary students in the Hohoe Municipality. Almost half of lifetime alcohol consumers were current drinkers. Among the lifetime alcohol consumers, self-reported effects included stomach pains or upset, accident, unprotected sex, loss of valuable items, excessive vomiting, diarrhea, risk of liver infection, debt, and petty theft. Factors perpetuating alcohol consumption among the students were peer pressure, increasing age (26 years and above), and academic adjustment problems. Being a Muslim was protective against alcohol consumption. Regular alcohol assessment should be carried out in tertiary schools to help identify students with potential alcohol problems in order for appropriated and tailored psychosocial interventions. Students with poor academic performance and psychological distress should be counseled to help them cope with their --- Availability of data and materials The datasets used or analysed during the current study are available from the corresponding author on reasonable request. --- Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s12888-021-03447-0. Additional file 1. Questionnaire. Authors' contributions RGA, NK, and AC conceived the study. RGA, AC, BOA, AS, and PYA wrote the methods section and performed the data analysis. RGA, NK, BOA, AS, AC, and PYA were responsible for the initial draft of thee manuscript. All the authors reviewed and approved the final version of the manuscript. --- Declarations Ethics approval and consent to participate Ethical approval for the study was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC) with a reference number (GHS-ERC:92/ 10/16). We strictly adhered to the ethical guidelines and protocols of the GHS-REC throughout the study. We sought institutional approval from the Ghana Education Service, Hohoe, and Heads of the various institutions. Before the commencement of data collection, written informed consent was sought from students aged 18 years and above before inclusion in the study. For students aged below 18 years, written informed consent was obtained from each student's parents or guardian before participating in the study. Additionally, written parental or guardian consent and child assent were sought from each student before inclusion in the study. Respondents' rights to withdraw from the study, confidentiality, participants' privacy, risk, and benefits involved in the study were duly explained to the respondents after which interested respondents voluntarily signed the written consent or assent forms. --- 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: Alcohol consumption constitutes a major public health problem as it has negative consequences on the health, social, psychological, and economic outcomes of individuals. Tertiary education presents students with unique challenges and some students resort to the use of alcohol in dealing with their problems. This study, therefore, sought to determine alcohol use, its effects, and associated factors among tertiary students in the Hohoe Municipaility of Ghana. Methods: An institutional-based cross-sectional study was conducted among 418 tertiary students in the Hohoe Municipality of Ghana using a two-stage sampling technique. Data were collected using structured questionnaires. A binary logistic regression modelling was used to determine the strength of the association between alcohol consumption and the explanatory variables. The level of significance was set at p < 0.05. Stata version 16.0 was used to perform the analysis.The lifetime prevalence of alcohol consumption was 39.5%. Out of them, 49.1% were still using alcohol, translating to an overall prevalence of 19.4% among the tertiary students. Self-reported perceived effects attributed to alcohol consumption were loss of valuable items (60.6%), excessive vomiting (53.9%), stomach pains/upset (46.1%), accident (40.0%), unprotected sex (35.1%), risk of liver infection (16.4%), depressive feelings (27.3%), diarrhoea (24.2%), debt (15.2%), and petty theft (22.4%). In terms of factors associated with alcohol consumption, students aged 26 years and above were more likely to have consumed alcohol [AOR = 4.4, 95%CI = 1.74, 11.14] than those in 16-20 years group. Muslim students had lower odds of alcohol consumption compared to Christians [AOR = 0.1, 95% CI = 0.02, 0.31]. It was also found that students who had peer influence [AOR = 3.7, 95%CI = 2.31, 5.82] and those who had academic adjustment problems [AOR = 3.6, 95% CI = 2.01, 6.46] were more likely to consume alcohol.

Introduction In recent years, open science has generated changes in the scientific research process, including in the development, evaluation, and use of new knowledge for researchers and society. The improvement and application of information technology has created alternative ways to assess, publish and disseminate research results that are characterised by their quality and veracity and researchers' scientific reputation, whereby different stakeholders are affected by this new scientific perspective [1]. Open science is a new approach to scientific practice based on cooperative research and new methods of knowledge distribution using digital technologies and new collaborative tools that promote joint effort along with the sharing of results and new knowledge as early and as widely as possible. The goal of open science is to participate with broader communities to address global challenges more effectively and guarantee that science and research are fundamental to the innovation, growth and development of countries [2]. tools that help in the development of open science, such as platforms for integration (software and hardware) and networks. This project emerged from the requirements of Colombian public policy and the guidelines of the National Development Plan, which prioritizes the establishment of solid ecosystems of open data where science, technology and innovation play an important role. The country needs to define a formal policy to promote open science that benefits society, especially for the scientific community with respect to legal requirements (copyrights) and institutional rules and requirements of researchers. Moreover, in this country, the main studies on open science focus on Colombian researchers' access to information, transparent science, and open access [9][10][11]. Various universities have research groups and initiatives to promote open science with the help of libraries and research offices. To analyse how acquainted Colombian researchers are with open science and its tools, a survey was used because it is the most frequently applied mechanism to explore researchers' perceptions, opinions, and knowledge of open science. Prior studies have examined specific knowledge areas based researchers' age, territorial scope or academic education. The main studies of the perception of open science and its components, such as open access, are the following. --- I To analyse data policy research in institutions, Leaders Activating Research Networks (LEARN) [12] developed the study 'Ready to manage research data?' in Europe and Latin America. It included thirteen questions to evaluate data management in different institutions. --- I To examine users' experience with open science networks, Open Science Grid [13] developed the Open Science Grid PKI General User Survey study with different network users. It included nine questions on users' experience with open science and their interactions in the network. --- I To evaluate the particularities and context of research and its relationship with global changes, Belmont Forum [14] established the study Skills for e-infrastructures and data management in global change research worldwide. It used twenty-one questions on research contexts related to data infrastructure requirements to promote open science. --- I To evaluate the knowledge and perceptions of open access in social science and the humanities, Edith Cowan University (ECU) [15] developed a study with thirteen questions related to knowledge of open access and its application as well as users' experience publishing in open access contexts. --- I To compare the perceptions, motivations, and behaviours of researchers in relation to open science in three areas-physics, economics, and medicine-the study called 'Open science: one term, five schools of thought' [16] was developed. It included eighteen questions to analyse the degree of acceptance of open science by researchers in three different areas of knowledge. --- I A study on perceptions of open access based on the experience and age of researchers was conducted on academic research faculty members possessing a PhD at U.S. universities and colleges. It included four questions on open access perceptions [17]. --- I In Spain, a study was performed to determine the perceptions of open access among PhD students, professors and researchers at a university. It included thirty-seven questions related to different elements of open access [18]. Hence, this study seeks to design a survey that includes different open science approaches to add value for determining researchers' perceptions of open science. As explained in the methodology section, various facets of these studies informed the design of the survey (see Table 1). --- Methodology --- Study Area and Population For this study, a survey was administered to Colombian researchers registered on the national platform Scienti in the application CvLAC, which contains the curriculum vitae of national researchers and is administered by Colciencias, the agency chiefly responsible for the administration of science, technology, and innovation in Colombia. The study population comprises 72,797 researchers registered on the Scienti platform as of December 2016, which are distributed in different Colombian departments. --- Sampling Technique, Sample Size, and Data Collection To achieve a suitable sample size from this population, a probabilistic sample was used to ensure, with confidence, that the different units of sample researchers have equal probabilities of being chosen. A sample size of 1042 researchers was calculated to guarantee a margin of error of 3% and a confidence level of 95%. Confidence intervals (CI) for the population proportion (P) were identified as defined in Equation ( 1), with sample proportion (P s ), population size (N), sample size (n), and the table value from the standard normal distribution at the 95% confidence level (Z = 1.96) [19]. Sample proportion (P s ) is the proportion of researchers in a sample who share a common trait [19]. Population proportion (P) is the proportion of total researchers who share a common trait [19]. The probability of acquaintance inclusion was assigned to be greater than zero, and a priori probabilities were assigned as a condition of the selection mechanisms, which allowed for precise and reliable statistical inferences of the target population and a national representative sample of Colombian researchers from the National Research System. --- CI f or P = P s <unk> Z P s (1 -P s ) n N -n N -1(1) To determine the different categories from the geographical distribution and the presence of researchers in every Colombian department, the technique used was random and stratified sampling. This study used principal component analysis to identify high correlations between selected variables for grouping (according to size of the researcher population in every Colombian department, the number of affiliated institutions, and the number of research groups). These variables indicated strong correlations (see Figure 1). Next, this study applied a hierarchical method with Ward's method and the k-means method using the function cluster.carac and selected the algorithm for strata Fan-Muller-Rezucha. Table 1 shows the categories and sample size of the survey. This study used principal component analysis to identify high correlations between selected variables for grouping (according to size of the researcher population in every Colombian department, the number of affiliated institutions, and the number of research groups). These variables indicated strong correlations (see Figure 1). Next, this study applied a hierarchical method with Ward's method and the k-means method using the function cluster.carac and selected the algorithm for strata Fan-Muller-Rezucha. Table 1 shows the categories and sample size of the survey. --- Survey and Instruments This research used a survey questionnaire. Surveys are the best method to cover a large population and ensure an accurate sample. The questionnaire was divided into five sections, with a total of 34 questions (see Table 2). The questions were selected based on a literature review and an expert panel from Colciencias (Colombian government organization for science, technology, innovation, and Colombian universities), and Antigua Manual guidelines [20] for perception studies --- Survey and Instruments This research used a survey questionnaire. Surveys are the best method to cover a large population and ensure an accurate sample. The questionnaire was divided into five sections, with a total of 34 questions (see Table 2). The questions were selected based on a literature review and an expert panel from Colciencias (Colombian government organization for science, technology, innovation, and Colombian universities), and Antigua Manual guidelines [20] for perception studies related to science and technology were followed to define the categories in the questionnaire. Moreover, the overall survey instrument underwent content validity analysis and pilot testing in an effort to purify and refine the survey instrument. It was determined that the survey completion took, on average, 35-40 min. The pilot test was sent to a group of researchers to determine the response time, precision, and understanding of the questions with the aim to assure that the instrument was relevant and appropriate for the study. Most researchers replied that the survey was clear and easy to answer, and some made suggestions that were applied before the survey was sent to other researchers. Moreover, the Cronbach's test demonstrated that the survey instrument was suitable for this study. This test calculates the internal consistency and reliability of questionnaires with Likert-type scales and items [19]. [ 16,23,24], Authors --- Survey Administration All surveys included a cover letter that explained the purpose of the survey, the benefits of participation, and background information on the study. It also included contact information, the time required to complete the survey (on average 35-40 min) and a submission deadline. The survey was sent using QuestionPro online survey software. The strategies to motivate participation in the survey included email broadcasting as well as communications with research directors of different universities to promote the study and to complete the survey. Every week, books were delivered to different universities, and researchers completed the survey through a draw. Every five days, the researchers were sent personalised reminders through the researcher database. A total of 3000 surveys were e-mailed to Colombian researchers registered on Scienti, the database for categorised Colombian researchers. During a 30-day time frame in the first semester of 2017, 1280 surveys were returned, of which 238 were incomplete. Therefore, the total number of usable surveys was 1042, which provided a suitable sample size, as explained in Section 3.2. Of these 1042 surveys, 40.40% were in Category 1, 16.12% Category 2, 14.30% Category 3 and 29.17% Category 4, which are representative of Colombia, according to the sampling plan. --- Results and Discussion This section presents the main results of the national survey on open science calculated using statistical techniques to ensure high reliability. A total of 1042 responses were received, with a confidence level of 95% and a margin of error of 3%. The majority of respondents knew about open science, especially as it relates to open science tools (software, repositories, and networks) and open data. These results indicate that researchers have different perspectives of open science. --- Sociodemographic Characteristics A national representative sample of 1042 researchers participated in this study. Of these researchers, 38% were women and 62% were men; 40% were between 25 and 55 years of age; 33.5% had completed a Master's and 25.8% had completed doctoral studies. With regard to areas of study, 37.38% of the researchers were in the social sciences and humanities, 19.78% in engineering, and 13% in the natural sciences. A total of 37% had between 5 and 10 years of experience as researchers, and the majority worked for a higher education institution or research center (87% and 8%, respectively). These sociodemographic characteristics ensure the study's representativeness in relation to different sociodemographic features. --- Knowledge and Perceptions of Open Science among Colombian Researchers These questions focused on analysing the researchers' beliefs, knowledge, and information habits regarding open science. The questionnaire began with a filtering question: respondents who knew about open science were asked to continue the survey, but if the answer was negative, the survey was considered complete because the researcher had no knowledge on the topic. The results indicated that 54.13% of respondents knew about open science. Figure 2 depicts hierarchical connections for words related to open science (from a sequence by repetition frequency) that it generates among words and concepts with an increased number of responses by survey respondents and how these words and concepts are associated and related by more and fewer mentions by researchers (e.g., free access is one of the words most often mentioned and is interconnected with accessibility and databases, and accessibility is related to open information and then with community). Information 2018, 9, x FOR PEER REVIEW 8 of 18 knew about open science were asked to continue the survey, but if the answer was negative, the survey was considered complete because the researcher had no knowledge on the topic. The results indicated that 54.13% of respondents knew about open science. Figure 2 depicts hierarchical connections for words related to open science (from a sequence by repetition frequency) that it generates among words and concepts with an increased number of responses by survey respondents and how these words and concepts are associated and related by more and fewer mentions by researchers (e.g., free access is one of the words most often mentioned and is interconnected with accessibility and databases, and accessibility is related to open information and then with community). Sharing and collaborative research have become imperative in modern science, but they require opportunities for free access to, and use of, data, cooperation between scientists and researchers in different fields of knowledge, and progressive and increased dialogue between science and society [25], as noted by the respondents to this survey. The open science movement is closely related to both the open data and open access movements, which support the sharing of data and publications, respectively [26]. The results regarding Colombian researchers' knowledge and perceptions reflect similar concerns, indicating that open data and open access are elements with higher recognition within open science. Another important finding from the survey is that information technologies are fundamental to the research process, and the Internet is the preferred media for the search for information. Moreover, researchers seek information about open science from the web pages of university repositories, among other sources, which indicates that they employ diverse information sources to stay up to date We found that 53.30% of Colombian researchers are not sufficiently well informed about open science, while 40.38% are informed. The Internet is the main media platform used to inform researchers about open science, followed by academic events (see Figure 4). Sharing and collaborative research have become imperative in modern science, but they require opportunities for free access to, and use of, data, cooperation between scientists and researchers in different fields of knowledge, and progressive and increased dialogue between science and society [25] These results indicate that the knowledge and perceptions of open science among Colombian researchers are limited. This finding confirms the hypothesis of this study that it is important to strategically develop their knowledge, especially at early education levels (university and Master's levels) and in departments with lower research capacities. These results concur with those of the authors of a past paper [3], who consider open science to be a relatively underdeveloped topic of discussion that has emerged as a catchphrase in today's scientific society. They view technological innovation as providing new opportunities to share knowledge, and that the Internet can be used as an enabling tool to improve collective knowledge. Sharing and collaborative research have become imperative in modern science, but they require opportunities for free access to, and use of, data, cooperation between scientists and researchers in different fields of knowledge, and progressive and increased dialogue between science and society [25], as noted by the respondents to this survey. The open science movement is closely related to both the open data and open access movements, which support the sharing of data and publications, respectively [26]. The results regarding Colombian researchers' knowledge and perceptions reflect similar concerns, indicating that open data and open access are elements with higher recognition within open science. Another important finding from the survey is that information technologies are fundamental to the research process, and the Internet is the preferred media for the search for information. Moreover, researchers seek information about open science from the web pages of university repositories, among other sources, which indicates that they employ diverse information sources to stay up to date on open science. This finding accords with that of the authors of a previous a previous paper [6] According to the Colombian researchers, the main drivers of open science are the following (see Appendix A Figure A1), open data and information (72% fully agree), the availability of digital technologies and higher capacity (62% fully agree), and new forms of dissemination and disclosure of results (59% fully agree). Thus, the researchers perceive that open science requires new technologies and strategies for information access and effective dissemination. The main barriers to open science identified by the Colombian researchers are the following (see Appendix A Figure A2), lack of financial resources (52% fully agree), limited knowledge of the potential benefits of open science (41% fully agree), and lack of motivation and incentives (41% fully agree). Thus, the researchers perceive that it is important for both governments and institutions to promote better practices to include open science in the research cycle. Colombian researchers consider the following to be the deficiencies of the current system that open science could overcome (see Figure 5). Restricted access and delays in disseminating academic results that limit knowledge transfer (67% fully agree), academic communication restricted by the current incentive structure (58% fully agree), and limited access to resources and scientific products (52% fully agree). The main implications of open science and its impact on society, the economy, and research for Colombian researchers are as follows (see Appendix A Figure A3), greater connections between science and society (62% fully agree), improved dissemination and appropriation of science, technology and innovation (58% fully agree), and enhanced benefits of knowledge transfer (58% fully agree). promote better practices to include open science in the research cycle. Colombian researchers consider the following to be the deficiencies of the current system that open science could overcome (see Figure 5). Restricted access and delays in disseminating academic results that limit knowledge transfer (67% fully agree), academic communication restricted by the current incentive structure (58% fully agree), and limited access to resources and scientific products (52% fully agree). The main implications of open science and its impact on society, the economy, and research for Colombian researchers are as follows (see Appendix A Figure A3), greater connections between science and society (62% fully agree), improved dissemination and appropriation of science, technology and innovation (58% fully agree), and enhanced benefits of knowledge transfer (58% fully agree). These findings indicate that Colombian researchers perceive that open science is promoted by different elements. The authors of a past paper [28] described seven drivers: emerging digital technologies (to deliver more rapid, reliable, and sustainable results), the need for collaboration (new strategies and models to collaborate on and disseminate research), the evolution of traditional peer review models (more transparency and accountability of research results), increased public scrutiny (higher expectations for research results within society), changes to research assessment metrics These findings indicate that Colombian researchers perceive that open science is promoted by different elements. The authors of a past paper [28] described seven drivers: emerging digital technologies (to deliver more rapid, reliable, and sustainable results), the need for collaboration (new strategies and models to collaborate on and disseminate research), the evolution of traditional peer review models (more transparency and accountability of research results), increased public scrutiny (higher expectations for research results within society), changes to research assessment metrics (altmetrics as an alternative measure to improve research evaluations), accessibility of research (research with public funds must allow better accessibility and traceable impacts), and reproducibility of results (to improve the quality and transparency of research). Open science has gradually been incorporated into scientific endeavours because it has the potential to improve the efficiency and quality of research by decreasing the costs of data collection, helping researchers exploit dormant or inaccessible data at a low cost, and increasing the opportunities for collaboration in research and innovation [29]. Moreover, the survey results indicate that Colombian researchers perceive that open science can contribute to improving structures and research processes to ensure greater access to and dissemination of science. These results are important in the context of open science's advantages, which include the following [30], greater availability and accessibility of publicly funded scientific research output; opportunities for rigorous peer review processes; greater reproducibility and transparency of scientific works; and greater impacts of scientific research, which can be disseminated throughout the scientific community to strengthen and enhance the open science process as a new form of research and as a way to achieve greater transparency and impact for the new knowledge generated. However, several studies have demonstrated that the main barriers to open science are research funding methods, the absence of alternative reputation systems for researchers' performance, research integrity to ensure that research findings are reliable, reproducible, and trustworthy, and the money spent on the research [31,32]. Moreover, the authors of a past paper [33] classified the barriers to open science into two categories: operational barriers (such as the difficulty of providing evaluations of the quality and rigour of research findings and the lack of skills and knowledge about the advantages of open science for research) and institutional barriers (such as inadequate funding schemes and institutional processes that inhibit processes related to open science). Another important aspect is the relationship between open science and society, as open science should empower populations through science and allow citizens to become involved in scientific efforts. In addition, open science can have positive implications for the development of a culture of scientific awareness [34]. --- Capacities and Abilities for Open Science This section examines the perceptions of Colombian researchers related to the activities, processes and tools used in open science and how these elements have improved projects and research activities. Colombian researchers have begun to use different tools related to open science to strengthen their research processes, such as consulting repositories of information (13%), using and updating academic networks (9.8%), having a researcher profile on Google Scholar, ORCID, Research ID, etc. (8.7%), consulting citation indexes (8.6%), investigating open access results (8.5%), exchanging information (7.8%), and open access publishing (7.6%) (see Appendix A Figure A4). These results indicate that the use of open science tools is limited in the Colombian scientific community. The main opportunities provided by open science according to the Colombian researchers are the following (see Figure 6), information exchange (20.31%), feedback from other researchers (18.63%), invitations to serve as an evaluator or reviewer of scientific or academic papers (16.34%), invitations to share investigation results with academic communities (15.59%), and participation in joint investigations (13.47%). The capacities and abilities for open science imply the use of different tools that increase both the efficiency of the research process and its diffusion, thereby increasing the effectiveness and productivity of scientific and research systems to engage in powerful data manipulation, provide analyses at low cost, and reduce duplication costs for collecting, creating, transferring, and reusing data and science [35,36]. According to the results of this study, the scientific community must be better informed about these benefits of the open science tools. Moreover, the survey results demonstrate that open science is becoming a research strategy that allows for improved research results and communication that can be enriched and strengthened through higher quality, transparency, and conformity with research networks through collaboration and information sharing. This finding concurs with previous works [5] that indicated that open science demands new forms of quality assurance to ensure the integrity of the research process when collaborative activities and data sharing are involved. They suggest adopting guidelines that allow journals to select which aspects are most relevant for their knowledge area and that increase transparency without becoming too difficult for journal editors and authors. Another finding related to capabilities and abilities indicates the importance of connecting society with science and technology as a means of empowerment and to strengthen a country's scientific culture. Moreover, these results are closely connected with citizen science, which involves the active participation of citizens in data collection, scientific experiments, and problem solving and can also occur at the behest of individuals who are forced to find scientific solutions to problems without being scientists themselves [5]. In their projects, Colombian researchers have used open science in the following ways, formulating a research question based on community problems (27.53%), sharing research results with a community (26.91%), and collecting information and data for research from people in the community (16.41%). --- Experiences and Participation in Open Science The capacities and abilities for open science imply the use of different tools that increase both the efficiency of the research process and its diffusion, thereby increasing the effectiveness and productivity of scientific and research systems to engage in powerful data manipulation, provide analyses at low cost, and reduce duplication costs for collecting, creating, transferring, and reusing data and science [35,36]. According to the results of this study, the scientific community must be better informed about these benefits of the open science tools. Moreover, the survey results demonstrate that open science is becoming a research strategy that allows for improved research results and communication that can be enriched and strengthened through higher quality, transparency, and conformity with research networks through collaboration and information sharing. This finding concurs with previous works [5] that indicated that open science demands new forms of quality assurance to ensure the integrity of the research process when collaborative activities and data sharing are involved. They suggest adopting guidelines that allow journals to select which aspects are most relevant for their knowledge area and that increase transparency without becoming too difficult for journal editors and authors. Another finding related to capabilities and abilities indicates the importance of connecting society with science and technology as a means of empowerment and to strengthen a country's scientific culture. Moreover, these results are closely connected with citizen science, which involves the active participation of citizens in data collection, scientific experiments, and problem solving and can also occur at the behest of individuals who are forced to find scientific solutions to problems without being scientists themselves [5]. We found that 30.64% of the respondents affirmed that their institutions have open science guidelines, especially in areas with higher research competence, such as Bogotá (46.22%), Antioquia (16.38%), Valle (7.08%), and Atlántico (5.18%). The institutional initiatives recognised by respondents include the following. Open access to databases, repositories, and publications; economic support for open access publications; promotion of open access institutional journals; and the development of policies or guidelines related to open access. Open science tools with higher use by universities and research centers include the following (see Appendix A Figure A5), open access to institutional repositories (14.98%), open access to databases (13.64%), open access to journals (11.76%), and normalization of profiles in academic networks (10.94%). These results predominate in regions with greater research capacity, such as Bogotá and Antioquia, indicating that universities and research centers with better results include open science within their research processes. We found that 50% of respondents had published at least six academic papers as researchers, with an average of three papers in open access publications using resources from the universities or research institutes where they work (52.5%), using resources from their research project (29.32%), and using their own resources (10.33%). With respect to open science policies, 93.75% of respondents believe that Colombia should have an integrated open science public policy (see Figure 7) that includes open access (95% fully agree) and the promotion of open science projects (93% fully agree) and open science tools (92% fully agree). These results are important as inputs to design and establish an adequate open science policy from the academic community's perspective. Information 2018, 9, x FOR PEER REVIEW 13 of 18 Open science tools with higher use by universities and research centers include the following (see Appendix A Figure A5), open access to institutional repositories (14.98%), open access to databases (13.64%), open access to journals (11.76%), and normalization of profiles in academic networks (10.94%). These results predominate in regions with greater research capacity, such as Bogotá and Antioquia, indicating that universities and research centers with better results include open science within their research processes. We found that 50% of respondents had published at least six academic papers as researchers, with an average of three papers in open access publications using resources from the universities or research institutes where they work (52.5%), using resources from their research project (29.32%), and using their own resources (10.33%). With respect to open science policies, 93.75% of respondents believe that Colombia should have an integrated open science public policy (see Figure 7) that includes open access (95% fully agree) and the promotion of open science projects (93% fully agree) and open science tools (92% fully agree). These results are important as inputs to design and establish an adequate open science policy from the academic community's perspective. Moreover, the main priorities of an open science policy according to the respondents are as follows (see Appendix A Figure A6), developing strategies and instruments that guarantee free access to scientific information in a timely manner (91% fully agree), improving researchers' abilities and competence in the use of information systems (83% fully agree), and designing effective incentives to participate in open science among the scientific community. This indicates that such a policy should begin with open data, the generation of competences and the provision of incentives in recognition Moreover, the main priorities of an open science policy according to the respondents are as follows (see Appendix A Figure A6), developing strategies and instruments that guarantee free access to scientific information in a timely manner (91% fully agree), improving researchers' abilities and competence in the use of information systems (83% fully agree), and designing effective incentives to participate in open science among the scientific community. This indicates that such a policy should begin with open data, the generation of competences and the provision of incentives in recognition that the engagement and effort of all stakeholders are important for achieving an effective open science policy in accordance with the needs of the country. These results demonstrate that open science faces different challenges, and considering that only 1.7% of the respondents reported attending training programmes in open science, it is important for Colombian researchers to be able to improve their capacities and knowledge of the tools used in open science. The experiences and participation in open science by Colombian researchers indicate that regions with better research competences have employed some elements of open science, including using institutional repositories. This finding accords with the results of the survey by authors of a past paper [37], in which researchers download papers from institutional repositories or their personal or university webpages that are generally useful to their research. Open access publication is still limited and focused on universities and research centers with greater recognition of their research activities, which indicates the importance of implementing initiatives and strategies to promote open science in all regions of Colombia to decrease regional disparities. This study's findings are in accord with the authors of a previous paper [38], who found that open science goes beyond open access to include publications or data incorporating diverse issues in the entire research cycle. This implies interoperability of the scientific infrastructure, open and shared research methodologies (such as open applications and informatics codes), and machine-friendly tools (text and data mining). Moreover, an effective open science policy must include topics related to developing the necessary infrastructure (to share data and findings), legal frameworks to ensure transparency and copyright protection when sharing and reusing the research output produced by others, new strategies to evaluate and assess research results, and incentive mechanisms (financial incentives). --- Conclusions This study analysed the perceptions, experiences, and knowledge of open science among Colombian researchers through an online survey that used a probabilistic sampling strategy, which allowed us to ensure the representativeness of the study. A total of 1042 responses were received, with a confidence level of 95% and a margin of error of 3%. The majority of the respondents had heard of open science, especially as it relates to open science tools (software, repositories, and networks) and open data. The researchers consider the rise of digital technologies, the search for new forms of collaboration, the greater availability of open data and information, and the public's demand for better and more effective science to be factors that have affected open science. In contrast, a lack of resources and the limited integration between traditional and open science are the most important barriers to the use of open science in research. These results are important inputs for building an adequate open science policy in Colombia, and they indicate the need to develop clear methodological and deontological rules regarding open science in which scientific collaboration and digital technologies are fundamental and involve both researchers and practitioners as well as rules concerning the use of data by nonscientific people. Moreover, these results highlight the importance of conducting behavioural studies on virtual research to understand the factors that influence the effective operation and performance of different open science tools [38,39]. A total of 43.54% of the respondents consider themselves to be very well informed or informed, while 53.30% do not consider themselves to be sufficiently well informed about open science. The main media platforms for information on open science are the Internet, conferences and universities. --- Conflicts of Interest: The authors declare no conflict of interest. --- Appendix The Main Detailed Results of the Survey

Open science can provide researchers diverse opportunities to collaborate, disseminate their research results, generate important impacts in the scientific community, and engage in effective and efficient science for the benefit of society. This study seeks to analyse and evaluate researchers' knowledge of open science in Colombia using a survey to determine adequate instruments with which to improve research in the framework of open science. The aim of the study is to determine researchers' current awareness of open science by considering demographic characteristics to analyse their attitudes, values, and information habits as well as the levels of institutionalism and social appropriation of open science. A representative sample of Colombian researchers was selected from the National Research System. An anonymous online survey consisting of 34 questions was sent to all professors and researchers at Colombian universities and research institutes. Sampling was random and stratified, which allowed for a representative sample of different categories of researchers, and principal component analysis (PCA) was used for the sample design. A total of 1042 responses were received, with a 95% confidence level and a margin of error of 3%. The majority of respondents knew about open science, especially in relation to open science tools (software, repositories, and networks) and open data. Researchers consider open science to be positively impacted by factors such as the rise of digital technologies, the search for new forms of collaboration, the greater availability of open data and information, and public demand for better and more effective science. In contrast, a lack of resources to develop research activities within the open science approach and the limited integration between traditional and open science are identified as the most important barriers to its use in research. These results are important for building adequate open science policy in Colombia.

Introduction Pain is the most common reason for seeking medical care, and approximately 25 million American adults suffer from daily chronic pain [1]. With Americans struggling to treat their chronic pain, the use of opioids for pain management has come under scrutiny due to a rise since 1999 in use and serious complications such as addiction and overdose deaths [2]. As reported by the National Pain Strategy (NPS), "prescribing practices, marketing, and misleading information on safety drove a steady and significant increase in the number of opioid prescriptions dispensed, rising from 76 million in 1999 to 219 million in 2011 [3]". To improve health outcomes among pain patients, there is a need to understand how patients and health care practitioners (HCPs) communicate about pain management or treatment plans [4]. Due to the physical and emotional complexities of pain, patients often struggle to articulate the level of distress they face, and HCPs are often unequipped with the time or the tools needed to provide these patients with a supportive response or well-rounded and integrated treatment plans [5,6]. The National Pain Strategy (NPS), the federal government's first coordinated plan for reducing the burden of chronic pain, emphasizes the need for strong communication between HCPs and patients. The NPS states that "Improvements in professional education about state-of-the-art care for pain, in all its dimensions, including better communication, empathy, cultural sensitivity, and risk management will yield significant care improvements [7]". Research has found that a shared decision-making approach to pain management-an approach that involves engaged collaboration between patients and HCPs-is an important part of an overall pain treatment plan [8]. But there are hurdles to this type of approach, including restraints on time for both providers and patients [9]. Trust between pain patients and providers, although not very well understood, also plays a key role in how patients and providers communicate and may have an effect on a patient's health outcomes [10]. To add complexity to these patient-provider conversations, health discussions are not just taking place in physicians' offices. Digital platforms, such as websites and social media sites (e.g., Facebook and Twitter), have become places where people not only find health information, but where they congregate, connect, and discuss their health questions and concerns with others who may be experiencing similar circumstances [11]. "One-in-four (26%) adult internet users say they have read or watched someone else's health experience about health or medical issues in the past 12 months. And 16% of adult internet users in the U.S. have gone online in the past 12 months to find others who share the same health concerns," according to 2014 Pew Research Center statistics [12]. The trend continues with the next generation. Not only are 9 out of 10 teens and young adults going online for health information, "about four in ten (39%) say they have gone online to try to find people with health conditions similar to their own, using methods such as participating in online forums or closed social media groups on specific issues, doing hashtag searches on social media, or following people with similar health conditions," according to a 2018 report from Hopelab and Well Being Trust [13]. In addition, learning networks (both digital and in-person) have been used in health care settings to connect knowledgeable communities-patients, providers, and researchers-to work on solutions for difficult-to-treat conditions [14]. Research has shown that learning networks improve health outcomes as participants from different areas of health care work toward a common goal [15]. It is in this environment that the internet becomes a powerful and empowering tool for patients to look for health information [16] and to make online connections with other like-minded individuals and communities. As a result, as people turn toward the internet for their health information, for community, and for connection, it's important to study their online behaviors-how and where people get their information-in an effort to improve how that information is delivered and consumed. The need for quality, evidence-based resources is not going unseen. A call to assess patient education materials and decision support resources as key components for effective pain care were reflected in the 2018 Federal Pain Research Strategy issued by the National Institutes of Health [17]. This paper seeks to closely examine how pain patients and providers communicate on Twitter and to explore how these conversations might help inform the information needs of pain patients. --- Why Twitter? Twitter is an online news and social networking platform where users post and interact using messages called "tweets." While it is not the most used social network, it has the research advantage of consisting of conversations and follow relationships that are almost entirely in the public domain. Twitter's use by health professionals is documented [18] and though not every person uses the platform, there are people commenting about a wide variety of topics. With this broad and varied range of topics comes tremendous research opportunity. For example, recent research explored the use of Twitter to communicate about and congregate around 379 different health conditions, but the researchers also found limitations in previous research [19]. Namely, these types of studies "have typically focused on a single, or a very limited set of related health conditions, usually different kinds of cancers. Very little work has compared Twitter communities of different health conditions which could uncover potential trends and highlight popular health topics [20]." This allows for opportunities in research to better understand the conversations and comparisons around different disease states and health conditions. Twitter users create their own lenses to view the rest of the platform. By choosing users to follow, they are creating blinders with which they only view content based on the interests of the people they follow. This behavior allows for analysis on how health communicators can effectively share information with specific audiences or view the ways information flows. Twitter also has an advantage in that users tend to cite other publications in their tweets, such as via linking a URL or mentioning the publication's account. Despite limited character allowances in tweets, the ability to add citations brings in large amounts of meaningful data. In fact, recent research shows that Twitter citations of medical research accurately predicts the citations of those publications in future published articles [21,22]. --- Study objective In face-to-face interactions between patients and HCPs, research has found that differences in points of view [23], as well as differences in language, create a disconnect in communication between pain patients and providers, and may contribute to the challenges of pain management and treatment [24]. Because of this disconnect and a need to improve our understanding of how pain communities operate on Twitter, we hypothesized that pain patients and HCPs, when compared with oncology patients and providers, engage with different audiences and share information from different sources on Twitter, indicative of a communications gap that exists online between pain patients and HCPs. To address this hypothesis, this paper will: 1. Define the differences and similarities in Twitter relationships and identify what the similarities and differences in engagement among patients and HCPs within a sample of social media accounts tell us. 2. Compare word use and citations among pain patients and HCPs. This evaluation focused on comparing the types of information sources that these audiences are sharing (medically focused sources, general consumer sources, or other types of sources). This analysis allowed us to evaluate whether both groups are sharing medically focused sources, or whether one or both groups may be sharing more general or consumer-focused sources of information. As part of this analysis, we also evaluated the extent to which both audiences are discussing pain-related topics, to confirm that a high amount of their respective citations were likely shared in relation to pain-focused topics. 3. Outline the challenges and limitations in addressing any differences between the audiences evaluated. --- Materials and methods Our research aims to define the audiences with whom patients and HCPs engage online and the information they share about pain management, specifically on Twitter. To define the audiences, we worked with Graphika Inc. to analyze the Twitter audiences most engaged in pain and oncology topics by conducting two separate Social Network Analysis (SNA) maps focused on these respective topics. We assessed the structure of Twitter relationships within the Pain and Oncology SNAs and compared the strength of the relationships between the patient and HCPs audiences within each SNA. This analysis was primarily focused on evaluating whether any potential gaps in communication exist between the patient and HCP audiences in the Pain SNA, when compared with the Oncology SNA. The creation of two separate SNAs provided comparisons between the audiences engaged on these issues, allowing us to define trends related to the communication patterns of the audiences within each map. While the main focus of the research was on the Pain SNA, oncology was chosen as a comparison due to what was perceived to be a highly developed online network of both patients and physicians. An SNA is the analysis and visualization of large networks of connected users on Twitter, and it provides insight into the social engagement of accounts focused on the specific topics and flow of information between these accounts. Network analysis has been used frequently in past research to study health-related issues and is an "approach to research that is uniquely suited to describing, exploring, and understanding structural and relational aspects of health [25]." SNAs of Twitter, specifically, have been used in past health research to evaluate "the relationship and interactions between Twitter users about a certain topic," such as a study that assessed "the connections between patients with cancer on Twitter and sought to identify the hubs, or Twitter users with the greatest connectedness to other users within the network [26]." SNA maps are comprised of individual Twitter accounts, which are connected to other accounts in the map via social relationships. The initial mapping processes, which were conducted on July 27, 2017, for the Pain SNA and May 19, 2017 for the Oncology SNA, were based on follow relationships and then further segmented by audiences using attentive clustering (grouping users based on the specific sources that they cite). To begin the creation of the SNA maps, we generated "seed lists" by compiling a sample of accounts with a focus on topics related to pain and oncology. The pain seed list (12 users) was smaller than the oncology seed list (22 users) as there were fewer accounts that were focused just on the subject matter. Starting with this list, all their followers, the users they followed, and individual tweets were collected. Collection also included new accounts discovered during the mining process. The Twitter dataset was collected using Twitter's Streaming Application Program Interface (API). To determine the placement of users into clusters, Graphika's algorithm was utilized. This algorithm, which has been used in previous research focused on social network analysis, also generated network statistics, including measurements of influence based on follow relationships within the map [27]. A Fruchterman-Reingold visualization algorithm was used in both maps to represent the patterns of connection between these accounts. It arranges the accounts in a visualization through a centrifugal force that pushes nodes to the edge and a cohesive force that pulls strongly connected nodes together. This method of segmenting users and generating broad observations about associations is an iterative process drawing on qualitative, quantitative, and computational methods. To create a map of segments and groups, we used a bipartite graph to provide a structural similarity metric between the accounts within the map, which is used in combination with a clustering algorithm to segment the map into distinct communities. Hierarchical agglomerative clustering was used to automatically generate segments and groups from sampled data. The identification of which audiences (patients, HCPs, etc.) each cluster was composed of was determined through reviewing the following: the members of the clusters (self-reported Twitter data); the sources they cited; the users they mentioned; and the users they followed. The review of the clusters was completed by prioritizing the users within each cluster who had the largest number of followers within the map. The outcome of this process was the creation of two separate SNA maps, focused on pain and oncology. The top accounts-12,086 accounts in the Pain SNA and 12,617 accounts in the Oncology SNA, as determined by those most well-connected to others in the SNA-were included in this research. Network statistics were generated for variables, including word use, sources cited, retweets, and mentions. The sources that each of the audiences cited (Tables 1 and2) were collected and tabulated between July 17, 2017, and March 31, 2018. We also analyzed the top 12,000 pairs of words within each audience in the Pain SNA, using data collected from June 27 to July 27, 2017. This analysis allowed us to confirm that the Pain SNA captured measurable conversations focused on pain topics. It also allowed us to summarize the thousands of tweets that took place in the Pain SNA, with the goal of identifying the topics that pain and provider audiences are discussing with the most frequency. --- Defining the study populations The figures represent the populations included in the study. The figures are visualizations of the nodes included in each SNA analysis conducted for this study and have been included as a visual illustration of the audiences evaluated within this study. Within the visualizations, each dot represents a node, which is the Twitter account associated with a specific individual or organization within each SNA. Size and position of the nodes are based on their relative follow relationships within the network: the largest nodes have the most follow relationships within the map, and nodes are positioned near the accounts that they follow within the visualization. Color is determined by attentive clustering, based on the sources that the organizations and individuals cite within their posts. The clusters within the Pain and Oncology SNA maps included in this study are organized into overall audience groups, which are shown within the following figures. The Pain SNA (Fig 1) is composed of 47 unique, attentive clusters organized into eight audience groups. The Chronic Pain Patients (Fig 2) are individuals engaged with information on a variety of chronic pain conditions and treatment or management approaches. This audience was grouped into 10 separate clusters based on either the causes of pain or another common interest (Arthritis, Migraines, Neurological Patients, Chronic Conditions, RSD-CRPS [reflex sympathetic dystrophy/complex regional pain syndrome], Engaged Patients, Pain Patient Advocates, Pain Support-Women Centric, Patient Advocacy, and Spoonies). The Spoonies, a self-selected term for people living with a chronic disease, tended to cluster together based on the ways they developed to manage their energy, despite having many different types of pain among them. The Pain SNA includes three separate HCP audiences (Fig 3 ): 1. HCPs, who are general HCPs that deal with pain as well as many other medical issues. Numbers indicate the order of word pairs mentioned; the top 10 for each audience was included along with the actual rank for the other audiences. A 1 ranking is the most frequently mentioned word pair for that audience. https://doi.org/10.1371/journal.pone.0226321.t001 2. Pain Medicine and Research, which is mostly composed of traditional HCPs who focus on either direct patient care or pain research. 3. Nonpharmacologic Pain Treatment, which includes traditional providers, such as physical therapists, and those who practice complementary health approaches, such as acupuncturists and massage therapists. The other audiences (Culture/Other, Public Health, Health Industry and Policy-News) are all engaged on pain topics, but for the most part are not directly engaged with patient-HCP communication. However, it should be noted that most of the Health Industry audience is composed of the pharmaceutical industry, which is highly engaged with the HCP audience. Numbers indicate the order of URLs cited; the top 10 for each audience was included along with the actual rank for the other audiences. A 1 ranking is the most frequently cited URL for that audience. --- Analysis of follow relationships The follow relationships between audiences were compared by collecting the total follows between groups, and then applying a density measure to correct for disparate audience sizes. The density measure normalized the data by weighting the total follows between each audience in accordance with its number of members. The normalization process assured that the size of --- Results The following figures are visualizations of the comparative follow patterns between the select SNA audiences that are discussed within this section. --- Define the structural differences and similarities in Twitter relationships Comparative follower patterns-Comparative patient data. Chronic pain patients follow other pain patients at a statistically higher rate than the amount, on average, that they follow all accounts within the Pain SNA map. Similarly, cancer patients are more likely than average to follow other cancer patients, when compared to a random mixing baseline ( Fig 7). They also follow physicians who specialize in oncology at a statistically higher rate than the amount, on average, that they follow all accounts within the Oncology SNA map. Chronic pain patients are less likely to follow other chronic pain patients than cancer patients are to follow other cancer patients ( Fig 7). However, the follow patterns of chronic pain patients suggest they are less attentive to information shared by pain medicine and research specialists on social media than cancer patients are to cancer physicians (Oncology Who do pain audiences follow? The higher-than-average follow rates between oncology physicians and patients, and pain physicians and patients, were demonstrated by comparing each observed value to a random mixing baseline. The likelihood of finding the observed follow rates was calculated given a binomial distribution with the baseline probability. Statistical significance was determined at a 95 percent confidence level. https://doi.org/10.1371/journal.pone.0226321.g006 HCPs). Chronic pain patients are less likely to follow pain medicine and research specialists (9%) than cancer patients are to follow cancer specialists (17%). Chronic pain patients and cancer patients are similarly likely to follow general HCPs (Figs 6 and7). Both chronic pain patients and cancer patients follow other patients at a higher rate than the amount, on average, that they follow all accounts within their respective SNA maps. However, both patient audiences appear to follow general HCPs within their respective focus areas less than they follow specialist HCPs within their areas. Pain and cancer specialists show similar follow patterns (Figs 6 and7). Like the patient groups, both follow accounts within their own audiences at a higher rate than average. They both also follow their respective patient groups at higher than average rates. However, many pain specialists also follow members of the nonpharmacologic pain treatment audience, whereas cancer specialists do not often follow any kind of analogous group focused on nonpharmacologic cancer treatments. While the SNAs have slightly different audience labels, both the Health Industry audience in the Pain SNA and the Oncology SNA's Life Sciences audience include the pharmaceutical industry. Please note, however, that as the name reflects, the Life Sciences audience in the Oncology SNA includes a large group of researchers. Comparative follower patterns-Comparative HCP specialists. The nonspecialist HCPs' (Figs 6 and7) relationships to the specialist follower patterns are more remarkable than the difference between those that appear on the Pain or Oncology SNAs. The nonspecialists within the Pain SNA appear to be less attentive to both patients and nonpharmacologic providers than the pain specialists. They also appear to be more likely to follow the Health Industry and Policy-News than the specialists. The nonspecialists in the Oncology SNA appear to be only slightly more likely to follow patients. However, the general HCPs appear to be more likely to follow oncology specialists than the general HCPs in the Pain SNA were to follow pain specialists (Figs 6 and7). Members of the general HCPs audience within the Pain SNA appear to follow chronic pain patients somewhat less than general HCPs within the Oncology SNA follow cancer patients. Unlike other audiences, the nonpharmacologic pain providers appear to be somewhat insular, in that they appear to be more likely to follow members within the same audience than all other audiences in the SNA (Fig 6). This pattern is a sign that this audience may be isolated from the rest of the SNA audiences-interestingly, this may be more of a self-reflection within this group rather than how others view them because other groups do follow them at substantial rates. --- Identify what the similarities and differences in engagement among patients and HCPs within the Pain and Oncology SNAs tell us As we examined the chronic pain SNA, we found that chronic pain patients follow each other at higher-than-average rates compared with a random mixing baseline, which suggests that they often get information from like-minded accounts; they also are more likely than oncology patients to cite consumer-focused information sources. They also appear to be engaged on general topics, such as pop culture, and topics related to nonpharmacologic pain treatment sources (Fig 6). In comparison, though cancer patients are equally likely to follow each other, they appear to be more likely to follow specialists than their chronic pain counterparts. They also cite health-focused sources such as jamanetwork.com and cancer.gov at higher rates than chronic pain patients. --- Compare word use and citations among pain patients and HCPs We then analyzed language use within the Pain SNA patient and provider audiences to gain further insights into the similarities and potential gaps between these audiences. In order to confirm that the initial analysis captured the pain conversation and to summarize the thousands of tweets that took place in the Pain SNA, the top 12,000 pairs of words were generated and ranked within each audience. Common word pairs that had no significance (i.e., pairs such as "good luck" and "happy birthday") were removed, as were proper nouns. While many words such as "health care" were used across the audiences, chronic pain patients were both focused on chronic pain and illness and most likely to use terms tied to feelings (i.e., pairs such as "feels like," "looks like," and "sounds like"). Specialist HCPs (both those involved in Pain Medicine and Nonpharmacologic Pain Treatment) had different lexicons in talking about pain. Table 1, the top word pairs used by the chronic pain patients, demonstrates that they were primarily discussing pain during the evaluated time period. Comparative sources (other social media sites not included). The information and media sources cited in audience members' tweets indicate which of these sources have the most influence over each audience. Understanding the URL citations by each cluster cites, compared to the URL citations of other clusters, provides insight into the type of content shared on Twitter by pain patients and providers. As not every tweet contains a URL citation, we expanded the collection period to nine months, which enabled the collection of 363,733 citations of 23,753 sources across all audiences in the Pain SNA, and then ranked which sources were used by each audience. While both patients and HCPs often post stories from large, traditional media sources (for example, both most frequently cite nytimes.com), only HCPs cite sources related to health care, including sources such as statnews.com and khn.org (Kaiser Health News). Pain patients do not cite medical or health resources. The pain patients' behavior of citing consumer sites, in combination with their focus on pain-related words within discussions, indicates that their online behavior appears to focus on pain, but they may not have adequate medically focused resources to cite. In Table 2, citations refer to the number of times the members of each audience mentioned the various Web domains on Twitter between July 2017 and March 2018. --- Outline the challenges and limitations in addressing any differences between the audiences evaluated The Twitter platform's Streaming API precise sampling method is not disclosed. Therefore, while we were able to get full data on the following relationships' specific tweets containing the language used, sources cited, and accounts mentioned analyses were only done based on that sampling. This may have impacted the citation ranking and our understanding of the language used. Inclusion of users into audiences was based on similarity of sources they cite, and then the audience name was identified, which creates a limitation that some users within each audience might behave like that audience but not be a member of it. For example, a journalist who is focused on covering a specific audience might appear as a member of that audience. As the focus of our research was to look at how the typical member of an audience interacted with other audiences, we normalized the data to account for audience size. Therefore, our findings are limited to how members of specific audiences act and not on how influential or active a specific audience is. --- Discussion In this paper, we sought to identify the online relationships between pain patients and providers to understand what insights those relationships might provide. We found that on Twitter, pain patients and providers appear to interact less than oncology patients and providers. Pain patients do not appear to follow medical professionals or share medical or health-related information on Twitter to the same extent as oncology patients. In addition, we found that pain patients do not communicate on Twitter in the same language as HCPs. This is of interest because it reinforces a larger disconnect between pain patients and providers that has been well-documented in the literature [28]. It shows that challenges in communication are not just occurring in face-to-face interactions, but also in their digital social network (Twitter) interactions, serving as an additional roadblock to what can be shared decision-making opportunities around pain management. Social media platforms are important tools for patient engagement and research has found that participating in online communities may improve health outcomes for certain conditions [29,30]. Likewise, studies have examined how communication and team-based provider care can be essential for a person's pain management plan [31]. Research has found that clear communication in a clinical setting is important for improved health outcomes in both pain patients [32] and oncology patients [33]. In fact, an article published by Thorne and Stajduhar identifies specific challenges that oncologists in Canada face when it comes to communicating with patients as they transition from primary cancer treatment to survivorship. The authors write: "Although extensive empirical work informs communication in certain highly sensitive contexts such as 'bad news' delivery and the transition to palliative care, less is understood about communications in the course of routine care [34]". While our research did not focus on the clinical relationship, how patients and providers from these respective medical communities follow one another and communicate about pain differs significantly. We provide some reasons why pain patient interactions on Twitter differ from those of pain providers: pain can be a part of many different conditions and, as a result, pain patients may not be organized online in the same way as other patients are, such as our oncology comparison; pain patients are also using a different vocabulary in their tweets than pain providers, which suggests that they may be viewing different sources of information than pain providers; in addition, pain patients might not have a central hub of evidence-based information to cite, such as a leading scientific and patient-friendly resource like cancer.gov. Research has also found that while the internet can be a place where pain information is found in abundance, at present, it is not well-used as a space for patient-provider interactions [35]. Our results, in addition to these potential explanations, point toward a need for an online, evidence-based resource hub that could benefit the pain patient community in the same way that cancer.gov serves as a resource of aggregated materials, information to bring to HCPs, studies, and content from many cross-sections of oncology. More research is needed to explore how an online analysis can translate to face-to-face physician/patient interactions and if the tools and outreach materials developed to close the engagement and language gap are improving health outcomes in people with pain. A comparative analysis using the same methodology could be conducted after additional resources are developed and deployed to see if online behavior is impacted. At the same time, traditional survey research could be used to determine whether similar patterns of behavior exist for patients that are not engaged with social media. --- All relevant data are within the paper and its Supporting Information files.

The objective of this study was to understand how pain patients and health care providers (HCPs) are engaging on Twitter and what insights this engagement might provide. By identifying how information is spread by and between these audiences, organizations such as patient advocacy groups may be better poised to develop and share materials that facilitate online communication between HCPs and pain patients, with an end goal of improving a shared decision-making process around pain management. We analyzed the Twitter audiences most engaged on pain topics by conducting a Social Network Analysis (SNA) of a large network of connected users on Twitter. The analysis segmented users based on the sources they cited and measured their influence based on who follows them. As a point of comparison, we also conducted an SNA of Twitter audiences most engaged on oncology topics. Oncology was chosen as a comparison due to what was perceived to be a highly developed online network of both patients and physicians. The populations included in this research included 12,086 accounts that were highly engaged on pain-related topics, and 12,617 accounts that were highly engaged on oncology-related topics. Network statistics were generated for variables including: word use, sources cited, retweets, and mentions. We also statistically analyzed the Twitter follow relationships among select HCPs and patient groups within each SNA. The creation of separate pain and oncology SNAs allowed the team to compare relationships and engagement related to these topics. We found that on Twitter, pain patients and providers appear to interact less than oncology patients and providers. Pain patients do not appear to follow medical professionals or share medical or health-related information on Twitter to the same extent as oncology patients. In addition, we found that pain patients do not communicate on Twitter in the same language as HCPs. Our results are important because they underscore that challenges in communication are not just problematic in face-to-face interactions, but also in digital social network (Twitter) interactions, serving as an additional roadblock to what can be shared decision-making opportunities around pain management. Contributing to this roadblock is access to quality information and a potential need for an online, evidence-based resource hub that could benefit the pain patient community in the same way that cancer.gov serves as a source of aggregated materials for oncology patients and HCPs. This study is an illustration of how social media networks like Twitter can be used to better understand the relationships,

Introduction --- M any children have divorced parents: one million marriages in the European Union ended in divorce in 2009 [1], a year in which there were 2.2 million marriages. Divorce rates in the United States are just as high. [2] Many divorced couples-more than 55% in the Netherlands-have children [3]. Divorce has been shown to have detrimental effects on children. Children of divorced parents perform worse in school, they have more behavioural problems, their psychological and emotional well-being is affected and they have lower self-esteem and more problematic social relationships than children from intact families [4][5][6]. Divorce or separation is regarded as 1 of 10 major adverse childhood experiences. The effects on emotional state, health risks, disease burden, sexual behaviour, disability and healthcare costs can continue for decades [7]. There is ample evidence indicating that divorce can lead to concurrent emotional and behavioural problems (EBP) in schoolage children and adolescents [4,6]. Evidence about the effects of divorce on behavioural and emotional problems in pre-school children is limited and inconclusive. Amato and Keith [8] concluded from their meta-analysis that younger children had fewer EBP after divorce than older children. Other studies showed that divorce is associated with EBP in pre-school children although these studies did not look at older groups for comparison [9,10]. Another study also showed that divorce did affect EBP rates in preschool children. However, this link was no longer found after controlling for maternal ethnicity and income. [11] The main aim of the present study was to investigate the relation between divorce or separation and EBP in children aged 2-4 years old (we will use the term 'divorce' to refer to both divorce and separation). We adjusted for relevant background characteristics such as the educational level of the parents. --- Methods Data were collected between August 2008 and June 2011 as part of the routine preventive health assessments undergone regularly by all Dutch children. The study was approved by the Medical Ethics Committee of Leiden University Medical Center. All data were anonymized before being sent to the research institute conducting the analyses. --- Sample The sample was obtained in a two-stage procedure. In the first step, all Dutch Child Health Care Services in the Netherlands were asked to participate in this study (at that time 55); 18 agreed to do so. The Child Health Care Services that agreed to participate were located throughout the country. In the second step, all these services were required to provide a random sample of children aged 24, 36 and 45 months who had received invitations for a routine well-child examination. Each Child Health Care centre was provided with a random numbers sequence to select this random sample of children sufficing the inclusion criteria. Parents of selected children were invited to participate in this study by using a letter, added to the routine invitation for the visit for their well-child examination. Data collection for this study took place across a longer period of time due to some organisations participating earlier than other ones. Once an organization agreed to participate, field work typically took some months. A total of 3692 parents were asked to participate in this study; 1092 parents (29.6%) of them explicitly refused to participate or did not return the questionnaire. This resulted in a response of 2600 parents (70.4%). We excluded children when the parents did not provide complete data on the questionnaires, and children who did not live in a family with two biological parents for reasons other than divorce or the termination of the relationship (a deceased parent or a foster family, for example), leaving us with a sample of 2490 children. Respondents were representative of the total sample in terms of gender, but nonresponse was higher in children with an ethnic background (compared with children with a Dutch background) and in children aged 4 years (compared with children aged 3 and 2 years). The Cohen effect size index w indicates that differences between responders and nonresponders with regard to child ethnicity, age and gender were small, with w varying between 0.01 and 0.17. --- Procedure and measures Parent-reported emotional and behavioural problems were assessed using the Child Behaviour Checklist 1.5-5 (CBCL) [12]. The CBCL was mailed to parents along with the standard invitation for the preventive health assessment routinely offered to all Dutch children. The completed CBCL questionnaire was returned to the Child Health Care Professional (CHP) in a sealed envelope. The CHP forwarded the envelopes to the research institute without opening them, as the CBCL was used for research purposes only, and made no part of routine identification by CHPs. The CHP then took a routine history and physically assessed each child. The CHP recorded the background characteristics of the child and the family: ethnicity, child age and gender, maternal and paternal educational levels, family size, the birth of a sibling last year, family moved to another place of residence, duration of pregnancy, type of delivery, weight at birth and divorce status of the parents (recent divorce/ lifetime divorce). The CBCL assesses parental reports about children's behavioural and emotional problems in the preceding 2 months. Its reliability and validity have been found to be sound in the Netherlands and elsewhere [12][13][14]. The CBCL consists of 99 problem items that are used to compute Externalising, Internalising and Total problem scores (TPS). Children were allocated to a normal range or an elevated range using the 90th percentile cut-off point. The number of parents who had divorced in the previous year was determined by asking 'Did the child experience one or more of the following life events in the last 12 months?' The parents who replied 'divorce/termination of the relationship of the parents' were classified as having divorced recently. Parents who have divorced recently may still live in one household, among other things for financial reasons. In that case, two biological parents are still present in the family. Lifetime divorce was assessed with the question 'How many biological parents were present in the family?' Parents that answered 'one, because of divorce or the termination of the parent's relationship' were classified as lifetime divorce. Information about lifetime divorce was available for 2373 parents. The country of birth of the (biological) parents was identified to determine ethnic status. The educational level for each parent was classified as the highest level achieved by that parent. In case of new family composition after divorce, we adhered to the two parents who had the main parenting roles. Family size was determined as the number of children in the family (one child, two children, three or more children). Type of delivery was categorised as normal birth or other (such as Caesarian section or forceps birth). --- Analyses We first assessed the differences in child and family characteristics between lifetime divorced and non-divorced families using chisquare tests. We repeated these analyses for recent divorce. We then investigated the relation between divorce (lifetime and recent) and children's behavioural (CBCL externalising score) and emotional (CBCL internalising score) and total problems [CBCL total problems score (TPS)] scores; differences were tested using chi-square tests. Our third step was to investigate the relation between lifetime divorce and children's emotional and behavioural problems using stepwise logistic regression analyses, both crude and adjusted for other determinants. The total score for the child's behavioural and emotional problems (CBCL TPS) was included as the dependent variable, and lifetime divorce and child and family characteristics as predictors. We repeated these stepwise logistic regression analyses using recent divorce as the predictor. Similar stepwise logistic regression analyses were performed with children's behavioural problems (CBCL externalising score) and emotional problems (CBCL internalising score) as the dependent variable. Sample sizes in these regression analyses (N = 2210 for lifetime divorce and 2246 for recent divorce) were smaller than the total sample sizes (N = 2373 and 2490), due to missing values for some of the predictor variables. --- Results --- Characteristics of divorced parents For all children, 4.0% of their parents were divorced during their lifetime, and 3.4% of their parents were divorced in the previous year (i.e. recent divorce). Table 1 shows the characteristics associated with the divorce status of the parents. Lifetime divorce was more likely in families of non-Dutch ethnicity, mothers and fathers with a low educational level, small families (one child), families who moved home last year, where no new sibling was born last year and with short pregnancy duration (<unk>37 weeks). Lifetime divorce was also found more frequently in children with a higher age (4 years). Recent divorce was more likely in families who moved home last year, families with short pregnancy duration and families in which a new sibling had been born in the previous year. Table 2 shows the association between lifetime and recent divorce and children's EBP. Lifetime divorce was more likely to be associated with children with total emotional and behavioural problems (CBCL TPS) and externalising problems (CBCL externalising score). Recent divorce was not related to any CBCL outcome. --- Relationship between divorce and child EBP (CBCL total problems score) Table 3 shows the results of the stepwise logistic regression analyses. The crude model shows that lifetime divorce was significantly more likely in children with EBP (as determined with the CBCL TPS; P = 0.02), whereas recent divorce was not significantly associated with CBCL scores. Table 3 also lists the other crude predictors of child EBP. In multivariate analyses, being a boy, higher child age (3 years as opposed to 2 years), lower education of the father, non-Dutch ethnicity and small families (one child as opposed to three or more) were associated with child EBP. However, the inclusion of child and family characteristics weakened the association between lifetime divorce and child EBP (P = 0.14) and reduced the odds ratio for lifetime divorce from 1.92 to 1.66, suggesting that 26% was due to confounding. Including child and family characteristics did not change the already non-significant association between recent divorce and child EBP. --- Association between divorce and child behavioural problems (CBCL externalising score) and emotional problems (CBCL internalising score) Table 4 presents the results of the stepwise logistic regression analyses for child behavioural problems and lifetime divorce. The crude model shows that lifetime divorce was significantly more likely in case of child behavioural problems (measured with a clinical CBCL externalising problem score) (P = 0.03). In multivariate analyses, being a boy, lower education of the father and mother, and non-Dutch ethnicity were associated with externalising problems in children. However, the inclusion of child and family characteristics weakened the association between lifetime divorce and behavioural problems of the child (P = 0.08). We did not find an association between divorce (recent or lifetime) and children's emotional problems, or between recent divorce and children's behavioural problems [not shown]. --- Discussion This study shows that 4.0% of parents divorced before their child reached the age of 2-4 years, and 3.4% of these parents had divorced recently (i.e. in the previous year). EBP (especially behavioural problems) in children aged 2-4 years were more likely in families with lifetime divorce (or separation). This association weakened after adjustment for relevant child and family characteristics, indicating that this association may be partly due to confounding factors such as the gender and age of the child, paternal education level, ethnicity and family size. We found that recent divorce or separation, by contrast with lifetime divorce, was not associated with EBP in pre-school children. A possible explanation is that these children had been exposed to the negative consequences of divorce for a shorter period. This suggests that negative consequences of divorce such as less parental involvement due to single parenthood or little or no contact with the father may be the actual cause of children's EBP [15,16]. Child EBP may then only become manifest when exposure to these factors accumulates over a longer period. We found that young children's behavioural problems were more likely in families with lifetime divorce, but that emotional problems were not. This confirms previous findings that divorce generally has more effects on externalising behaviours than on internalising problems [5,8]. It is likely that difficult, externalising behaviour is the primary response of preschool children to stressors such as divorce or separation. These immediate and strong behaviour effects may resolve over time and become internalising behaviours as children get older. This hypothesis concurs with research showing a linear decrease in externalising problems and an increase in internalising problems with age [17]. Another explanation for the finding that children's behavioural problems were more likely in families with lifetime divorce, but that emotional problems were not may be the ability of parents to recognise EBP in their child. It is likely that emotional symptoms in young children (such as too little social interaction with others and being withdrawn) are harder for parents to identify as potential problems than externalising symptoms such as marked noncompliance, aggression towards peers, and high activity levels. This may result in the under-recognition of emotional problems by comparison with behavioural problems. No multi-informant perspective was used in the current study to be able to cross-check this hypothesis. Although the CBCL has shown excellent validity and reliability [12][13][14], information on EBP of children typically differs per informant (e.g. it differs between parents and other professional care-takers). Different approaches to assessing children's problems could therefore lead to different findings. --- Strengths and limitations Our study has several strengths. It had a high response rate and it covered the entire Dutch population, limiting the likelihood of selective response and enhancing its representativeness. Limitations should also be taken into account when interpreting our findings, however. In particular, we did not assess potentially important factors such as the remarriage of either partner, the amount of contact with the father, and interparental conflict. Parental education measured in this study concerned the biological parents only. As a result, available data about the current developmental contexts of children was limited, in particular for children growing up in blended families. Data on the time lags between relationship problems and formal divorce, and emergence of EBP was not available either, which may have diluted some of the associations and thus have led to an underestimation of the associations. --- Implications Based on the cross-sectional design of our study and the heterogeneous context of divorces, no causal inferences can be made on the basis of our results. Our findings show that EBP (especially behavioural problems) are more likely in pre-school children after divorce. Given the higher levels of distress around parents' divorce and the risk for later problems [4][5][6][7], divorcing families should receive appropriate level of services. However, the currently available preventive intervention programmes to support families after parental break-up primarily focus on school-aged children [18]. Our findings imply that not only school-aged children but also pre-school aged children of divorced parents may need appropriate support in order to prevent or reduce EBP. Several reviews have shown that (group work) intervention programmes can help children through the changes associated with divorce [19,20]. From a developmental perspective, at preschool ages, parents instead of their children may the most suitable target for interventions aiming to prevent or decrease child distress and EBP. As an example, the evidence-based New Beginnings Program has been shown to be promising for decreasing child EBP and increasing children's general functioning and well-being. It aims at improvement of parent-child relationship quality and parenting practices (e.g. teaching the use of effective disciplining) [18,21]. We found that young children's behavioural problems were more likely in families with lifetime divorce, but that this did not apply to emotional problems. This association of divorce with behavioural problems may be explained in several ways. First parental divorce may indeed cause behavioural problems due to factors related to the divorce such as more distress for their children and insufficient parenting in relation to family disruption. A second explanation might hold the reverse, however, with child behavioural problems being a cause of parental divorce as it challenges parental competences. Third, both child behavioural problems and family divorce might be due to a joint underlying cause, being a genetically determined tendency towards externalizing behaviours. Evidently, causal pathways require further study, including the use of other methods of assessment such as observation or professional assessment of these children. Important factors like the remarriage of either partner, the amount of contact with the father, and interparental conflicts could affect the link between divorce and EBP in children. Longitudinal research is needed to learn more about dynamic family characteristics subsequent to divorce and the effect on EBP in children of this age group. Our findings demonstrate the importance of identifying and providing support for pre-school children of divorced parents since they suggest that negative effects may occur in the longer term. --- Conflicts of interest: None declared. --- Key points Our study adds to the understanding of the effects of divorce on behavioural and emotional problems in pre-school children. We found that behavioural and emotional problems (and behavioural problems in particular) in children aged 2-4 years old were more likely in families with a divorce (or separation) at any time in the past. Our findings demonstrate the importance of identifying and providing support for pre-school children of divorced parents since they suggest that negative effects may occur in the longer term. --- Introduction --- T he incidence of teenage pregnancy has decreased during the last decade in developed countries, 1 being 3.4-7.9 childbirths per 1000 15-to 19-year-olds in the Nordic countries in 2015. 2 In the United States, and in England and Wales the incidence of teenage pregnancy is substantially higher; 31.3 births per 1000 teenagers in the U.S 3 and 21.0 in England and Wales in 2011. 1 A large proportion of teenage pregnancies end in induced abortion, 1,4-6 i.e. 60% in Finland, 78% in Denmark and Sweden, 2 30% in the U.S. 3 and 43% in England and Wales 7 in recent years. Teenage mothers have a poorer social background and face more socioeconomic and health problems later in life compared with older mothers. 8-10 We have shown that teenage pregnancy, ending in both childbirth and abortion, is associated with an increased prevalence of psychiatric morbidity in comparison with non-pregnant teenagers. However, this risk is already increased before pregnancy and is not affected by the outcome of pregnancy. 11 According to studies carried out in Sweden and the U.K., women with a history of teenage childbirth also have a higher risk of premature death compared with women who conceive later in life. 12,13 Independently of social background, premature death, especially by suicide, violence,

Background: This study examines the link between divorce or separation and emotional and behavioural problems (EBP) in children aged 2-4 years. Methods: We obtained cross-sectional data for a nationally representative Dutch sample of children aged 2-4 years within the setting of the national system of routine visits to well-child clinics. A total of 2600 children participated (response rate: 70%). Before the visit, parents completed the Child Behaviour Checklist and a questionnaire with questions about divorce or separation. We assessed the associations of children's EBP with a divorce either in the previous year or at any time in the past after adjustment for other child and family factors. Results: Four percent of the children had parents who had divorced before the child reached the age of 2-4 years, and 3.4% of these parents had divorced in the previous year. EBP (and particularly behavioural problems) were more likely in children aged 2-4 years old in cases of lifetime divorce or separation. This association was weaker after adjustment for relevant child and family characteristics: it may be partly due to confounding factors such as paternal education level, ethnicity and family size. A divorce in the previous year was not linked to child EBP. Conclusions: These findings show the importance of identifying care needs and providing care for pre-school children whose parents have divorced since they suggest that there may be negative effects in the longer term.

Introduction In the last decade, the United Kingdom (UK), like many other high-income countries, predominantly in the global north, has witnessed a rapid rise in referrals of gender diverse 1 children and adolescents to specialist under-18s Gender Identity Development Services (GIDS) (Kaltiala et al, 2020). For example, in 2009-10 the Portman and Tavistock Clinic, the sole provider of GIDS in England and Wales, had 77 young people referred to their services. By 2017-18 (the time period in which our data was collected) this rose to 2445. The most recent figures suggest this rate is beginning to level off with referral numbers at 2590 in 2018-19 (Tavistock & Portman, 2019). In a population estimated to be 65.64 million (mid 2018), with 18.9% of that total population aged under 18 (ONS, 2018), these numbers are still very small. However, concern about the size of the annual increases in referrals, along with questions about who is being referred and how long they have to wait, has garnered unprecedented national media attention and a government inquiry (Women and Equalities Select Committee, 2016). Alongside expanding numbers, data has shown that referrals of clients who were assigned female at birth referrals were 3 times higher than for clients assigned male at birth; a significant shift since 2009. This pattern has drawn specific attention from broadsheet newspapers, the Women & Equalities Select Committee, and so-called 'gender critical' activists (Gilligan, 2019), resulting in UK public discourse currently featuring deeply inflammatory, polarised and politicised accounts of trans people's lives, identities and healthcare needs. In the UK, this is the context in which children, young people and their families come to understand the stigma and discrimination associated with gender diverse identities and health service provision. Evidence shows that gender diverse children and their parents are most likely to access information through a range of online sources (Carlile, 2020). Their knowledge, 1 We use gender diverse in this paper to recognise children's gender expressions that do not conform to socially expected norms. Gender diverse can also be referred to as gender variant, trans, non-binary and gender queer, although some of these terms are more readily associated with adolescent and adult identifications rather than primary age children. understanding, expectation and experience of trans and non-binary identities and health service provision will inevitably be shaped by the concerns raised in these sources. In this paper, we outline in more detail the contested status of gender diversity in childhood and in the UK healthcare system, before reflecting on our empirical data documenting parent/carer expectations and experiences of accessing health care for primary school-age gender diverse children within this context. --- Gender diversity in childhood: a contested possibility There has been significant research and debate about appropriate treatment and support pathways for transgender experiences since the 1950s, but terms such as 'transgender' or 'gender dysphoria' were rarely applied to children or adolescents. UK-based education researchers have argued that transgender children have always existed, but should more accurately be categorised as 'apparent and non-apparent' in terms of their visibility within social systems (Hellen, 2009). Writing prior to the increase in numbers of children and adolescents seeking referral, Kennedy and Hellen observed that 'apparent transgender children are relatively rare' (2010 p. 26). They argued that rather than not existing, children with these feelings chose to actively conceal them in order to achieve conformity with the heavily policed gender norms of early childhood. Despite this, trans people are very much 'aware they are transgender at much younger ages than previously considered' (Kennedy & Hellen, 2010 p. 25). The diagnostic term 'gender identity disorder in childhood' first appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM) III in 1980, not long after the removal of 'homosexuality' in 1973. This term was initially critiqued by feminists and queer theorists (e.g. Sedgwick, 1991) for operating as a psychomedical device for normalizing expressions of the cross-gender behaviour that sometimes emerged as part of a lesbian or gay identity. This argument has more recently been challenged as 'cisnormative' (Ansara & Hegarty, 2011), indicating a prejudiced ideological approach that privileges the social norm that gender expression and sex characteristics always align. As referral rates have risen, there has also been an increased focus on confirming the validity of gender diversity classifications and treatment for those who are under 18. 'Gender incongruence in adolescence', the terminology applied by International Classification of Diseases, eleventh revision (ICD-11), has become accepted within trans healthcare as a diagnostic category that justifies access to medical support for gender affirmation (WPATH, 2012). The model of care available in the UK, like other global north countries such as US and Australia, has shifted towards 'trans-affirming approaches that aim to promote gender exploration and affirmation without constraints or barriers by facilitating access to different forms of transition' (Sansfaçon et al, 2020 p.1). However, concerns continue to be expressed by a minority of clinical and feminist commentators about the potential risk of adverse long-term effects of hormone treatments, the strategies employed to determine informed consent to accessing gender affirming medical care among children or youth, and if so from what age those strategies should apply (e.g. Ashley, 2019;Heneghan & Jefferson, 2019;Wren, 2019). What is often overlooked in the media representations of these issues is that medical options for affirming gender among gender diverse young people, such as puberty blockers, are only one mode of support available for those aged 12-16. In line with WPATH (2012) recommendations and NHS England GIDS service specifications (NHS, 2017), full consideration of an individual's competence and capacity to consent is made during a period of careful consultation and assessment before any form of medical care is able to be accessed. Access to an appropriate process of reflection is supported by evidence that only approximately 40 per cent of young people who contact the leading GIDS clinic in the UK go on to undergo physical treatments (Carmichael, 2016). Additionally, for those that do, the key purpose of 'puberty blockers' is to open up a temporal space in which the bodily transformations associated with the development of secondary sex characteristics can be paused, allowing time for further reflection about future gender pathways, while reducing the intense gender dysphoria and distress reported by these adolescents (Roen, 2011). Puberty blockers do not prevent growth or other dimensions of normal adolescent development, and so are regularly (and safely) used to delay 'precocious puberty', reduce the impacts of adolescent endometriosis or support an extended period of pre-pubertal growth among children with idiopathic short stature (Giordano, S., & Holm, S. (2020). Controversy is more apparent for the ICD-11 diagnosis 'gender incongruence of childhood', which is applied to gender diverse children who have not yet reached puberty. Many leading trans-affirmative clinicians working with gender diverse youth are against the inclusion of this diagnosis in the ICD (e.g. Winter et al, 2019). They argue that there is no need for a psychomedical framework to be applied to pre-pubescent children who are exploring their gender: "These young children do not need puberty suppressants, masculinising or feminising hormones, or surgery. Rather, they need a safe emotional space with the freedom to explore, embrace, and express their gender identity" (Winter et al, 2019 p. 672). The need for these forms of early social support is increasing with substantial evidence demonstrating that transgender youth report higher rates of depression, suicidality and self-harm, and eating disorders when compared with their peers (Connolly et al, 2016;Strauss et al, 2020). Parents, advocates and transgender affirmative researchers also highlight the risk of delayed access to supportive healthcare (e.g. Carlile, 2020;Pearce, 2018), compared to evidence of the positive impact that early support with the social aspects of gender transition can have on the mental health and wellbeing of gender diverse children and adolescents (Olsen et al, 2016). In England, the preferred route of referral to GIDS is through the local Child and Adolescent Mental Health Service (CAHMS). This is in line with WPATH (2012) guidelines that recommend that any underlying mental health concerns be explored and managed prior to progressing to the stage of accessing gender affirming care. GIDS also accept referrals through the primary care system, from a general practitioner/doctor (GP), and from other health, education and social care professionals including LGBT+ and trans-specific groups who support gender diverse young people and their families. With greater visibility of gender diversity, parents and carers have become more knowledgeable and cognisant of early indicators of gender diversity, and are seeking information, support, advice and treatment for younger aged children (Carlile & Paechter, 2018). The rapid rise in referrals has undermined GIDS ability to meet these needs in a timely way. Despite expanding service provision through NHS investment and the operation of satellite clinics in cities outside of London and Leeds, waiting times have increased from 9-10 months in 2015 to 2 years in 2020. The negative impacts of waiting and delay are now widely expressed in social media, by both young people and their families, in contrast with the accusations by a minority of voices that the process does not provide sufficiently in-depth care or time for consideration before commencing clinically supported forms of care (Swerling, 2020). There are several theories currently circulating about why we might be seeing an increase in the presentation of gender diverse young people to clinical care settings, often linked to a presumed correlation between gender identity and media representations. Research has found evidence of an association between increased media coverage of topics related to trans and gender diverse people and increasing numbers of young people presenting to gender clinics (Pang et al, 2020). Controversially, some have argued that these positive media representations are fuelling an imagined phenomenon described as 'rapid onset gender dysphoria' (Littman, 2018). Interest in this unsubstantiated theory has been driven by the distress of some parents who believe that their child (adolescent or young adult) only expressed signs of gender dysphoria after having accessed information about gender diversity online. This perspective has been robustly critiqued for its lack of scientific evidence, its association with 'transantagonistic websites', and for attempting to 'weaponise scientific-sounding language evidence' to refute research evidence that demonstrates the important benefits of supporting gender affirmation (Ashley, 2020 p. 779). An alternative interpretation is that wider access to information about trans lives enables young people to have access to the language they need to describe their experience, and the confidence to seek out health services earlier, rather than waiting for adulthood. The sociologist Ken Plummer (1995) wrote saliently about the socio-political flow of stories, social change and the ways in which stories can be transformed from inner whispers to being articulated in wider public discourse. Following Plummer (1995), we propose that it is possible we are currently witnessing an important shift in our social world, one that permits us to be better able to hear and affirm stories of gender diversity in childhood and adolescents, including within health services. --- Expectations and experiences of health services among parents/carers of gender diverse children Parental expectations of healthcare for their gender diverse children are framed by the psychosocial discourses governing gender, sexuality and child development (Johnson, 2018). These discourses include normative assumptions about gender and sexuality expressions, which can both manifest in terms of gender variance, alongside assumptions about child developmental'stages' or 'phases', 'neuro-plasticity and the developing brain', and associated development risks such as mental ill-health and suicidal distress (Johnson, 2015;McDermott & Roen, 2016). We and others have argued elsewhere (Johnson, 2018;Winters et al, 2018) that it is also important to understand the support needs of trans and gender diverse children within these discussions, emphasising their voices and including them from a much younger age. For primary age children this dialogue will usually happen within the parent/carer dyad. Parental expectations will also be shaped by exposure to the polarised contemporary discourses about trans healthcare for under 18s and competing interpretations of the impact of waiting for access to care. The first position, often articulated by trans-affirmative parents of gender diverse children, is that delayed access to specialist services increases the risk of gender dysphoria having devastating impacts on a child's mental health. The opposite position, often articulated by 'gender critical' authors in the UK (e.g. Brunskell-Evans & Michele Moore, 2017), is that access to gender affirming medical care is provided too early to young people who may regret it when they are older. The latter interpretation deliberately frames access to care as an ethical question of whether and when clinical treatment should be made available for children and adolescents. However, these issues are typically expressed using divisive and dismissive terminology e.g. 'the fabrication of the transgender child', 'the transgender experiment on children' and 'the transgender trend' (Brunskell-Evans & Michele Moore, 2017), and make unsubstantiated associations between support for gender diverse young people and the erasure or devaluing of homosexuality, particularly lesbianism (Shrier, 2020). The gender critical approach (e.g. Stock, 2018) has gained significant populist appeal in recent years through the support of specific journalists and media platforms and particular forms of Twitter dissent aiming to discredit proposed changes to the Gender Recognition Act (GRA, 2004) as well as GIDS. The GRA review proposed improving self-identification processes for gender diverse adults by allowing birth certificates to be changed without evidence of a medical diagnosis. Critics of this proposal (Stock, 2018) argued that the proposal would lead to the erasure of cisgender women's rights and safety (see Serrano, 2007 andHines, 2019 for extended discussions of the false dichotomy between transgender and feminist politics, and Zanghellini, 2020 for a review of the problematic philosophical position proposed by gender critical commentators on trans inclusion). In contrast to debates about whether or not trans healthcare should be made available, some researchers have begun to focus on documenting experiences of trans healthcare for under 18s (Carlile, 2020). Our research builds on this by introducing an innovative focus on the experiences of parents/carers of primary school-age children. Most young people who access GIDS are in the 14-16 years old category. This is not surprising given the lengthy waiting times after a referral is secured, and because they specialise in puberty specific treatment pathways. However, GIDS also receive referrals for much younger children, reflecting an emerging need for information and support for pre-pubescent children and their families. The aim in this study was to understand the health care expectations and experiences of parents/carers seeking support for gender diverse children aged 4-12 years. --- Methods and Analysis This paper forms part of a larger, mixed methods project which utilised participatory research principles to engage stakeholders and practitioners (a local Trans Network, a national charitable organisation and the England-based GIDS) in the design of the study. This paper reports findings from the first study, a mixed methods e-survey, delivered via Survey Monkey, which was completed by 75 parents/carers of gender diverse primary school-aged children in the UK. The aim was to gather both metrics and qualitative, open-text data related to primary school-aged gender diverse population parent/carer experiences and expectations of health services used. The survey design and recruitment benefitted from stakeholder and practitioner collaboration in two ways. First, it increased the validity and relevance of survey items and ensured we were asking questions that filled gaps in current practitioner and on-the-ground knowledge. Secondly, the use of public social media recruitment adverts was supplemented by recruitment through our stakeholders' networks. A limitation was that our sample may have been overly representative of parents who had contact with these stakeholder networks. --- The Mixed Methods E-Survey The cross-sectional survey included 52 questions in 4 sections, 14 of which were open-text. First, a background and initial presentation section included six questions, e.g. 'How old is your child at the moment?' Second, an involvement with services section contained 7 questions about GP/Doctor, GIDS, Child and Adolescent Mental Health Services (CAHMS), School and Educations Services and Other services, e.g. 'Can you please give an example of how your Doctor / GP Service/ GIDS/CAMHS/ School Education 1) was helpful?' The third section focused on overall views of services provided. Finally, we collected 10 demographic information responses about the parents/carers, the children and their families. The survey generated 86 responses. For quality purposes, only 75 survey respondents who answered 75% of key survey questions were included in the analysis. --- Analytic Methods The quantitative data was summarised using SPSS software to establish frequency data for all 38 quantitative items in the E-survey. The qualitative data set was derived from the 14 open-text questions, generating 14,029 words across 441 responses, ranging from one word to 977. This data was analysed thematically by coding and identification of overarching themes about family experiences of health care service provision. Thematic Analysis is a flexible type of qualitative analysis that is useful for identifying broad patterns of meaning across a data set, including opentext survey data (Braun & Clarke, 2006). --- Findings In this section we present key descriptive statistics from the quantitative survey data including 'demographics', as well as two themes: 'journey to health service provision' and 'views of health services used'. We then outline two overarching themes generated from the qualitative open-text data, 'waiting' and 'isolation', and interpret these in relation to the literature. --- Demographics All of the respondents confirmed they were 'parents/carers'. Just 26/75 reported their gender identity, and of the 26, most identified as women (just three as men) and cisgender, and one person as a trans parent/carer. Most were 'White', except one'mixed heritage' respondent. All were either in the 41 -50 years old (50%) or the 31 -40 years old (47%) age groups. The study sample was geographically distributed across Scotland, Wales and England, however no parents/carers responded from Northern Ireland. This is broadly representative of UK population estimates (Office for National Statistics (2020), with 83.5% living in England, and the English sample scattered fairly representatively around all main regions, with the exception for the North-West and South-East which were represented at 2-3 times higher than the UK national population estimates at region level (Statistica, 2020). The average age of the child concerned, at the time of the survey, was 8.5 years old (ranging between 4 and 12 years old). These children were equally as likely to have been assigned male or female at birth (51% presumed male, 49% presumed female). Just over half were 'currently living all the time as the gender they identify with' (53%), 13% were 'living some of the time as the gender they identified with' and 17% had not socially transitioned. Most of the gender diverse children were defined as 'White' (86%), 9%'mixed/multiple' heritage, 2% 'Black' and 3% 'other'. The sample closely matched the national heritage profile, in addition to family household data (Office for National Statistics, 2011 Census) and reported family income (Office for National Statistics, 2017). --- Journey to health service provision Once families became aware that their child was displaying gender diverse characteristics, most (68%) indicated that they conducted online research to explore the subject, with 56% then contacting a gender support group. Most respondents (64%) reported they had discussed these observations with someone else within a month, but for a small number (16%) it took more than a year to do so. There was a 4 year gap between the average age of the child when their parent/carer became aware that they were displaying gender diverse characteristics (median age = 3 years old), and the average age of the child when parents/carers initially consulted the first of the statutory services (i.e. GP/CAMHS/GIDS.). --- Views of health services used Eighty-five percent of parents/carers had consulted their GP service about their gender diverse child (Mean age = 7 years old). Of these participants, most felt their initial concerns had been taken seriously (65%). However, only a small proportion agreed their GP was knowledgeable about the needs of primary-aged gender diverse children or their parents/carers (16%), that they had received good advice (24%), that they had received good support (38%) or that they were happy with the service (34%). While over half of the respondents (59%) reported that they had been referred on to other services, many parents/carers reported they had to often direct their GP service to appropriate resources or provide them with the specific information about where they needed the GP to refer them on to. Mostly following a GP referral, 62% of the sample had consulted their CAMHS with the average age of first contact for their gender diverse child at 8 years old. Some parents/carers indicated (in the open-text responses) that they viewed contact with CAMHS as a necessary 'gateway' to access a referral to GIDS. Again, most (65%) agreed that CAMHS took their concerns seriously, but the vast majority disagreed with the statement that the service was knowledgeable about the needs of gender diverse children (64%) or their parents/carers (67%). As with the GP service, a lack of good advice (only 15% agreed) and lack of good support received (27% agreed) often accompanied a disagreement with the statement that CAMHS was knowledgeable about family needs. A large proportion of families (66%) reported they had consulted a GIDS (Mean and Median age = 9 years old), nearly all using Tavistock services in England (e.g. London or Leeds), and the remainder accessing Sandyford (Scotland). Most who had not yet accessed a GIDS were on the waiting list to access one. Most respondents (76%) agreed that the GIDS clinics took their concerns seriously, but only half agreed that GIDS were knowledgeable about the needs of gender diverse children and their parents/carers (53%). Only 39% agreed that the waiting time to see the GIDS team was acceptable, and less than half (42%) were happy with the service they received. Nevertheless, most (65%) agreed they would be happy to return to the service in the future. Finally, a third of parents/carers selected a community-led group for supporting gender diverse children and their parents in the UK as the most useful form of support (32%), followed by Schools (20%), GIDS (13%), GP (8%) and CAMHS (2%). --- 'Waiting' The first overarching theme in qualitative accounts of the support provided by health services for gender diverse children was the experience of waiting, which was frequently entwined with a feeling of loss. This theme was described by participants in three main ways. First, waiting was a feature at every step of the journey through healthcare and was described as unwanted and unnecessary. Second, waiting was associated with a loss of time which caused unnecessary harm to their children. Third, waiting was experienced as a feeling of being suspended in a vacuum, not knowing what to do for the best to support their child, while awaiting official information. All of these experiences created significant frustration, worry and anxiety for parents and carers, as in the following example: The parent/carer here describes the temporal and material dimensions of waiting, including the 'loss of time' involved in waiting to be seen, as well as the time spent on lengthy journeys to GIDS due to the limited geographical spread of specialist provision in the UK. The material cost of travel, accommodation and lost wages also had an impact on personal finances; an experience shared widely amongst parents and carers needing access to specialist services. Waiting was also experienced as a vital loss of time in the development of the children for whom the participants were caring. Slow access to GIDS meant that some children had begun to experience adolescent-related physical changes associated with gender dysphoria and distress, particularly secondary sex characteristics such as breasts. For this parent/carer and many others, the degree of distress expressed by their child was keenly felt, despite finding the services helpful and useful: Extract 2: [GIDS] waiting list is very long (around 12 months), but they were very approachable. Still waiting for appointment. Hopefully more funding would be available to expand service. Hormone blockers would be good to be prescribed by GP as waiting lists are so long. Having well developed breasts and periods is quite a source of distress for my child. (Parent/Carer 49) As already noted in the themes on the journey to and experiences of health services, children, young people and their families have often been living with gender diversity for a significant amount time before they family chose to seek out health service support. For those with a clear idea about the appropriate pathway for their child, the length of time spent waiting for an appointment at GIDS, followed by a further period of exploration and reflection, can feel like an unnecessary delay to achieving relief from the bodily distress created by the development of secondary sex characteristics associated with puberty. This is one of the challenges faced in navigating the current system in the UK, in which years can stretch out from the initial discussion within the family to accessing GIDS, and during that time significant changes can happen to the child as they enter puberty. Being prescribed puberty blockers is for some parents a way to put these changes on hold, described as a chance to 'pause' and reflect on the experience of gender development through adolescence (Roen, 2011). This aspect of time for reflection after having accessed GIDS was welcomed by some parents: Extract 3: It's giving my child time to process life and future as he is and will provide blockers to allow the extra time (Parent/carer 56). Many parents/carers also reported feeling that they and their child were stuck in a knowledge vacuum during long periods of waiting. This led to 'anxiety and other issues' which were perceived as being avoidable (extract 4). Here, parents felt lost and unsure without expert guidance and left to rely on 'unofficial' information found online, which was largely aimed at older trans and non-binary people: Extract 4: Real need for child focused literature. My child is experiencing dysphoria but has not yet decided to socially transition despite it being a year since she came out. She is reliant on YouTube based guidance for peer support and is nervous about next steps. This is causing anxiety and other issues that could be avoided if we had access to more child friendly info whilst waiting on professional intervention. (Parent/Carer 43) We note here that feelings of uncertainty can be exacerbated by the period spent waiting for expert intervention, or for trusted information from a GP. Parents and their children may be wellversed in accessing online media and resources but raised concerns about the availability of more appropriately child-focused resources for younger age groups. The impact of this lack of official information left these parents feeling isolated and unprepared to support their children in an informed manner. In this vacuum of guidance, many referenced the information and support offered by a national UK parent support group as vital to their survival while waiting to access statutory services (see extract 5 & 8). Extract 5: Need more [information]-it's a lonely place being on a waiting list for 9 months, [charity name] are a saviour and should get funding (Parent/Carer 20) --- 'Isolation' Linked to the theme of 'waiting', the second overarching theme related to feelings of isolation. This presented in three main ways. First, many parents/carers shared accounts of feeling lonely and cut off from other parents. Second, many experienced their journeys through the healthcare system as a solo 'fight' or 'battle'. Finally, parents/carers reported feeling isolated as a result of their own fears of being judged and misunderstood by others. The geographic spread of families with a gender diverse child was identified in the data as contributing to feelings of isolation and challenges in meeting other parents: Extract 6: Can be isolating. Don't know anyone else locally parenting [a] transgender ASD (autism spectrum disorder) child. Confidentiality prevents professionals from making helpful links. Process is long and a battle to get into services for vulnerable child. No blueprint to muddle through. (Parent/Carer 51) The coalescence of ASD and gender diversity is gaining more attention within GIDS, but this is less common within the general population. The child of the parent/carer in extract 6 has a particular set of support needs and a lack of contact with other parents/carers in a similar situation is central to their feelings of isolation, loneliness and exhaustion. For these caregivers, this sense of isolation is exacerbated by a perception that healthcare professionals could facilitate connections to other parents/carers in a similar position but are unable to do so for reasons of confidentiality, privacy or data sharing regulations. In addition, the lack of information available for parents/carers of primary-aged children (e.g., 'no blue-print') also adds to their sense that their experience is one of isolation, disorientation and combat. In extracts 7 and 8, caregivers explain their experience of having to 'battle' or 'fight' to gain access to healthcare services, largely because of a lack of knowledge about primary-aged gender diverse children at GP and CAMHS level. A sense of survival comes from seeking out information, particularly from the 'internet' (extract 7), or by getting support from a UK charity (extract 8), or GIDS (extract 8): Extract 7: I have had to dig my way and approach people myself and fight and pester services for appointments and come across as a pushy parent, which I am not. I think GPs should all have a person in the practice that is familiar with this subject to help guide families in the right direction. Goodness know what state we would be in if it weren't for the internet. (Parent/Carer 30) Extract 8: Be more knowledgeable! That is all. I felt like everything came from me; if I hadn't had the support of [Charity name] / GIDS God knows where we would be now. (Parent/Carer 58) The lack of knowledge experienced within primary care and the pressure to provide information to services, such as GPs, CAHMS and schools, contributed to feelings of isolation. Parents/carers also reported feeling judged as a 'pushy parent' (Extract 7) by service providers, which -given their aim was simply to access the care their children needed -contributed to feelings of stigmatisation and isolation. This was described by one parent as 'isolating, judgemental and unsupportive', Parent/carer 55). These experiences were so marked in the data that parents/carers often made a point of reporting when a service provider was not experienced as 'judgemental' (extract 9), which suggests there is much work to be done in better preparing the healthcare workforce for supporting parents and children from the first time that the issue of gender diversity is raised in consultation: Extract 9: 20 year[s] of practising as a GP... he saw that we needed support and he wasn't judgemental. (Parent/Carer 26) --- Discussion Our findings demonstrate a desperate need for improved knowledge to better support parents/carers of gender diverse primary age children. A lack of knowledge was reported in caregiver experiences of advice seeking from GPs and CAMHS, which although not acceptable, is not particularly surprising given that the numbers of gender diverse children who seek healthcare are low from a general population perspective. However, given the pathway to GIDS generally requires a referral via CAMHS, and a referral to CAMHS requires input from the GP, a more complex picture emerges whereby it is easy to understand how some parents/carers and children may experience barriers or delays if their local GP or CAMHS were not informed or supportive. Our findings also illustrate the negative experiences of waiting, the impacts of a loss of time and money on family circumstances, the cumulative impacts of uncertainty and isolation and the significant anxiety and emotional labour involved in navigating health services that are not sufficiently prepared to support gender diverse primary-age children. In addition to the emotional costs experienced by families, it is important to note that we also observed evidence of the structural and material impacts of lengthy and expensive travel times that could discourage engagement with appropriate services among families from lower socio-economic backgrounds. Waiting has been described as 'one of healthcare's core experiences' (Baraitser & Salisbury, 2020 p. 128), and indeed, these parents/carers described feeling intense distress while waiting and watching for the feared impacts that puberty was likely to have on their child's gender dysphoria and mental distress. Others described waiting to be seen at a specialist clinic with the hope of accessing essential information and possibly reduce their child's and their own anxieties. Within the context of GIDS, clinicians have reported feeling very much aware of the impact of current waiting times on young people and their families and have publicly noted that the recent levelling off of referral rates should lead to improvements. As Polly Carmichael (Tavistock & Portman, 2019) states: We appreciate how distressing it can be for young people and their families who are waiting to be seen...Whilst we still have a substantial waiting list, this levelling off, if sustained, should allow us to more effectively anticipate the resources required to reduce waiting times. This is positive news for the young people and families referred to the service. We argue that this phrase 'waiting to be seen' has particular resonance for those who are trans and non-binary. What we may well be witnessing in the increased referral rates and numbers seeking support for gender diverse children is a critical moment in which trans and non-binary genders are finally 'being seen' as a legitimate experience, and one that is deserving of access to medical and social care and support, if desired. What remains problematic is an overreliance on information from online sources that are unmediated and potentially inaccurate about appropriate forms of support for pre-pubescent children. Improvement in the knowledge of GPs and CAMHS has the potential to improve health service experiences of parents and their gender diverse children in primary care. A more nuanced understanding of referral pathways using ageappropriate gender diverse support groups could also reduce pressure on GIDS. Our sample was drawn from trans-affirmative parents/carers and demonstrated how challenging and isolating their experiences can be. They flagged a lack of knowledge in many generalist services (GP/CAMHS), of waiting for access to 'expert' knowledge in specialist service (GIDS) and chronic experiences of uncertainty, anxiety and distress. While it is understandable that parents/carers desire more certainty and reassurance in seeking the 'next steps' for their gender diverse children, focusing too much on issues of 'certainty' also risks perpetuating an overly limited narrative of medical transition or affirmation as the only or at least most familiar pathway for gender diverse children. The notion of achieving certainty regarding gender implies an either/or discourse that privileges binary assumptions about how gender is experienced. This is contra to UK and Australian school-based research that suggest young people's understanding, experience and language around gender is expanding as the

The politics of trans health has drawn considerable attention in recent years, and yet little is known about the support needs and experiences of primary school age children and their families. This paper presents findings from a UK mixed-method study that aimed to understand parents/carers' views and experiences of support received from health services for primary school age (4-11) gender diverse children and their families. Data was collected via an e-survey including 10 open-ended questions with 75 parents/carers addressing experiences with (i) primary health services, including general practice (GP) clinics and child and adolescent mental health services (CAMHS) (ii) specialist gender identity development services (GIDS) (iii) non-health related support including transgender groups and online resources. Findings are organised into four themes comprising two which draw on the cross-sectional survey data ('journey to health service provision' and 'view on health services used') and two from the open-text qualitative data ('waiting' and 'isolation'). Contemporary discourses about gender diversity and childhood and the validity of trans healthcare for children and adolescents shape parental experiences, including their desire for better information, more certainty in healthcare pathways and more expedient access to support services to reduce anxiety, distress and isolation. The emotional costs of waiting are compounded by the material costs of accessing the limited number of specialist services. Experiences could be improved through ensuring both GPs and CAMHS are better prepared through appropriate training, expanding access to trans-specific support groups for families and others involved in caring for children and young people, and exploring the provision of schoolbased support for gender diverse primary-age children.

the knowledge of GPs and CAMHS has the potential to improve health service experiences of parents and their gender diverse children in primary care. A more nuanced understanding of referral pathways using ageappropriate gender diverse support groups could also reduce pressure on GIDS. Our sample was drawn from trans-affirmative parents/carers and demonstrated how challenging and isolating their experiences can be. They flagged a lack of knowledge in many generalist services (GP/CAMHS), of waiting for access to 'expert' knowledge in specialist service (GIDS) and chronic experiences of uncertainty, anxiety and distress. While it is understandable that parents/carers desire more certainty and reassurance in seeking the 'next steps' for their gender diverse children, focusing too much on issues of 'certainty' also risks perpetuating an overly limited narrative of medical transition or affirmation as the only or at least most familiar pathway for gender diverse children. The notion of achieving certainty regarding gender implies an either/or discourse that privileges binary assumptions about how gender is experienced. This is contra to UK and Australian school-based research that suggest young people's understanding, experience and language around gender is expanding as the social imaginary becomes ever more infused with the values and rights frameworks relating to gender equality and gender diversity (Bragg et al, 2018;Jones et al, 2016). We argue, then, that what is needed for parents/carers of gender diverse primary-age children, children who are not yet ready to engage with the medical services provided by specialist clinics -even if this ends up the preferred pathway -is better and earlier access to knowledge and support. Earlier access to high quality health services which include supports of a range of kinds may help families mediate and manage anxiety, distress, loneliness, and isolation and provide a safe environment in which to explore gender, celebrate diversity and develop new ways of living with uncertainty. In a sector where the waiting lists for a specialist service are extremely long, improvements need to take place to make primary care services better prepared to provide accurate knowledge and interim supports, and for support services to be more broadly resourced and accessed in other settings, including social support groups for children and their caregivers. Well-informed GP and CAMHS services could be referring parents/carers and their young children to third-sector support groups. Indeed, our findings suggest that community-run groups for gender diverse young people and parental support groups are an effective source of knowledge and support. With appropriate funding and training, they could play a more vital role in supporting parents/carers and gender diverse children, to complement the pathways into and services provided within specialist clinical care settings. Although not explored here, schools also have an important role to play in supporting the needs of young gender diverse children and should be meaningfully engaged in the design and delivery of a more integrated and wellinformed system of support services (Carlile, 2020). --- Conclusion International guidelines for advancing transgender health focus on recommendations for provision of affirmative pathways into care, with the expectation that appropriate forms of healthcare will be accessible, albeit within the constraints of local health systems and cultural practices (WPATH, 2012). Our research demonstrates that even if there is a commitment to this model of care, as there is in the UK, experiences of healthcare are shaped by material challenges within a public health system that is often overloaded and under-resourced. In our analysis of the experiences and expectations of the caregivers of gender diverse children, the issues faced in the UK context include long waiting lists, barriers to physically accessing specialist services that require significant time and travel, potentially excluding lower income families, and a referral pathway that often creates further delay because of a lack of initial knowledge and support in both primary care and CAMHS. These issues are located in a context in which the knowledge of many people about trans issues, including parents/carers and those working in generalist primary care settings, is shaped by a highly emotive and divisive public 'debate' about the legitimacy and value of trans lives. This context therefore adds in additional, and unhelpful, questions about the safety and appropriateness of trans healthcare models for under 18s and invites parental anxiety to be heightened about the issue of children and young people's right and ability to consent. The current context also features shaming discourses about the role of 'pushy parents' and implies they are motivated by a desire for 'gender normality' in their children, which is believed to be driven by a form of homophobia. In this context, it not surprising that parents describe themselves as feeling isolated and judged, struggling to find support appropriate for their children and themselves. We look forward to more positive frameworks and pathways being developed in the coming years to improve the experience of gender diverse children and their caregivers.

The politics of trans health has drawn considerable attention in recent years, and yet little is known about the support needs and experiences of primary school age children and their families. This paper presents findings from a UK mixed-method study that aimed to understand parents/carers' views and experiences of support received from health services for primary school age (4-11) gender diverse children and their families. Data was collected via an e-survey including 10 open-ended questions with 75 parents/carers addressing experiences with (i) primary health services, including general practice (GP) clinics and child and adolescent mental health services (CAMHS) (ii) specialist gender identity development services (GIDS) (iii) non-health related support including transgender groups and online resources. Findings are organised into four themes comprising two which draw on the cross-sectional survey data ('journey to health service provision' and 'view on health services used') and two from the open-text qualitative data ('waiting' and 'isolation'). Contemporary discourses about gender diversity and childhood and the validity of trans healthcare for children and adolescents shape parental experiences, including their desire for better information, more certainty in healthcare pathways and more expedient access to support services to reduce anxiety, distress and isolation. The emotional costs of waiting are compounded by the material costs of accessing the limited number of specialist services. Experiences could be improved through ensuring both GPs and CAMHS are better prepared through appropriate training, expanding access to trans-specific support groups for families and others involved in caring for children and young people, and exploring the provision of schoolbased support for gender diverse primary-age children.

INTRODUCTION Childhood obesity is a major public health problem globally [1]. In Finland, recent statistics showed that 29% of boys aged 2-16 years and 18% of girls were living with overweight (including obesity), and 9% of boys and 4% of girls with obesity [2]. Childhood obesity tends to continue into adulthood [3]. Excess weight is associated with several physical and psychosocial health concerns in childhood and later in adulthood [4]. The majority of children with obesity also have other risk factors for arterial diseases, and the risk increases as obesity becomes more severe [4][5][6][7]. In addition, children living with obesity are more likely to suffer bullying, social exclusion, low self-esteem, and body image dissatisfaction than their peers with healthy weight [8,9]. There are several individual and societal factors behind obesity in children, such as heredity, lifestyle habits and obesogenic living environment [4,10]. Previous studies have shown that obesity is associated with socioeconomic position (SEP), both in adults and children [11,12]. Parents' education has a strong, inverse association with childhood obesity in high-income countries, but the opposite relationship in most of the middle-income and low-income countries [12,13]. In general, children with low SEP in high-income countries and children with high SEP in low-income countries are at higher risk of overweight than other SEP groups [12,14]. Finnish administrative registers include information on measured height and weight of children and parents' socioeconomic position. In a previous study the association of a large set of registry-based indicators on parents' SEP and childhood obesity was analyzed and parents' education and the household's disposable monetary income were found to be the variables most strongly associated with obesity in children [15]. In the present study we had two aims: 1) to examine associations between parents' SEP variables, which were most strongly associated with obesity in their offspring [15], and the prevalence of overweight and obesity in children aged 2-17 years, based on data from two Finnish administrative registers; and 2) to discover if linked, registry-based data on children's height and weight and parents' SEP could be used to monitor national childhood obesity. --- METHODS --- Study Population Data on children's height and weight were extracted from the Register of Primary Health Care Visits (Avohilmo), maintained by the Finnish Institute for Health and Welfare (THL) [16]. Avohilmo includes real-time data on primary healthcare visits, including measured height and weight, collected via automatic data transmission from electronic health records of primary health care units. The data extraction criteria were that a child had visited a child health clinic, school health care or student health care between 1st of January 2018 and 31st of December 2018 and both height and weight were recorded during the visit (n = 397,047). Indicators extracted for the current study included date of birth, sex, age and height and weight measurements with their respective measurement dates. The exact age at measurement was calculated based on the child's date of birth and the date of health care visit. The data were validated as follows; 1) deviation statistics for height and weight values were calculated using the Finnish growth standard as reference values (relative to weight by sex and height, height by sex and age, body mass index (BMI, kg/m 2 ) by sex and age, children's BMI corresponding to the adult BMI (ISO-BMI kg/m 2 ) [17], 2) children with deviation values outside the [-4,4] boundary were excluded, 3) height and weight measurements resulting in ISO-BMI <unk>50 were excluded. In addition, 1,537 children were excluded because valid height and weight measurements were not available in 2018. As a result, the data included 395,510 children who were 2-17 years old and had at least one valid height and weight measurement in 2018. Avohilmo's data on children's height and weight were linked on an individual level with Statistics Finland's data from 1 January 2014 to 31 December 2018 on adults' (both parents') socioeconomic position (SEP) living in the same address as a child using deterministic linkage and personal identification code. Data on parents' SEP were not found for 7,887 children. In addition, siblings and half-siblings and families with two female or two male adults were excluded from the analysis (n = 193,200). As a result, each parent was included in the data only once, as was only one child from each family. The number of families with two female or two male adults was 374. The final data included 194,423 (100,216 boys and 94,207 girls) children with measured height and weight and information on parents' SEP. --- Definition of Overweight and Obesity Overweight and obesity were defined according to the WHO growth reference for children [18,19]. For children from two to five years of age, the definition for overweight and obesity were a BMI-for-age value greater than +2 SD and +3 SD above the WHO Child Growth Standard median, respectively [18,20]. For children over 5 years old, overweight and obesity were defined as a BMI-for-age value greater than +1 SD and +2 SD above the WHO Growth Reference median, respectively [19,21]. The prevalence of overweight (including obesity) and obesity in boys and girls by parents' SEP are presented in Supplementary Tables S1,S2. --- Indicators of Socioeconomic Position The following parents' SEP indicators were selected for analyses; mother's and father's educational level of highest qualification/ degree, household's disposable monetary income, and in addition, the father's and mother's age and municipality group of municipality of domicile according to the 2016 regional division. The SEP variables had several categories. For the analysis the SEP variables were re-categorized as follows: 1) Parental age was classified into six categories: <unk>30, 30-34, 35-39, 40-44, 45-49, <unk>50 years and 2) child's age classified into four categories: 2-6.99, 7-12.99, 13-15.99 and 16-17.99 years. 3) Father's and mother's educational level of highest qualification/degree was classified into three categories: low, medium and high. The category of low education included parents who did not have a degree, i.e., they had completed at most primary school. The category of medium level of education included parents who had completed secondary or high school or vocational school. The category of high education included parents who had a bachelor's degree, master's degree or higher degree. 4) Household's disposable monetary income was calculated considering the size of the household as follows: Each household's yearly disposable monetary income/12/ weighting coefficient. Weighting coefficient: 1.0 to the first adult, 0.5 to the second and each subsequent person aged 14 years and over, 0.3 to each child aged under 14 years, 0.4 to each child of unknown age [22]. Household's disposable monetary income was classified into three categories: low (<unk>1,525 euros per month), middle (from 1,525 to 4,065 euros per month) and high (>4,065 euros per month). 5) Municipality of domicile according to the 2016 regional division was classified into three categories: urban, semi-urban and rural municipalities. In urban municipalities at least 90% of the population lives in urban settlements or the population of the largest urban settlement is at least 15,000. In semi-urban municipalities, 60%-90% of the population lives in urban settlements and the population of the largest urban settlement is at least 4,000 but less than 15,000. In rural municipalities, less than 60% of the population lives in urban settlements and the population of the largest urban settlement is less than 15,000 or 60%-90% of the population lives in urban settlements and in which the population of the largest settlement is less than 4,000 [23]. Data characteristics are shown in the Table 1. --- Statistical Analyses Before categorizing, most of the SEP indicators were imputed. If no previous individual data were available (preferably in 2017 or secondly in 2014-2016), data from 2018 were used. Parents' education was imputed using values from previous years. For continuous predictors, individual trends were fitted and used for prediction of missing values. For continuous predictor data with only one observation, one trend line was fitted and used for prediction of missing values. The analyses were carried out using a randomly selected training data (n = 155,479, 80% of the data; 80,216 boys and 75,263 girls) and left out data (n = 38,944, 20% of the data; a Overweight and obesity were defined according to the WHO growth reference for children [18,19]. b The prevalence of overweight includes obesity. 20,000 boys and 18,944 girls), which was used for model testing and validation. Risk ratios for bernoulli-distributed overweight (RR OW ) and obesity (RR OB ) according to SEP were estimated using generalized linear models and using the log -link function. --- Model Fitting Generalized linear models for overweight (including obesity) and obesity were fitted for boys and girls separately. The effects of four predictor indicators (father's education, mother's education, household's disposable monetary income and municipality group of municipality of domicile) were analyzed by adjusting for child's, mother's and father's age. As a first step, the univariate effect of four predictor indicators were analyzed using adjustments. In the second step, alternative multivariate main effect models were analyzed. Finally, all predictor and adjusting indicators were tested for interactions. --- Multivariate Model Fitting and Testing The following alternative multivariate models were fitted: 1. Full model of main effects (four predictors and three adjusting indicators), 2. Models to exclude one of the predictors (four submodels), 3. Models to include one twoway interaction between predictors or between one predictor and one adjusting indicator (18 submodels). All models were fitted in training data and submodels were tested in left out data. Deviance residuals were predicted for full model and all submodels. The sum of squared deviance residuals (D) in left out data was used as a test statistic to test the model against full model. The difference of D-statistics were considered as chi-square distributed with the number of freely estimated parameters dropped as degrees of freedom. Chi-square statistic for main effects: Chi-square = (D-statistic of the full model of main effects) -(D-statistic of submodel). Chi-square statistic for interactions: Chi-square = (D-statistic of model with one interaction) -(D-statistic of the full model of main effects). The final model was validated by comparing Area under the ROC curve (AUC) in training and left out data. The nonsignificant result from the test for equality of AUC between training and left out data was considered a valid model for obesity or overweight. Stata/MP 17.0 statistical software was used for all data management and statistical analyses. The significance level was 0.001 for all tests. --- RESULTS The prevalence of overweight and obesity was higher in boys than in girls and in older children compared to younger children. In total, 31% of boys and 24% of girls had overweight or obesity. Overweight (including obesity) and obesity were the most common in 7-13-year-old boys and girls (in boys 35% and 15%, in girls 29% and 9%, respectively) (Supplementary Tables S1,S2). --- Association of Overweight and Obesity and Parents' SEP Indicators For boys and girls, all main effects were significant for obesity and overweight models, except for household's disposable monetary income for girls' overweight and obesity models. None of the tested interactions were significant. All final models were valid with no significant differences in AUCs between training and left out data (Tables 2345). In multivariate models the risk for obesity was lower in boys in families with higher household's disposable monetary income (RR OB 0.76, 99.9% CI 0.61-0.94) compared to boys in families with low income. The risk for overweight was higher in boys in middle-income families (RR OW 1.08, 99.9% CI 1.03-1.14) compared to boys in low-income families. The risk for overweight and obesity was lower in boys and girls whose father had high education (boys: RR OW 0.72, 99.9% CI 0.68-0.77, RR OB 0.58, 99,9% CI 0.51-0.65; girls: RR OW 0.72 99.9% CI 0.66-0.77, RR OB 0.54 99.9% CI 0.46-0.63, respectively) compared to children with a lowly educated father. Comparison of the highest with the lowest level of mother's education showed decreased risk for overweight and obesity in boys (boys: RR OW 0.79, 99.9% CI 0.74-0.84, RR OB 0.58, 99.9% CI 0.51-0.65, respectively) and in girls (RR OW 0.78 99.9% CI 0.72-0.84, RR OB 0.56 99.9% CI 0.48-0.65) in children with highly educated mothers (Tables 2345). Risk for overweight and obesity was lower in boys and girls living in urban areas (boys: RR OW 0.85, 99.9% CI 0.80-0.89, RR OB 0.77, 99.9% CI 0.70-0.85; girls: RR OW 0.80 99.9% CI 0.75-0.85, RR OB 0.69 99.9% CI 0.61-0.78, respectively) compared with boys and girls in rural areas (Tables 2345). --- DISCUSSION Our study, with data from two Finnish administrative registers, showed that overweight and obesity in children were inversely associated with parents' SEP (household's disposable monetary income, father's and mother's education), i.e., the prevalence of obesity was higher in children with parents with lower SEP. Furthermore, overweight and obesity were more prevalent in children living in rural areas than children living in urban areas. All the observed associations were stronger regarding obesity, as compared to overweight. Many previous surveys, conducted in high-income countries, have found that the parents' low SEP is associated with higher risk of childhood obesity [13,14,24]. Our registry-based study supports these earlier findings. A similar association between SEP and the prevalence of overweight and obesity in children has previously been observed in Finnish boys and girls, whether using indicators of family SEP [25][26][27], indicators of adolescent's own social position (school achievement, school attendance) or indicators of family's material affluence [26]. In addition, a large, Finnish prospective birth cohort study found that exposure to neighborhood socioeconomic disadvantage (average annual income, unemployment, and level of education) constitutes an important risk factor for the development of childhood obesity [28]. Magnusson et al. [29] concluded in their review that there are social inequalities in overweight and obesity in the Nordic countries, in spite of socially egalitarian ideals and a reputation for low levels of inequality. They discussed that causes behind the social gradient may not be the ones that have made the prevalence rise in the whole population. Furthermore, some factors which affect the whole population may affect population groups with low SEP even more seriously [29]. Reasons for this could be several: people with more resources may have greater potential to avoid the adverse effects of an obesogenic living environment, education increases consciousness on health and healthy lifestyle, higher income increases freedom of choice concerning food and leisure activities [30]. One potential explanatory factor behind the social gradient is stress. Parents' low SEP may negatively affect the psychosocial security experienced in families, for example due to job insecurity or living in a poorer residential area [31]. Häkkänen et al. found that living in a divorced or single-parent family was related to the development of obesity and living in non-native families was related to the persistence of obesity among girls [32]. In childhood, family and living environment play important roles in adopting, establishing and promoting healthy lifestyles through role modelling and support for engaging in healthy lifestyle habits [33][34][35][36][37]. Previous Finnish studies have shown a socioeconomic gradient between parents' SEP and lifestyle habits in childhood and adolescence [36,[38][39][40]. A systematic review identified several factors, such as parental obesity, child-care attendance, and high TV viewing time, which mediate the relationship between SEP and childhood overweight and obesity [41]. The authors of the review concluded that families from different SEP groups had different risk and protective factors for children's obesity. Regarding families with low SEP, parental obesity and maternal depressive symptoms were strong risk factors for overweight and obesity in children, whereas long maternal working hours and a permissive parenting style were risk factors for families with higher SEP [41]. In addition, social disadvantage affects families for several generations [42]. Children in families with low SEP are more likely to become adults with low SEP who accumulate less wealth to pass on to future generations [43]. In line with previous research, we observed that overweight and obesity were more common in children living in rural areas than in urban areas [25,29,44,45]. Similar results have been found in Sweden, where overweight and obesity in 6 to 9 year-old children were approximately 2 and 3 times more prevalent, respectively, in areas with lower education than in areas with higher level of education. These associations were explained by lower educational attainment in the rural areas [29]. In our study, the risk for children's overweight and obesity in urban vs. rural areas diluted when adjusted for parents' education and household income but did not disappear completely. Hence, other explanations are needed. An explanation could be that children have fewer opportunities for physical activity (long distances to school and forums for sports and other organized physical activity, fewer opportunities to use public transport, fewer alternatives for active transport on foot or by bicycle, safety concerns) in rural areas [46]. In our study, the associations between parent's SEP and overweight and obesity in children were quite similar in boys and girls in different age groups. Although the results, by indicators we used, were quite consistent, the association may still be more complex than that. According to a systematic review, health behaviors contribute to the association between SEP and health outcomes, but the contribution varies according to geographic location, sex, age, health outcomes and methodological differences between studies [47]. The association between SEP and obesity also varies by several demographic (e.g., age, sex, ethnicity) or environmental (e.g., countries, urban/rural) factors [12]. Furthermore, each SEP indicator has a different background and measures different, often interrelated aspects of socioeconomic stratification. Different SEP indicators may also be more or less relevant to different health outcomes and at different stages of life [13,48]. Finally, children do not have a degree of education, occupation, or income of their own [13], and regarding adolescents, Koivusilta et al. [26] have stressed that health differences between adolescents are an outcome of several mechanisms, not a direct result of socioeconomic inequality between families. They mentioned that adolescents are experiencing a transition from being children living under parents' care to being more like independent actors in a wider society. At that stage of life, adolescents' schooling, education, and family's material commodities are important because they reflect the adolescents' own social position and standard of living. Health differences may begin to increase when problems accumulate and intertwine in these spheres of life, for example, because of economic problems or inadequate social networks [26]. Finland has a comprehensive public health care system and almost all families with children use the child health clinic and school health care services, irrespective of their socioeconomic background [49,50]. This provides an excellent possibility to discuss lifestyle habits, to monitor children's growth and to identify children with a high risk of obesity. In addition, regular growth monitoring of all children enables national monitoring of overweight and obesity in children, because the data on height and weight are transferred to the national administrative register Avohilmo. Avohilmo has previously been found to be a reliable source for monitoring the prevalence of overweight and obesity in children [51,52]. Accordingly, the prevalence of overweight and obesity in children has been reported annually at the national, regional and municipal level as part of the reporting of the FinChild register since 2018 [2]. In this study, we linked data from the Avohilmo register to another administrative register, Statistic Finland, to investigate associations between parents' SEP and overweight and obesity in children. The possibility for individual-level linkage of register data and availability of various indicators of socioeconomic position is quite unique. Statistics Finland's data on parents' SEP were found for most of children whose height and weight data were available in the Avohilmo register. Our findings were in line with previous studies' results on association between parents' SEP and childhood obesity, confirming that linking data of administrative registers offers a possibility to monitor the prevalence of overweight and obesity in children according to the parents' SEP. The use of registry-based data is cost-effective since health examination studies or questionnaires are not needed. This enables the development of the Finnish monitoring system on overweight and obesity in children [2] to also cover parents' SEP, as well as the degree of urbanization of the municipality of domicile. To make this possible, further development is needed to make the linking of data from different administrative registers as flexible and up to date as possible. --- Strengths and Limitations The main strength of the study is the large and comprehensive data from two administrative registers: the register of Primary Health Care Visits (Avohilmo) and Statistics Finland providing objective measures for both children's height and weight and parents' SEP. Parents' SEP was found for almost all children (98%). Altogether, our data included measured height and weight and parents' SEP for almost 200,000 children. As far as we know, there is no similar, large registry-based data available in other countries on both childhood obesity and parents' SEP. Statistics Finland's data on SEP is collected from various national registers, for example from the Population Register and the Income Register, making the data more comprehensive and reliable than data collected through questionnaires. The advantage of using register data is that there is no response-bias such as lower participation to surveys by people with obesity or low SEP [53]. In addition, there are not so many missing values, as there may be when asking children, or asking adults about information that they may consider sensitive, such as education and income. However, there are also some limitations in the study. First, although the Avohilmo data collection has covered all outpatient primary health care delivered in Finland since 2011, the coverage of data on children's height and weight was approximately 40% in 2018. Because most children and families attend to health checkups and children are measured regularly, the low coverage of height and weight data is mainly due to problems with the electronic health records and technical data transmission in use [52]. The future challenge is to improve the coverage of Avohilmo data on the height and weight to it's full potential, over 90%. It requires good collaboration between public health service providers, producers of patient's electronic health records, and THL. In addition, according to Statistics Finland's data on adults living at the same address as a child, it is not always possible to verify if adults are parents, biological parents, or stepparents of the child. It is also difficult to ensure, whether the family is a nuclear family or a stepfamily. One limitation is also that Statistics Finland's indicator "educational level of the highest qualification/degree" includes only degrees in secondary education or higher. However, very few people in Finland have no basic education. Therefore, if a person did not have a degree in secondary education, we assumed that the person had primary education. Another limitation is that the registry data used in the present study does not include information on health behavior such as diet and physical activity. While no causal conclusions can be drawn from this crosssectional study, our findings have important public health implications in Finland. The study showed that it is possible to develop the Finnish monitoring system on overweight and obesity in children to cover several aspects of parents' SEP, as well as the degree of urbanization of the municipality of domicile. Our results also emphasize that primary prevention of obesity is essential, including identification of children at increased risk of obesity. Obesity prevention requires wide collaboration and a health-in-all-policies approach to improve children's health and health equity. --- Conclusion Parents' low SEP, measured with several indicators, was associated with overweight and obesity in children in Finland. Linking data of administrative registers on children's growth and parents' SEP is a potential, feasible and valid approach to monitor the prevalence of overweight and obesity in children by parents' SEP. --- ETHICS STATEMENT Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. 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 PM, EL, SL-J, and TL designed the study. EL had access to all the data and performed all statistical analyses. EL, PM, SL-J, and TL contributed to checking the data. PM wrote drafts of the manuscript, as well as the final version of the manuscript. All authors contributed to the article and approved the submitted version. --- AUTHOR DISCLAIMER The content of this publication reflects only the views of the authors, and the European Commission is not liable for any use that may be made of the information it contains. --- CONFLICT OF INTEREST The authors declare that they do not have any conflicts of interest. --- SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found online at: https://www.ssph-journal.org/articles/10.3389/ijph.2023.1605901/ full#supplementary-material

Objectives: To examine associations between parents' socioeconomic position (SEP) and child overweight and obesity, using registry data. Methods: Data (final n = 194,423) on children's height, weight and parents' SEP were drawn from the national Register of Primary Health Care Visits (Avohilmo) and Statistics Finland. Risk ratios for bernoulli-distributed overweight (RR OW ) and obesity (RR OB ) according to SEP were estimated using generalized linear models and using a log -link.The risk for obesity was lower in boys from high-income families (RR OB 0.76), for overweight and obesity was lower in boys (RR OW 0.72, RR OB 0.58) and girls (RR OW 0.72, RR OB 0.54) with highly educated fathers, in boys (RR OW 0.79, RR OB 0.58) and girls (RR OW 0.78, RR OB 0.56) with high-educated mothers and in boys (RR OW 0.85, RR OB 0.77) and girls (RR OW 0.80, RR OB 0.69) living in urban areas, as compared to low-income families, low-educated parents, and rural residence, respectively.The risk of overweight and obesity was increased in children with low SEP or rural residence. Administrative registers are a valid approach to monitor childhood obesity by parents' SEP.

Introduction In the most cited article on social networks, 1 Granovetter (1973) argued that the most important connections we have may not be with our close friends but our acquaintances: people who are not very close to us, either physically or emotionally, help us to relate to groups that we otherwise would not be linked to. For example, it is from acquaintances that we are more likely to hear about job offers (Rees, 1966; Corcoran, Datcher and Duncan, 1980; Granovetter, 1995). Those weak ties serve as bridges between our group of close friends and other clustered groups, hence allowing us to connect to the global community in a number of ways. 2Interestingly, the process of how we meet our romantic partners in at least the last hundred years closely resembles this phenomenon. We would probably not marry our best friends, but we are likely to end up marrying a friend of a friend or someone we coincided with in the past. Rosenfeld and Thomas (2012) show how Americans met their partners in recent decades, listed by importance: through mutual friends, in bars, at work, in educational institutions, at church, through their families, or because they became neighbors. This is nothing but the weak ties phenomenon in action. 34 But in the last two decades, the way we meet our romantic partners has changed dramatically. Rosenfeld and Thomas argue that "the Internet increasingly allows Americans to meet and form relationships with perfect strangers, that is, people with whom they had no previous social tie". To this end, they document that in the last decade online dating5 has become the second most popular way to meet a spouse for Americans (see Figure 1). Figure 1: How we met our partners in previous decades. Source : Rosenfeld and Thomas, 2012. Online dating has changed the way people meet their partners not only in America but in many places around the world. As an example, Figure 2 shows one of the author's Facebook friends graph. The yellow triangles reveal previous relationships that started in offline venues. It can clearly be seen that those ex-partners had several mutual friends with the author. In contrast, nodes appearing as red stars represent partners he met through online dating. These individuals have no contacts in common with him, and thus it is likely that, if it were not for online dating, they would have never interacted with him. 6 Because a third of modern marriages start online (Cacioppo et al., 2013), and up to 70% of homosexual relationships, the way we match online with potential partners shapes the demography of our communities, in particular its racial diversity. Meeting people outside our social network online can intuitively increase the number of interracial marriages in our societies, which is remarkably low. Only 6.3% and 9% of the total number of marriages are interracial in the US and the UK, respectively. 7 The low rates of interracial 6 Although admittedly some of those links may have created after dating, what is clear is that the author was somewhat connected to these agents beforehand by some mutual connections, i.e. Granovetter's weak ties. 7 "Interracial marriage: Who is marrying out", Pew Research Center, 12/6/2015; and "What does the 2011 census tell us about inter-ethnic relationships?", UK Office for National Statistics, 3/7/2014. Triangles are partners met offline, whereas starts are partners met online. marriage are expected, given that up until 50 years ago these were illegal in many parts of the US, until the Supreme Court outlawed anti-miscegenation laws in the famous Loving vs. Virginia case. 8 This paper aims at improving our understanding of the impact of online dating on racial diversity in modern societies. In particular, we intend to find out how many more interracial marriages, if any, occur after online dating becomes available in a society. In addition, we are also interested in whether marriages created online are any different from those that existed before. Understanding the evolution of interracial marriage is an important problem, for intermarriage is widely considered a measure of social distance in our societies (Wong, 2003; Fryer, 2007; Furtado, 2015), just like residential or school segregation. Moreover, the number of interracial marriages in a society has important economic implications. It increases the social network of both spouses who intermarry by connecting them to people of different race. These valuable connections translate into a higher chance of finding employment (Furtado and Theodoropoulos, 2010). 9 This partially explains why the combined income of an White-Asian modern couple is 14.4% higher than than the combined income of an Asian-Asian couple, and 18.3% higher than a White-White couple (Wang, 2012). Even when controlling for factors that may influence the decision to intermarry, Gius (2013) finds that all interracial couples not involving African Americans have higher combined incomes than a White-White couple. 10 Interracial marriage also affects the offspring of couples who engage in it. Duncan and Trejo (2011) find that children of an interracial marriage between a Mexican Latino and an interracial partner enjoy significant human capital advantages over children born from endogamous Mexican marriages in the US. 11 Those human capital advantages include a 50% reduction in the high school dropout rate for male children. 12 --- Overview of Results This article builds a novel theoretical framework to study matching problems under network constraints. Our model is different to the previous theoretical literature on marriage in that we explicitly study the role of social networks in the decision of whom to marry. Consequently, our model provides new testable predictions regarding how changes in the structure of agents' social networks impact the number of interracial marriages and the quality of marriage itself. In particular, our model combines non-transferable utility matching à la Gale and Shapley (1962) with random graphs, first studied by Gilbert (1959) and Erd<unk>s and Rényi (1959), which we use to represent social networks. 13 literature has consistently found that an immigrant who married a native often has a higher probability of finding employment (Meng and Gregory, 2005; Furtado and Theodoropoulos, 2010; Goel and Lang, 2009). Marrying a native increases the probability of employment, but not the perceived salary (Kantarevic, 2004). 10 In some cases, intermarriage may even be correlated with poor economic outcomes. Examining the population in Hawaii, Fu (2007) finds that White people are 65% more likely to live in poverty if they marry outside their own race. 11 Although Hispanic is not a race, Hispanics do not associate with "standard" races. In the 2010 US census, over 19 million Latinos identified themselves as being of "some other race". See "For many Latinos, racial identity is more culture than color", New York Times, 13/1/2012. 12 Pearce-Morris and King (2012) examines the behavioral well-being of children in inter and intraracial households. They find no significant differences between the two groups. 13 Most of the literature studying marriage with matching models uses transferable utility, following the seminal work of Becker (1973, 1981). A review of that literature appears We consider a society composed of agents who belong to different races. All agents want to marry the potential partner who is closest to them in terms of personality traits, but they can only marry people who they know, i.e. to whom they are connected. As in real life, agents are highly connected with agents of their own race, but only poorly so with people from other races. 14 Again inspired by empirical evidence (Hitsch, Hortasu and Ariely, 2010; Banerjee et al., 2013), we assume that the marriages that occur in our society are those predicted by game-theoretic stability, i.e. no two unmarried persons can marry and make one better off without making the other worse off. In our model, there is a unique stable marriage in each society (Proposition 1). After computing the unique stable matching, we introduce online dating in our societies by creating previously absent ties between races and compute the stable marriage again. 15 We compare how many more interracial marriages are formed in the new expanded society that is more interracially connected. We also keep an eye on the characteristics of those newly formed marriages. In particular, we focus on the average distance in personality traits between partners before and after the introduction of online dating, which we use as a proxy for the strength of marriages in a society (ideally, all agents marry someone who has the same personality traits as them). Perhaps surprisingly, we find that making a society more interracially connected may decrease the number of interracial marriages. It also may increase the average distance between spouses, and even lead to less married people in the society (Proposition 2). However, this only occurs in rare cases. Our main result affirms that the expected number of interracial marriages in Browning, Chiappori and Weiss (2014). Although our model departs substantially from this literature, we point out similarities with particular papers in Section 2. 14 The average American public school student has less than one school friend of another race (Fryer, 2007). Among White Americans, 91% of people comprising their social networks are also White, while for Black and Latino Americans the percentages are 83% and 64%, respectively (Cox, Navarro-Rivera and Jones, 2016). Patacchini and Zenou (2016) document that 84% of the friends of white American students are also white. For high school students, less than 10% of interracial friendships exist (Shrum, Cheek and Hunter, 1988). Furthermore, only 8% of Americans have anyone of another race with whom they discuss important matters (Marsden, 1987). 15 We obtain the same qualitative results if we increase both interracial and intraracial connections, because the marginal value of interracial connections is much larger; see Appendix B. On a related note, although some dating websites allow the users to sort partners' suggestions based on ethnicity, many of them suggest partners randomly. For our main result, we only need that online daters meet at one partner outside their social circle. Rosenfeld and Thomas (2012) suggest that this is indeed the case. in a society increases rapidly after new connections between races are added (Result 1). In particular, if we allow marriage between agents who have a friend in common, complete social integration occurs when the probability of being directly connected to another race is 1 n, where n is the number of persons in each race. This result provides us with our first and main testable hypothesis: social integration occurs rapidly after the emergence of online dating, even if the number of partners that individuals meet from newly formed ties is small. The increase in the number of interracial marriages in our model does not require changes in agents' preferences. Furthermore, the average distance between married couples becomes smaller, leading to better marriages in which agents obtain more desirable partners on average (Result 2). This second result provides another testable hypothesis: marriages created in a society with online dating last longer and report higher levels of satisfaction than those created offline. We find this hypothesis interesting, as it has been widely suggested that online dating creates relationships of a lower quality. 16 Finally, the added connections in general increase the number of married couples whenever communities are not fully connected or are unbalanced in their gender ratio (Result 3). This result provides a third and final testable hypothesis: the emergence of online dating leads to more marriages. We contrast the testable hypotheses generated by the model with US data. With regards to the first and main hypothesis, we find that the number of interracial marriages substantially increases after the popularization of online dating. This increase in interracial marriage cannot be explained by changes in the demographic composition of the US only, because Black Americans are the racial group whose rate of interracial marriage has increased the most, going from 5% in 1980 to 18% in 2015 (Livingston and Brown, 2017). However, the fraction of the US population that is Black has remained relatively constant during the last 50 years at around 12% of the population (Pew Reseach Center, 2015). To properly identify the impact of online dating on the generation of new interracial marriages, we exploit sharp temporal and geographic variation in the pattern of broadband adoption, which we use as a proxy for the introduction of online dating. This strategy is sensible given that broadband adoption has limited correlation to other factors impacting interracial marriages and eliminates the possibility of reverse causation. Using this data from 2000 to 2016, we conclude that one additional line of broadband internet 3 years ago (marriages take time) affects the probability of being in an interracial marriage by 0.07%. We obtain this effect by estimating a linear probability model that includes a rich set of individual-and state-level controls, including the racial diversity of each state and many others. Therefore, we conclude that there is evidence suggesting that online dating is causing more interracial marriages, and that this change is ongoing. Moreover, shortly after we first made available our paper online on September of 2017, Thomas (2018) used recently collected data on how couples meet to successfully demonstrate that couples that met online are more likely to be interracial, even when controlling for the diversity of their corresponding locations. Thomas estimates that American couples who met online since 1996 are 6% to 7% more likely to be interracial than those who met offline. His findings further establish that online dating has indeed had a positive impact on the number of interracial marriages, as predicted by our model. With respect to the quality of marriages created online, both Cacioppo et al. (2013) and Rosenfeld (2017) find that relationships created online last at least as long as those created offline, defying the popular belief that marriages that start online are of lower quality than those that start elsewhere, and are in line with our second prediction (in fact, Cacioppo et al., 2013 finds that marriages that start online last longer and report a higher marital satisfaction).17 Finally, with respect to our third hypothesis that asserts that online dating should increase the number of married couples, Bellou (2015) finds causal evidence that online dating has increased the rate at which both White and Black young adults marry in the US. The data she analyzes shows that online dating has contributed to higher marriage rates by up to 33% compared to the counterfactual without internet dating. Therefore, our third prediction is consistent with Bellou's findings. --- Structure of the Article We present our model in Section 2. Section 3 introduces the welfare indicators underlying the further analysis. Sections 4 and 5 analyze how these measures change when societies become more connected using theoretical analysis and simulations, respectively. Section 6 contrasts our model predictions with observed demographic trends from the US. Section 7 concludes. --- Model 2.1 Agents There are r races or communities, each with n agents (also called nodes). Each agent i is identified by a pair of coordinates (x i, y i ) <unk> [0, 1] 2, that can be understood as their personality traits (e.g. education, political views, weight, height, etcetera). 18 Both coordinates are drawn uniformly and independently for all agents. Each agent is either male or female. Female agents are plotted as stars and males as dots. Each race has an equal number of males and females, and is assigned a particular color in our graphical representations. --- Edges Between any two agents of the same race, there exists a connecting edge (also called link) with probability p: these edges are represented as solid lines and occur independently of each other. Agents are connected to others of different race with probability q: these interracial edges appear as dotted lines and are also independent. The intuition of our model is that two agents know each other if they are connected by an edge. 19 We assume that p > q. We present an illustrative example in Figure 3. 18 For a real-life representation using a 2-dimensional plane see www.politicalcompass.org. A similar interpretation appears in Chiappori, Oreffice and Quintana-Domeque (2012) and in Chiappori, McCann and Pass (2016). We use two personality traits because it allows us to use an illustrative and pedagogic graphical representation. All the results are robust to adding more personality traits. 19 This interpretation is common in the study of friendship networks, see de Mart<unk> and Zenou (2016) and references therein. Our model can be understood as the islands model in Golub and Jackson (2012), in which agents' type is both their race and gender. = 0.2. Our model is a generalization of the random graph model (Erd<unk>s and Rényi, 1959; Gilbert, 1959; for a textbook reference, see Bollobás, 2001). Each race is represented by a random graph with n nodes connected among them with probability p. Nodes are connected across graphs with probability q. The r random graphs are the within-race set of links for each race. In expectation, each agent is connected to n(r -1)q + (n -1)p persons. A society S is a realization from a generalized random graph model, defined by a four-tuple (n, r, p, q). A society S has a corresponding graph S = (M <unk> W ; E), where M and W are the set of men and women, respectively, and E is the set of edges. We use the notation E(i, j) = 1 if there is an edge between agents i and j, and 0 otherwise. We denote such edge by either (i, j) or (j, i). --- Agents' Preferences All agents are heterosexual and prefer marrying anyone over remaining alone. 20 We denote by P i the set of potential partners for i, i.e. those of different gender. The preferences of agent i are given by a function <unk> i : P i <unk> R + that has a distance interpretation. 21 An agent i prefers agent j <unk> P i over agent k <unk> P i if <unk> i (i, j) <unk> <unk> i (i, k). The intuition is that agents like potential partners that are close to them in terms of personality traits. The function <unk> i could take many forms, however we put emphasis on two intuitive ones. The first one is the Euclidean distance for all agents, so that for any agent i and every potential partner j = i, <unk> E (i, j) = (x i -x j ) 2 + (y i -y j ) 2 (1) and <unk> E (i, i) = <unk> 2 <unk>i <unk> M <unk> W, i. e. the utility of remaining alone equals the utility derived from marrying the worst possible partner. Euclidean preferences are intuitive and have been widely used in the social sciences (Bogomolnaia and Laslier, 2007). The indifference curves associated with Euclidean preferences can be described by concentric circles around each node. The second preferences we consider are such that every agent prefers a partner close to them in personality trait x, but they all agree on the optimum value in personality trait y. The intuition is that the y-coordinate indicates an attribute that is usually considered desirable by all partners, such as wealth. We call these preferences assortative. 22 Formally, for any agent i and every potential partner j <unk> P i, <unk> A (i, j) = |x i -x j | + (1 -y j ) (2) and <unk> E (i, i) = 2 <unk>i <unk> M <unk> W. The <unk> functions we discussed can be weighted to account for the strong intraracial preferences that are often observed in reality (Wong, 2003; Fisman et al., 2008; Hitsch, Hortasu and Ariely, 2010; Rudder, 2014; Potarca and Mills, 2015; McGrath et al., 2016). 23 21 The function <unk> can be generalized to include functions that violate the symmetry (<unk>(x, y) = <unk>(y, x)) and identity (<unk>(x, x) = 0) properties of mathematical distances. 22 If we keep the x-axis fixed, so that agents only care about the y-axis, we get full assortative mating as a particular case. The preferences for the y attribute are also known as vertical preferences. 23 It is not clear whether the declared intraracial preferences show an intrinsic intraracial predilection or capture external biases, which, when removed, leave the partner indifferent to match across races. Evidence supporting the latter hypothesis includes: Fryer (2007) documents that White and Black US veterans have had higher rates of intermarriage after serving with mixed communities. Fisman et al. (2008) finds that people do not find partners of their own race more attractive. Rudder (2009) shows that online daters have a roughly equal user compatibility. Lewis (2013) finds that users are more willing to engage in interracial dating if they previously interacted with a dater from another race. Inter or intraracial preferences can be incorporated into the model, as in equation (3) below <unk> i (i, j) = <unk> ij <unk>(i, j)(3) where <unk> ij = <unk> ik if agents j and k have the same race, and <unk> ij = <unk> ik otherwise. In equation ( 3), the factor <unk> ij captures weightings in preferences. The case <unk> ij <unk> 1 implies that agent i relative prefers potential partners of the same race as agent j, while <unk> ij > 1 expresses relative dislike towards potential partners of the same race as agent j. Although our results are qualitatively the same when we explicitly incorporate racial preferences using the functional form in equation ( 3), we postpone this analysis to Appendix B. A society in which all agents have either all Euclidean or all assortative preferences will be called Euclidean or assortative, respectively. We focus on these two cases. In both cases agents' preferences are strict because we assume personality traits are drawn from a continuous distribution. --- Marriages Agents can only marry potential partners who they know, i.e. if there exists a path of length at most k between them in the society graph. 24 We consider two types of marriages: 1. Direct marriages: k = 1. Agents can only marry if they know each other. 2. Long marriages: k = 2. Agents can only marry if they know each other or if they have a mutual friend in common. To formalize the previous marriage notion, let <unk> k (i, j) = 1 if there is a path of at most length k between i and j, with the convention <unk> 1 (i, i) = 1. A marriage <unk> : M <unk> W <unk> M <unk> W of length k is a function that satisfies <unk>m <unk> M <unk>(m) <unk> W <unk> <unk>m<unk> (4) <unk>w <unk> W <unk>(w) <unk> M <unk> <unk>w<unk> (5) <unk>i <unk> M <unk> W <unk>(<unk>(i)) = i (6) <unk>i <unk> M <unk> W <unk>(i) = j only if <unk> k (i, j) = 1 (7) We use the convention that agents that remain unmarried are matched to themselves. Because realized romantic pairings are close to those predicted by stability (Hitsch, Hortasu and Ariely, 2010; Banerjee et al., 2013), we assume that marriages that occur in each society are stable. 25 A marriage <unk> is k-stable if there is no man-woman pair (m, w) who are not married to each other such that <unk> k (m, w) = 1 (8) <unk>(m, w) <unk> <unk>(m, <unk>(m)) (9) <unk>(w, m) <unk> <unk>(w, <unk>(w)) (10) Such a pair is called a blocking pair. Condition ( 8) is the only nonstandard one in the matching literature, and ensures that a pair of agents cannot block a direct marriage if they are not connected by a path of length at most k in the corresponding graph. Given our assumptions regarding agents' preferences, Proposition 1. For any positive integer k, every Euclidean or assortative society has a unique k-stable marriage. Proof. For the Euclidean society, a simple algorithm computes the unique kstable marriage. Let every person point to their preferred partner to whom they are connected to by a path of length at most k. In case two people point to each other, marry them and remove them from the graph. Let everybody point to their new preferred partner to which they are connected to among those still left. Again, marry those that choose each other, and repeat the procedure until no mutual pointing occurs. The procedure ends after at most rn 2 iterations. This algorithm is similar to the one proposed by Holroyd et al. (2009) for 1-stable matchings in the mathematics literature26 and to David Gale's top trading cycles algorithm (in which agents' endowments are themselves), used in one-sided matching with endowments (Shapley and Scarf, 1974). For the assortative society, assume by contradiction that there are two k-stable matchings <unk> and <unk> such that for two men m 1 and m 2, and two women w 1 and w 2, <unk>(m 1 ) = w 1 and <unk>(m 2 ) = w 2, but <unk> (m 1 ) = w 2 and <unk> (m 2 ) = w 1. 27 The fact that both marriages are k-stable implies, without loss of generality, that for i, j <unk> <unk>1, 2<unk> and i = j, <unk>(m i, w i ) -<unk>(m i, w j ) <unk> 0 and <unk>(w i, m j ) -<unk>(w i, m i ) <unk> 0. Adding up those four inequalities, one obtains 0 <unk> 0, a contradiction. The fact that the stable marriage is unique allows us to unambiguously compare the characteristics of marriages in two different societies. 28 Figure 4 illustrates the direct and long stable marriages for the Euclidean and assortative societies depicted in Figure 3. Marriages are represented as red thick edges. --- Online Dating on Networks and Expansions of Societies We model online dating in a society S by increasing the number of interracial edges. Given the graph S = (M <unk> W ; E), we create new interracial edges between every pair that is disconnected with a probability. 29,30 S denotes a society that results after online dating has occurred in society S. S has exactly the same nodes as S, and all its edges, but potentially more. We say that the society S is an expansion of the society S. Equivalently, we model online dating by increasing q. Online dating generates a society drawn from a generalized random graph model with a higher q, i.e. with parameters (n, r, p, q + ). --- Welfare Indicators We want to understand how the welfare of a society changes after online dating becomes available, i.e. after a society becomes more interracially connected. We consider three welfare indicators: 1. Diversity, i.e. how many marriages are interracial. We normalize this indicator so that 0 indicates a society with no interracial marriages, and 1 equals the diversity of a colorblind society in which p = q, where an expected fraction r-1 r of the marriages are interracial. Formally, let R be a function that maps each agent to their race and M * be the set of married men. Then dv(S) = |<unk>m <unk> M * : R(m) = R(<unk>(m))<unk>| |M * | • r r -1 (11) 2. Strength, defined as <unk> 2 minus the average Euclidean distance between each married couple. This number is normalized to be between 0 and 1. If 29 Online dating is likely to also increase the number of edges inside each race, but since we assume that p > q, these new edges play almost no role. We perform robustness checks in Appendix B, increasing both p and q but keeping its ratio fixed. 30 We could assume that particular persons are more likely than others to use online dating, e.g. younger people. However, the percentage of people who use online dating has increased for people of all ages. See: "5 facts about online dating", Pew Research Center, 29/2/2016. To obtain our main result, we only need a small increase in the probability of interconnection for each agent. every agent gets her perfect match, strength is 1, but if every agent marries the worst possible partner, strength equals 0. We believe strength is a good measure of the quality of marriage not only because it measures how much agents like their spouses, but also because a marriage with a small distance between spouses is less susceptible to break up when random agents appear. Formally st(S) = <unk> 2 -m<unk>M * <unk> E (m,<unk>(m)) |M * | <unk> 2 (12) 3. Size, i.e. the ratio of the society that is married. Formally, sz(S) = |M * | n (13) 4 Edge Monotonicity of Welfare Indicators Given a society S, the first question we ask is whether the welfare indicators of a society always increase when its number of interracial edges grow, i.e. when online dating becomes available. We refer to this property as edge monotonicity. 31 Definition 1. A welfare measure w is edge monotonic if, for any society S, and any of its extensions S, we have w(S ) <unk> w(S)(14) That a welfare measure is edge monotonic implies that a society unambiguously becomes better off after becoming more interracially connected. Unfortunately, Proposition 2. Diversity, strength, and size are all not edge monotonic. Proof. We show that diversity, strength and size are not edge monotonic by providing counterexamples. To show that size is not edge monotonic, 31 Properties that are edge monotonic have been thoroughly studied in the graph theory literature (Erd<unk>s, Suen and Winkler, 1995). Edge monotonicity is different from node monotonicity, in which one node, with all its corresponding edges, is added to the matching problem. It is well-known that when a new man joins a stable matching problem, every woman weakly improves, while every man becomes weakly worse off (Theorems 2.25 and 2.26 in Roth and Sotomayor, 1992). consider the society in Figure 3 and its direct stable matching in Figure 4a. Remove all interracial edges: it is immediate that in the unique stable matching there are now four couples, one more than when interracial edges are present. For the case of strength, consider a simple society in which all nodes share the same y-coordinate, as the one depicted in Figure 5. There are two intraracial marriages and the average Euclidean distance is 0.35. When we add the interracial edge between the two central nodes, the closest nodes marry and the two far away nodes marry too. The average Euclidean distance in the expanded society increases to 0.45, hence reducing its strength. The average Euclidean distance between spouses increases after creating the interracial edge between the nodes in the center. To show that diversity is not edge monotonic, consider Figure 6. There are two men and two women of each of two races a and b. Each gender is represented with the superscript + or -. Stability requires that <unk>(b - 1 ) = a + 1 and <unk>(b + 2 ) = a - 2, and everyone else is unmarried. However, when we add the interracial edge (a + 1 b - 2 ), the married couples become <unk>(b - 1 ) = b + 1, <unk>(a + 2 ) = a - 1, and <unk>(a + 1 ) = b - 2. In this extended society, there is just one interracial marriage, out of a total of three, when before we had two out of two. Therefore diversity reduces after adding the edge (a + 1 b - 2 ). The failure of edge monotonicity by our three welfare indicators makes evident that, to evaluate welfare changes in societies, we need to understand how welfare varies in an average society after introducing new interracial edges. We develop this comparison in the next Section. A further comment on edge monotonicity. The fact that the size of a society is not edge monotonic implies that adding interracial edges may not lead to a Pareto improvement for the society. Some agents can become worse off after the society becomes more connected. Nevertheless, the fraction of agents that becomes worse off after adding an extra edge is never more than one-half of the society, and although it does not vanish as the societies grow large, the welfare losses measured in difference in spouse ranking become asymptotically zero.? discusses both findings in detail. --- Expected Welfare Indicators To understand how the welfare indicators behave on average, we need to form expectations of these welfare measures. We are able to evaluate this expression analytically for diversity, and rely on simulation results for the others. --- Diversity The expected diversity of a society with direct marriages is given by E[dv(S direct )] = q (r-1)n 2 p n 2 + q (r-1)n 2 • r r -1 (15) where q(r -1)n/2 is the expected number of potential partners of a different race to which an agents is directly connected, and pn/2 is the corresponding expected number of potential partners of the same race. The term r r-1 is just the normalization we impose to ensure that diversity equals one when p = q. Equation ( 15) is a concave function of q, because <unk> 2 E[dv(S direct )] <unk>q 2 = -pr(r -1) (pn + q(r -1)n) 3 <unk> 0 (16) and therefore a small increase in q around q = 0 produces an even larger increment in the expected diversity of a society. If we consider long marriages, we observe a more interesting change. The expected diversity in a society with long marriages is given by E[dv(S long )] = P (B) (r-1)n 2 P (A) n 2 + P (B) (r-1)n 2 • r r -1(17) where P (A) denotes the probability that any agent (say i) is connected to another member of his community (i ) by a path of length at most 2, and P (B) denotes the probability that any agent (i) is connected to any agent of another community (j) by a path of length at most two, perhaps via another agent (h) who does not share race neither with i nor with j. These are given by P (A) = 1 -(1 -p) E(i,i )=0 (1 -p 2 ) n-2 E(i,i )=E(i,i )=0 (1 -q 2 ) (r-1)n E(i,h)=E(h,i

We used to marry people to whom we were somehow connected. Since we were more connected to people similar to us, we were also likely to marry someone from our own race. However, online dating has changed this pattern; people who meet online tend to be complete strangers. We investigate the effects of those previously absent ties on the diversity of modern societies. We find that social integration occurs rapidly when a society benefits from new connections. Our analysis of state-level data on interracial marriage and broadband adoption (proxy for online dating) suggests that this integration process is significant and ongoing.

society. If we consider long marriages, we observe a more interesting change. The expected diversity in a society with long marriages is given by E[dv(S long )] = P (B) (r-1)n 2 P (A) n 2 + P (B) (r-1)n 2 • r r -1(17) where P (A) denotes the probability that any agent (say i) is connected to another member of his community (i ) by a path of length at most 2, and P (B) denotes the probability that any agent (i) is connected to any agent of another community (j) by a path of length at most two, perhaps via another agent (h) who does not share race neither with i nor with j. These are given by P (A) = 1 -(1 -p) E(i,i )=0 (1 -p 2 ) n-2 E(i,i )=E(i,i )=0 (1 -q 2 ) (r-1)n E(i,h)=E(h,i )=0 (18) P (B) = 1 -(1 -q) E(i,j)=0 (1 -pq) 2n-2 E(i,i )=E(i,j)=0 (1 -q 2 ) (r-2)n E(i,h)=E(h,j)=0(19) Plugging the values computed in equations ( 18) and ( 19) into (17), we can plot that function and observe that it grows very fast: after q becomes positive, the diversity of a society quickly becomes approximately one. To understand the rapid increase in diversity, let us fix p = 1 and let q = 1/n. Then P (B) = 1 -(1 -q) 2n-1 (1 -q 2 ) (r-2)n (20) = 1 -(1 -q) rn-1 (1 + q) (r-2)n (21) = 1 -(1 - 1 n ) rn-1 (1 + 1 n ) (r-2)n (22) = n<unk> 1 -e -2 <unk> 0.86 (23) Substituting the value of P (B) into ( 17), we obtain that E[dv(S long )] <unk>.86r.86r+.14, which is very close to 1 even when r is small (E[dv(S long )] <unk>.92 already for r = 2), showing that the diversity of a society becomes 1 for very small values of q, in particular q = 1/n. The intuition behind full diversity for the case of long marriages is that, once an agent obtains just one edge to any other race, he gains n 2 potential partners. Just one edge to a person of different race gives access to that person's complete race. Although we fixed p = 1 to simplify the expressions of expected diversity, the rapid increase in diversity does not depend on each race having a complete graph. We also obtain a quick increase in diversity for many other values of p, as we discuss in Appendix B. When same-race agents are less interconnected among themselves, agents gain fewer connections once an interracial edge is created, but those fewer connections are relatively more valuable, because the agent had less potential partners available to him before. 32 To further visualize the rapid increase in diversity we use simulations. We generate several random societies and observe how their average diversity change when they become more connected. We create ten thousand random societies, and increase the expected number of interracial edges by increasing 32 This finding should not be confused with (and it is not implied by) two well-known properties of random graphs. The first one establishes that a giant connected component emerges in a random graph when p = 1/n, whereas the graph becomes connected when p = log(n)/n; for a review of these properties see Albert and Barabási (2002). The second result is that the property that a random graph has diameter 2 (maximal path length between nodes) has a sharp threshold at p = (2 ln n/n) 1/2 (Blum, Hopcroft and Kannan, 2017). Result 1 is also similar to, but not implied by, the small world property of simple random graphs (Watts and Strogatz, 1998), where an average small path length occurs in a regular graph after rewiring a few initial edges. the parameter q. In the simulations presented in the main text we fix n = 50 and p = 1. 33 As predicted by our theoretical analysis, a small increase in the probability of interracial connections achieves perfect social integration in the case of long marriages. 34,35 For the cases with direct marriages, the increase in diversity is slower but still fast: an increase of q from 0 to 0.1 increases diversity to 0.19 for r = 2, and from 0 to 0.37 with r = 5. 36 Figure 7 summarizes our main result, namely: Result 1. Diversity is fully achieved with long marriages, even if the increase in interracial connections is arbitrarily small. With direct marriages, diversity is achieved partially, yet an increase in q around q = 0 yields an increase of a larger size in diversity. We have showed that with either direct (k = 1) or long (k = 2) marriages diversity increases after the emergence of online dating, although at very different rates. An obvious question is whether online dating actually helps to create long marriages. We study the case of long marriages not because we expect that if a man meets a woman online, then that man will be able to date that woman's friends. Rather, we study it because it shows that when people meet their potential spouses via friends of friends (k > 2), a few existing connections can quickly make a difference: recall that meeting through friends of friends is the most common way to meet a spouse both in the US and Germany (around one out of every three marriages start this way in both countries (Rosenfeld and Thomas, 2012; Potarca, 2017)). 37 Our analysis shows that immediate social integration occurs for all values of k <unk> 2. The mechanism we consider for those larger values of k is that, once 33 We restrict to n = 50 and ten thousand replications because of computational limitations. The results for other values of p are similar and we describe them in Appendix B. 34 Perfect social integration (diversity equals one) occurs around q = 1/n, as we have discussed. The emergence of perfect integration is not a phase transition but rather a crossover phenomenon, i.e. diversity smoothly increases instead of discontinuously jumping at a specific point: see Figure B1 in Appendix B. 35 This result is particularly robust as it does not depend on our assumption that the marriages created are stable. Stability is not innocuous in our model, as we could consider other matching schemes that in fact are edge-monotonic. 36 Empirical evidence strongly suggests that q is very close to zero in real life. See footnote 13. 37 Ortega (2018b) finds the minimal number of interracial edges needed to guarantee that any two agents can marry for all values of k. The yellow and orange curves are indistinguishable in this plot because they are identical. Exact values and standard errors (which are in the order of 1.0e-04) are provided in Appendix A, as well as the corresponding graph for an assortative society, which is almost identical. an interracial couple is created, it serves as a bridge between two different races. For example, if woman a marries man b of a different race, in the future it allows agent a, an acquaintance of woman a, to meet agent b, an acquaintance of man b, allowing a and b to marry. In summary, we expect that some marriages created by online dating will be between people who meet directly online, but some will be created as a consequence of those initial first marriages, and thus the increase in the diversity of societies will be somewhere in between the direct and the long marriage case. Result 1 implies that a few interracial links can lead to a significant increase in the racial integration of our societies, and leads to optimistic views on the role that dating platforms can play in modern civilizations. Our result is in sharp contrast to the one of Schelling (1969, 1971) in its seminal models of residential segregation, in which a society always becomes completely segregated. We pose this finding as the first testable hypothesis of our model. Hypothesis 1. The number of interracial marriages increases after the popularization of online dating. --- Strength & Size A second observation, less pronounced than the increase in diversity, is that strength is increasing in q. We obtain this result by using simulations only, given that it seems impossible to obtain an analytical expression for the expected strength of a society. 38 Exact values and standard errors (which are in the order of 1.0e-04) provided in Appendix A, as well as the corresponding graph for an assortative society, which is very similar. The intuition behind this observation is that agents have more partner choices in a more connected society. Although this does not mean that every agent will marry a more desired partner, it does mean that the average agent will be paired with a better match. It is clear that, for all combinations of parameters (see Appendix B for further robustness checks), there is a consistent trend downwards in the average distance of partners after adding new interracial edges, and thus a consistent increase in the strength of the societies. We present this observation as our second result. Result 2. Strength increases after the number of interracial edges increases. The increase is faster with long marriages and with higher values of r. Assuming that marriages between spouses who are further apart in terms of personality traits have a higher chance of divorcing because they are more susceptible to break up when new nodes are added to the society graph, we can reformulate the previous result as our second hypothesis. Hypothesis 2. Marriages created in societies with online dating have a lower divorce rate. Finally, with regards to size, we find that the number of married people also increases when q increases. This observation, however, depends on p <unk> 1. 39 This increase is due to the fact that some agents do not know any available potential spouse who prefers them over other agents. Figure 9 presents the evolution of the average size of a society with p = 1/n. The increase in the number of married people becomes even larger (and does not require p <unk> 1) whenever i) some races have more men than women, and vice versa, 40 ii) agents become more picky and are only willing to marry an agent if he or she is sufficiently close to them in terms of personality traits, or iii) some agents are not searching for a relationship. All these scenarios yield the following result. Result 3. Size increases after the number of interracial edges increases if either p <unk> 1, societies are unbalanced in their gender ratio, or some agents are deemed undesirable. The increase is faster with long marriages and with higher values of r. The previous result provides us with a third and final testable hypothesis, namely: Hypothesis 3. The number of married couples increases after the popularization of online dating. 39 Using Hall's marriage theorem, Erd<unk>s and Rényi (1964) find that in a simple random graph (r = 1) the critical threshold for the existence of a perfect matching is p = log n/n, i.e. a marriage with size 1. Even when p = q, this critical threshold is only a lower bound for a society to have size 1. This is because there is no guarantee that the stable matching will in fact be a perfect one. 40 See Ahn (2018) for empirical evidence on how gender imbalance affects cross-border marriage. Exact values and standard errors (which are in the order of 1.0e-04) provided in Appendix A, as well as the corresponding graph for an assortative society, which is very similar. 6 Hypotheses and Data --- Hypothesis 1: More Interracial Marriages What does the data reveal? Is our model consistent with observed demographic trends? We start with a preliminary observation before describing our empirical work in the next subsection. Figure 10 We observe that the number of interracial marriages has consistently increased in the last 50 years. However, it is intriguing that a few years after the introduction of the first dating websites in 1995, like Match.com, the percentage of new marriages created by interracial couples increased. The increase becomes steeper around 2006, a couple of years after online dating became more popular: it is around this time when well-known platforms such as OKCupid emerged. During the 2000s, the percentage of new marriages that are interracial rose from 10.68% to 15.54%, a huge increase of nearly 5 percentage points, or 50%. After the 2009 increase, the proportion of new interracial marriage jumps again in 2014 to 17.24%, remaining above 17% in 2015 too. Again, it is interesting that this increase occurs shortly after the creation of Tinder, considered the most popular online dating app. 42 The increase in the share of new marriages that are interracial could be caused by the fact that the US population is in fact more interracial now than 20 years ago. However, the change in the population composition of the US cannot explain the huge increase in intermarriage that we observe, as we discuss in detail in Appendix C. A simple way to observe this is to look at the growth of interracial marriages for Black Americans. Black Americans are the racial group whose rate of interracial marriage has increased the most, going from 5% in 1980 to 18% in 2015. However, the fraction of the US population that is Black has remained constant at around 12% of the population during the last 40 years. Random marriage accounting for population change would then predict that the rate of interracial marriages would remain roughly constant, although in reality it has more than tripled in the last 35 years. The correlation between the increase in the number of interracial marriages and the emergence of online dating is suggestive, but the rise of interracial marriage may be due to many other factors, or a combination of those. To precisely pin down the effect of online dating in this increase, we proceed as follows. --- Empirical Test of Hypothesis 1 We use the following strategy in order to rigorously test our prediction that online dating increases the number of interracial marriages. Our empirical setup exploits state variations in the development of broadband internet from 2000 to 2016, which we use as a proxy for online dating. There is little concern for reverse causality, which would imply that broadband developed faster in states where there was a higher number of interracial couples. Our dependent variable is a dummy showing whether a person's marriage is interracial. We use a variety of personal and state-level covariates in order to identify the relationship between online dating and interracial marriages as precisely as possible. Figure 11 displays a preview of the relationship between broadband development and interracial marriage by state. We use three main data sources for our analysis. All data concerning individuals is downloaded from IPUMS, and we restrict our analysis to married individuals only. Although the data is only on the individual level, it is possible to construct marriage relationships, by employing a matching procedure described at IPUMS website. As additional control variables, we employ education, age, and total income,43 as these are likely to affect the marriage decision. We construct the broadband data using information from reports by the Federal Communications Commission (FCC), which is the regulatory authority in the United States responsible for communication technology. Following Bellou (2015), 44 we use the number of residential high-speed internet lines per 100 people as our explanatory variable. Data is available for the years 2000 to 2016. However, we have to discard Hawaii from our analysis, as observations are missing up to 2005. We download additional state controls from the Current Population Survey. Following Bellou's work, we include variables like the ratio of the male divided by female population within a state, age bins and the ratio of nonwhite people in a state. This last explanatory variable is especially important in our context of interracial marriages. might affect earnings. Excluding income as explanatory variable leaves the coefficients virtually unchanged. As additional robustness check, we estimate a similar model at state level in Appendix D. 44 She uses a similar specification to examine the role of internet diffusion in the creation of new marriages. Our dataset is described in detail in Appendix D. We estimate the following reduced form equation by a linear probability model: Inter ist = <unk> + <unk> Broadband st + <unk> 1 X ist + <unk> 2 Z st + F E s + F E t + ist (24) where Inter ist is one if a person is in an interracial marriage and 0 otherwise. The indices relate to person i, living in state s at time t. We are mostly interested in the coefficient <unk>, as it captures the propensity of online dating. The values in X are covariates relating directly to the person, while Z represents time varying state variables. We additionally include state-and year fixed effects, and cluster the standard errors ist at the state-year level. Our rich battery of control variables enables us to clearly identify the relationship between interracial marriages and broadband internet, which can be seen as an instrument for online dating. As marriages take a while to form, we include the broadband variable with a 3 year lag based on empirical evidence (Rosenfeld, 2017). 45 The first column in Table 1 states that one additional line of broadband internet 3 years ago affects the probability of being in an interracial marriage by 0.07%. The coefficient is positive, as predicted by our theoretical model. In column (2) we include controls at the state level and find that the relationship between interracial marriages and broadband remains significantly positive. This continues to be true when including the individual covariates, all of which decrease the probability of a marriage being interracial. Perhaps surprisingly, education enters negatively. A potential underlying reason might be that education leads to more segregated friendship circles, a conjecture worth being explored in subsequent work. Column ( 4) is now the specification outlined in (24). Even with all controls, the effect of broadband penetration on interracial marriages is highly significant and positive. This result suggests a causal relationship in the sense described by our model. As additional evidence for this claim, we see that once we replace the lagged broadband with its contemporaneous counterpart, the coefficient declines in size, which means that the state of 45 In Appendix D we follow a different strategy. We construct shares of interracial marriages per state and year and estimate this with panel methods. The advantage is that the dependent variable is continuous rather than dichotomous, however we cannot use individual controls and introduce standard errors via aggregation. These standard errors should be negligible given the amount of observations we have available. The state-year level specification also generates significant coefficients with the expected signs, confirming our results. --- Interracial Marriage (1) (2) (3) (4) (5) Broadband (-3).00071 broadband 3 years ago has a bigger effect on interracial marriages as compared to broadband today. This is because it takes time for marriages to form. Overall, the work we have presented here, jointly with robustness checks described in Appendix D, suggests that there is empirical support for our hypothesis of online dating leading to more interracial marriages. Furthermore, the work of Thomas (2018), released shortly after we made the first version of our paper available online, has provided further evidence of the role of online dating in the creation of new interracial marriages. Using a self-collected dataset representative of the US population (known as "how couples met and stayed together" or HCMST), Thomas finds that couples who met online were more likely to be interracial, even after controlling for the racial composition of their locations and confounding factors. In particular, after analyzing information about 3,036 American couples, he finds that couples who met online since 1996 are 6 to 7 percent more often interracial than couples who met purely offline. His finding, using different methods and data, is similar to ours and provides further support for Hypothesis 1. His dataset is freely available online for replication purposes. --- Hypothesis 2 & 3: More and Better Marriages With regards to Hypothesis 2 and 3, which establish the creation of better and more marriages, respectively, we do not provide novel empirical work but we survey existing research from different disciplines. There are two articles which have focused on whether relationships created online last longer than those created elsewhere. The first one is Cacioppo et al. (2013). They find that marriages created online were less likely to break up and exhibited a higher marital satisfaction, using a sample of 19,131 Americans who married between 2005 and 2012. They write: "Meeting a spouse on-line is on average associated with slightly higher marital satisfaction and lower rates of marital break-up than meeting a spouse through traditional offline venues". The second one is Rosenfeld (2017). Analyzing the HCMST dataset from 2009 to 2015, he finds no difference in the duration of marriages that start online and offline. Besides their methodological differences, what it is clear is that both papers find that marriages created online last at least as long as those created elsewhere, disproving the common popular belief that online relationships are only casual and of lower quality (see footnote 15). This finding aligns with Hypothesis 2 of our model. With regards to Hypothesis 3, which states that the advent of online dating leads to a higher number of marriages, there is in fact empirical evidence supporting it. Bellou (2015) examines the role that internet penetration (in the form of broadband deployment) has had in the number of White and Black young adults who decide to marry. She uses data from the Current Population Survey and the FCC from 2000 to 2010. She finds that wider internet availability has indeed caused more interracial marriages among people between 21 and 30 years old. In particular, she finds that marriage rates are currently higher by 13% to 33% from what they might have been if the internet had not been available, despite a pre-existing downward trend in the propensity to marry among young adults. 7 Final Remarks 7.1 Limitations of our Model Our model does not explain three observed characteristics of interracial marriages. First, it does not explain why interracial marriages are more likely to end up in divorce (Bratter and King, 2008; Zhang and Van Hook, 2009). Second, it does not explain why some intraracial marriages from a particular race last longer than intraracial marriages from another race (e.g. Stevenson and Wolfers, 2007 document that Blacks who divorce spend more time in their marriage than their White counterparts). And third, our model does not explain why interracial marriage between specific combinations of race and gender are more common than others (marriage between White men and Asian women is much more common than marriage among Asian men and White women; similarly marriage between Black men and White women is much more common than marriage between Black women and White men, see Chiappori, Oreffice and Quintana-Domeque, 2016.). A theoretical model that can account for all those stylized facts is still missing (see Fryer, 2007 for a discussion of how well existing models of marriage explains observed interracial marriage trends). --- Further Applications The theoretical model we present discusses a general matching problem under network constraints, and hence it can be useful to study other social phenomena besides interracial marriage. Furthermore, the role of connecting highly clustered groups is also not only linked to online dating. Another example is the European student exchange program "Erasmus", which helped more than 3 million students and over 350 thousand academics and staff members to spend time at a University abroad. 46 Although it would be interesting to test our model in these and other scenarios, we leave this task for further research. --- Conclusion We introduce a theoretical model to analyze the complex process of deciding whom to marry in the times of online dating. Our model is admittedly simple and fails to capture many of the complex features of romance in social networks, like love. However, in our view, the simplicity of our model is its main strength. It generates strong predictions with a simple structure. The main one is that the diversity of societies, measured by the number of interracial marriages in it, increases after the introduction of online dating. Not only is this prediction consistent with demographic trends, but an empirical analysis of interracial marriages within each US state suggests that online dating is indeed partially responsible for the observed increase in interracial marriage. And if that is the case, in words of the MIT Technology Review (2017): "the model implies that this change is ongoing. Thats a profound revelation. These changes are set to continue, and to benefit society as result". Simple models are great tools for conveying an idea. Schelling's segregation model clearly does not capture many important components of how people decide where to live. It could have been enhanced by introducing thousands of parameters. Yet, it has broadened our understanding of racial segregation, and has been widely influential: according to Google Scholar, it has been quoted 3,258 times by articles in a variety of field ranging from sociology to mathematics. It has provided us with a way to think about an ubiquitous phenomenon. Our model is a modest attempt that goes in the same direction. --- Appendices (for online publication only). A Appendix A: Simulation Results --- B

We used to marry people to whom we were somehow connected. Since we were more connected to people similar to us, we were also likely to marry someone from our own race. However, online dating has changed this pattern; people who meet online tend to be complete strangers. We investigate the effects of those previously absent ties on the diversity of modern societies. We find that social integration occurs rapidly when a society benefits from new connections. Our analysis of state-level data on interracial marriage and broadband adoption (proxy for online dating) suggests that this integration process is significant and ongoing.

Introduction Starting with the Black Report 35 years ago, many major government inquiries into population health have recommended policy change across a broad range of key areas in order to reduce inequality in the distribution of the social determinants of health (SDH). Popular targets for reform include: early childhood services; education and training; tackling poverty; and the redistribution of wealth. [1][2][3][4] Policy recommendations regarding the SDH span changes to policy processes, such as advocating the use of health inequality impact assessments and encouraging the integration of health into diverse policies (ie, Health in All Policies), 5 to changes in specific policies ranging from child and maternal nutrition to the provision of care to the elderly. [1][2][3][4] The authors of these reports anticipate that implementation of such policy adjustments will move us closer to the goal of reducing inequalities in the distribution of the SDH. Alongside these developments there has been a growing interest in systems science and the insights it might provide for action on the SDH. 6,7 The health of individuals and populations is affected by broad social factors that influence the conditions in which people grow, live, work, and age. 3,8 Hence, social inequalities -and the inequalities in health outcomes associated with them -are now understood to emerge from complex local, regional, national, and global systems which are inextricably linked. 9,10 Increasingly, researchers in this field argue that inequalities in the SDH cannot be ameliorated "without an analytic focus on how these complex systems act together (and) coalesce to produce them. " 10 Systems science is a broad term for a range of methodologies and perspectives that seek to elucidate the behavior of complex systems and inform efforts to address these problems. The World Health Organization (WHO) has stated that systems thinking provides a more complete understanding of realworld settings and ways to produce change. 11 In healthcare, systems-based approaches have been applied in a range of areas, including general practice, 12 and health service organisations. 13,14 There have also been attempts to apply a systems lens to complex public health problems, such as tobacco control 15 and obesity. 16,17 Such approaches are a move away from linear and simple input/output models towards dynamic models, as a means to generate policies that are adaptive to changing state of the system. The concept of 'adaptive policies' has received increasing attention in public policy as a means to generate policies that can deal with both the complexity and uncertainty involved in governing wicked problems. 18,19 It is argued that a dynamic, self-adjusting feedback system (which characterises many of the wicked problems that drive poor social and, in turn, health inequalities) cannot be effectively governed by a static, unbending policy. 20 That is, a static policy is unlikely to help decision-makers reach the desired ends, particularly over time. Static policies have no facility to deal with any unintended consequences of their implementation, including those which exacerbate the target problem, or the creation of new and unexpected problems. 18,21,22 Adaptive policies which encompass a degree of 'learning' can shift according to the state of the system and are therefore seen as potentially being both more effective and cheaper (in the long run) than static policies. 18,21 In particular, adaptive policies are considered to be a more appropriate policy design structure for dealing with uncertain future scenarios when compared to static policies. 18,21 This is not because adaptive policies, or the people making them, are better able to predict outcomes. It is because adaptive policy refers to a policy structure that attempts to be flexible across a range of anticipated scenarios, and can reasonably expect to deal well with unanticipated changes in trends. 22 The 'adaptive policy' response to managing the inherent risk of acting within a complex system, such as future dynamics changes in the social determinants to health, embraces the notion of shifting and responding to unanticipated change. In this paper, we introduce and expand the concept of adaptive policies to reduce inequalities in the distribution of the SDH. We then outline two illustrative examples of adaptive policies to demonstrate their potential for reducing SDH inequality. We anticipate that this paper will contribute to creative thinking for policy change in this area. --- Adaptive Policies Policy is defined as "what governments choose to do and or not to do. Hence, public policy is concerned primarily with governmental action and inaction. " 23,24 In an extension of this definition, 'adaptive policy' introduces the notion that a policy includes within itself instruments for monitoring and adaptation in the face of uncertainty. Adaptive policies are, therefore policies that have both (a) Internal instruments or methods to responds to change over time, and (b) An explicit learning orientation for the people charged with policy implementation. 19 The term 'adaptive policy' did not arise until the 1980s, though the concepts at the heart of adaptive approaches were first articulated in the early 1900s with regard to the need for experimentation in policy to encourage continual learning and adjustments. 25,26 In the 1980s, Rondinelli argued that policy must "cope more effectively with... uncertainty and complexity... requiring an adaptive approach that relies on strategic planning, on administrative procedures that facilitate innovation, responsiveness and experimentation and decision-making processes that join learning with action. " 27 Since this time, the need for learning and adaptation have become well-acknowledged in natural resource management and environmental policy discourse, 28 public policy, [29][30][31] and in public health policy discourse. 11 Swanson et al 18,22 outlines 4 key features of adaptive policies: 1. They can perform well under a range of anticipated conditions with little or no alteration. 2. They include monitoring processes and identify when changes in context are significant enough to affect performance. --- They have built-in triggers for adjustment (these can include deliberations for determining policy adjustments, review process and so forth) which means that they can maintain performance or terminate when no longer needed. 4. Ideally, they can also accommodate unforseen changes in context, for which the policy was not originally designed, ensuring that policy goals can be achieved despite unanticipated issues. A commonly understood illustrative example of an adaptive policy, which uses built-in triggers and monitoring processes to adapt and adjust, is the monetary system and the function of the Reserve Bank of Australia. The role of the Reserve Bank is to stabilise the currency under uncertain shifting global economic conditions, thereby protecting the welfare of citizens. This role is adaptive because it has a built-in monitoring process -the Board of the Reserve Bank meets every month to evaluate economic conditions -and a flexible policy lever -the Reserve Bank can choose to raise or lower interest rates. Without requiring any additional policy to be passed by any level of government in Australia, the Reserve Bank can push or pull its policy lever in the direction it believes will be most effective at placing saving, spending and investment behaviour within optimal parameters. --- Adaptive Policies for Addressing Inequalities in the Social Determinants of Health In the remainder of the paper, we provide illustrative examples of adaptive policy approaches for addressing inequalities in the SDH. These examples are designed to be illustrative, rather than prescriptive, and to broaden the discourse on the potential benefits of adaptive policies. As inequalities in the SDH are dynamic (ie, they change over time and across location), the strategic use of adaptive policies may help to mitigate them without the need for successive changes to legislation or regulation. Indeed, research has shown that static policies, over time, can drift substantially from their original mandate. 32 Adaptive policies, in this situation, can be self-adjusting. A recent WHO report 20 notes the potential of adaptive policies for addressing SDH (in this instance, alcohol). Drawing on systems science, the report argues that policies must be dynamic if they are to address the complexity of current health challenges. 1. An Adaptive Approach to Food and Fuel Subsidisation -an Extension of the Indian Ration Card India is home to 400 million people living on incomes under $1.25 per day and 190 million people who are chronically under-nourished. 33 Since 1960 the Indian Government has administered a ration card system with the aim of providing a subsidised minimum of food and fuel to the entire Indian population. 34 The ration card is available to all households and has three different categories based on household income level. Each ration card entitles households to a set amount of subsidised wheat, rice, sugar, kerosene and LP Gas which is purchased from government-run Fair Price Stores. 34 There are some 500 000 Fair Price Stores across India which operate in parallel to traditional stores in which prices are set by the market. India has undergone a sustained period of development characterised by increasing per capita gross domestic product (GDP), urbanisation and some widening of inequalities. 35,36 As a result of this development, more households consume a larger amount of unsubsidised food and a smaller proportion of households are reliant on ration cards than was the case 20 years ago. This change in consumption patterns presents an opportunity for the implementation of an adaptive policy. At present, each of the States in India sets the prices of the ration goods. Prices are changed infrequently and price increases are the occasion of much political debate, even among wealthier middleclasses. A small tax on the sale of unsubsidised goods could be directed to reducing the cost of subsidised goods. The positive feedback loop of such a policy is presented in Figure. This would be an 'adaptive' policy because the amount of the subsidy would increase in line with increases in unsubsidised consumption. Thus consumption of market priced grains by the middle class would further reduce the cost of subsidised grains for the poor. In effect the successes of India's development are utilised to reduce the inequality caused by that development. Technological advancements in the ration card system also make a policy of this type feasible. To combat corruption Indian states have begun to link ration cards to bank accounts and other forms of identification. 34 When the ration cardholder purchases goods from a Fair Price Store, they do so at full price and the subsidy is automatically credited to a nominated bank account. The subsidy credited to the consumer could increase incrementally as consumption of market price grains increase. Of course a minimum subsidy level would need to be set to ensure that the subsidy did not decrease from existing levels. This policy fits the criteria for adaptive policies outlined above in that: (1) It performs well under changing conditions as the economic circumstances of the country change, (2) Monitors consumption of unsubsidised goods, (3) Triggers an increase in the amount of subsidy given on subsidised goods. --- An Adaptive Approach to Educational Inequalities Education is now understood to be both a key determinant of health and an important source of social and health inequalities, due to differences in the quality of education received by different groups. 3,4 Inequalities in educational access, quality and outcomes affects physical and mental health, as well as later income and employment. 4 Many western industrialised countries have developed dual, or tiered, education systems. In addition to universally available public systems, countries such as the United States, United Kingdom, and Australia have private schooling systems which, in addition to sourcing income from private sources through fees, can also receive government funding. 37 As private services grow, however, public services have tended to deteriorate, leaving those without the means to purchase private ones with a lower quality of service. [38][39][40][41] Dual education systems can drive inequalities, as those without the means to buy private education receive an increasingly lower standard of education, which has flow-on effects for the types of employment they can secure later and the income employment provides. 38,39 These tiered systems can, over time, generate very large disparities between groups, as public education systems become'residualised.'That is, a public service only provided for the poor, as a minimum safety net. 38,42 An adaptive approach to removing disparities between public and private systems would be to make public funding of private schools contingent on public school performance. When public schools perform well (thereby closing the gap in education outcomes, and their subsequent flow-on effects for social inequalities), private schools receive more funds. When public schools perform poorly, private schools receive less funds. In turn, government funding of public schools would need to be performance-based in a way that provides additional support for low socio-economic areas or schools where students are 'falling behind.'Here a set of review processes is triggered, as occurs with the Reserve Bank, with the authority to authorise further action (eg, more resources such as teachers, a change in structure and so on). Taking the Australian context as an example, government funding of public and private schools could be distributed inversely on the basis of standardised test performance. Currently, all Australian Schools take part in the National Assessment Program -Literacy and Numeracy (NAPLAN). 43 The NAPLAN tests aim to establish the proficiency of students in a range of skills deemed essential for children to progress, both through school, and their later working life. They are undertaken nationwide on a yearly basis. An adaptive education policy in Australia would establish a funding scheme for public schools whereby schools that perform poorly on NAPLAN's receive additional resources. This is in stark difference to American systems, for example, where performance-based funding (where funding is given only when students perform well) has led to 'gaming' of the system and a failure to raise or equalise educational outcomes. 44,45 In addition, a set of contingency measures could be 'triggered' through the monitoring of an individual school's performance over time. If a school continues to perform poorly despite increased investment further support measures, or review processes, could be triggered when certain thresholds are reached (ie, a failure to improve performance three years in a row). Review committees would be able to authorise further action (eg, more resources such as teachers, a change in structure and so on). These contingency policies, plans and programs might target non-school dimensions of students' lives, in addition to the school environment, in recognition of the fact that school performance is influenced by a wide range of social and cultural factors. Similarly, poor performing schools that receive an influx of resources could be encouraged to invest in outreach efforts, in addition to measures that secure high quality teachers and learning environments within the school. Finally, such an approach would need to be accompanied by a capping on the amount of revenue that private schools could source from private sources (ie, fees), to stop inequalities growing at the 'top end' of the social gradient. Indeed, adaptation was arguably at the heart of the Gonski Review of the education system in the Australian context, which suggested that school resourcing needed to be reviewed on a regular basis to enable schools and teachers to adapt to local needs and changes in the environment. 46 The adaptive approach to tackling educationally driven inequities described above is not dissimilar from educational reforms proposed in the United States in the 1970s. At the time, over 50% of US education funding was localised -drawn from property taxes in local school districts. This approach perpetuates inequalities, driven by variations in property taxes and values between poor and wealthy neighbourhoods. Here, schools in low socio-economic districts with low property values are able to raise less funds relative to school districts in wealthier areas, thereby creating and driving inequalities in education standards. A ground-breaking report on educational inequalities in the United States, known as the Fleischmann Report, 47 argued that more equality could be achieved through a centralised funding scheme; the "Fleischmann Commission proposed that New York become the first state in the nation to take over all the financial powers of its many local school boards. " 47,48 Once state governments acquired the funds, they would redistribute the money so that the lower 65% of the state's school districts would rise to the spending levels of those that were in the upper 35%. Initially, rich districts could keep spending at current rates while the poor districts catch up. After that, a cap would be placed whereby wealthy areas would be forbidden to raise more money -preventing inequity from reentering the system. Moreover, districts with substantial numbers of children performing poorly in key areas, were to receive a 50% bonus for each such child. 47 While this example deals somewhat narrowly with the issue of disparities between public and private education, it exhibits the following characteristics: (1) requires little alteration once put in place, (2) monitors school performance and (3) triggers adjustments to school funding in accordance to this performance, and (4) has safeguards against unexpected outcomes through triggering review processes (thus dealing with future uncertainty by ensuring that issues are considered as they arise). --- Conclusion Reducing inequalities in the distribution of the SDH is highly complex. While linear relationships are easy to conceptualise, focusing on linearity takes us further away from understanding how to create change in real world settings. Moving the agenda forward requires more sophisticated policy approaches that can deal with the complex, nonlinear relationships that drive inequality. In this paper, we have provided examples of policies that have builtin adaptation or learning. This, we contend, is a potentially useful feature for the design of effective policies for redressing inequalities in the SDH; social inequality is a dynamic problem, requiring flexible and adaptive policy responses. Care must be taken, however, to ensure that adaptive policies are themselves changed in the face of unanticipated future scenarios. Of course, adaptive policies (like static ones) are not immune to the political process. Fleischmann's recommendations, for example, were not implemented in full due to political resistance. However, once implemented such policies (theoretically) should withstand political pressure and lobbying better than policies which require continuous cycles of legislation -providing they are implemented in full at the outset. This is because once they are in place, there are fewer opportunities for political pressure and influence as they are not continuously open for review as static policies often are because of their need for updating through legislative change. Hence, despite the challenges of realpolitik, policy experts concerned with inequality should find adaptive approaches highly valuable. --- Ethical issues Not applicable. --- Competing interests Authors declare that they have no competing interests. --- Authors' contributions GC drafted the manuscript, BC and NC assisted with the development of examples. EM designed the systems diagrams. All authors reviewed and refined the paper. --- Authors' affiliations 1 Regulatory Institutions Network, Australian National University, Canberra, ACT, Australia. 2 Centre for Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia. 3 Maths and Science Institute, Australian National University, Canberra, ACT, Australia.

Inequalities in the social determinants of health (SDH), which drive avoidable health disparities between different individuals or groups, is a major concern for a number of international organisations, including the World Health Organization (WHO). Despite this, the pathways to changing inequalities in the SDH remain elusive. The methodologies and concepts within system science are now viewed as important domains of knowledge, ideas and skills for tackling issues of inequality, which are increasingly understood as emergent properties of complex systems. In this paper, we introduce and expand the concept of adaptive policies to reduce inequalities in the distribution of the SDH. The concept of adaptive policy for health equity was developed through reviewing the literature on learning and adaptive policies. Using a series of illustrative examples from education and poverty alleviation, which have their basis in real world policies, we demonstrate how an adaptive policy approach is more suited to the management of the emergent properties of inequalities in the SDH than traditional policy approaches. This is because they are better placed to handle future uncertainties. Our intention is that these examples are illustrative, rather than prescriptive, and serve to create a conversation regarding appropriate adaptive policies for progressing policy action on the SDH.

INTRODUCTION During a WeChat phone call during the spring festival of 2021, Brother Gu, in his early thirties for the first time revealed his economic troubles to his younger brother Little Gu. Before the Covid-19 pandemic broke out, Brother Gu and his wife, Sister Wang, supported their two children by running a breakfast stall in the early morning and a noodle restaurant throughout the daytime in a city in Hunan, a mountainous province in southern China. However, the pandemic significantly changed their tiring yet promising situation, as both the breakfast stall and noodle restaurant were prohibited from opening in early 2020. Even though the lockdown was quickly lifted, and the municipal government claimed that the region had returned to normal within less than three months, the impact was severe on Brother Gu's family because their stall and small restaurant never regained their business. The couple struggled for over half a year, spending most of their savings to cover daily expenses, but still found no solutions to climb out of their economic deficit. Brother Gu had no other choice but to seek help from his younger brother. Little Gu, though a precarious contract worker himself, did provide a feasible solution to his elder brother. He persuaded Brother Gu to step into the field of cryptocurrency to make ends meet. Though at first not familiar with the mechanisms of cryptocurrency himself, Little Gu was a fast learner. Within one month, he decided to purchase several computer graphics cards (GPUs) from Xianyu, a second-hand e-commerce app, and built his first equipment to mine Ethereum, at that time the second largest blockchain network after Bitcoin. This trial met with success, which encouraged him to believe that crypto mining could bring a lucrative income at a relatively low cost and thus significantly improve both his brother's and his own living conditions. Some scholars and practitioners argue that by being independent from both the government and traditional financial intermediaries, blockchain as a decentralized and new technology could help to financially incorporate the impoverished, particularly the unbanked, in developing countries, and endow these disadvantaged social groups with greater opportunities (e.g., Larios-Hernández, 2017;Mavilia & Pisani, 2020). If this assumption is true, how specifically can the disadvantaged benefit from blockchain? How does blockchain, as a set of technologies, along with the value of cryptocurrencies, influence the marginal population in return? To tackle these empirical questions, this study follows a group of amateur miners who offer their computational power to the peer-to-peer network, adding new blocks to the chain in order to win crypto coins as a supplementary income during their under/unemployment. Specifically, I argue that these amateur miners can be regarded as members of shehuiren, literally "society people", a specific type of subaltern in post-socialist Chinese society. Based on the intertwinement of various remaining socialist structures and neoliberal economic reform "with Chinese characteristics" since 1978 (Harvey, 2005), the term itself connotes a subordinate, inferior, temporary, and even ambiguously illicit social position. By following these shehuiren miners, this study specifically unpacks (1) how and why they act by adopting, adjusting themselves to, and revamping the dynamically changing blockchain-related technologies; and (2) if their adoption, innovation, or quitting of these technologies can create certain outcomes, at which level these outcomes will appear, and how they will in turn affect the miners themselves. I pay special attention to the multiple types of actions and agencies that occur during this process of reconfiguring a subaltern scene of blockchain. Here, the blockchain scene refers to collections of heterogeneous actors-technologies, discourses, places, institutions, artifacts, forces, and people-that together assemble the particular socio-technical phenomena as a form of ordering around blockchain (Casemajor & Straw, 2017). Therefore, rather than being restricted to human beings' motivations, I concentrate on the traceable impacts and dislocations through which various entities have the potential to "make some differences to a state of affairs" (Latour, 2005, p. 53). In this specific case, these entities include, but are not limited to, the subaltern miners, blockchain as a set of technologies, public narratives, cryptocurrency markets, and the Chinese authorities. In other words, by investigating how some subaltern shehuiren engage in blockchain as amateur miners, this research tries to enrich the understanding of how blockchain infiltrates disadvantaged populations' everyday lives, reshaping their perceptions of time, space, value, and social relationships. At the same time, I also examine the extent to which blockchain technologies are, in turn, transformed amid local scenes that physical structures, community systems, people of diversified backgrounds, and cultural values impact in different ways (Silver & Clark, 2016). These mutual interactions thus reconstruct a subaltern scene of using, poaching, and reshaping blockchain in a specific socio-economic and techno-cultural context beyond the socio-technical scenescape that is frequently dominated by urban elites who enjoy rich cultural capital. The following section starts with a brief introduction to the role of amateur miners on blockchains, including their technical functions, sociological backgrounds, and the basic mechanisms of their digital profiteering. Then I propose that shehuiren can be utilized as an alternative perspective to understand how subalternity is actualized in post-socialist China in particular. After defining the two key terms of this current study, miners and contextualized meanings of the subaltern, and describing my ethnographic method, I analyze in detail three aspects of how shehuiren-as a specific subaltern subjectivity in post-socialist China-are reshaping and being reshaped through crypto mining. First, I examine how the subaltern, who are usually mystified as the late adopters or even conservative refusers of new technologies, actively incorporate themselves into the emerging technology-oriented network. I argue that because of being marginalized in existing unequal socio-economic structures, shehuiren are more likely to accept not just new technologies but any new ideas that can help them overcome economic struggles even just temporarily once they have access to reliable learning resources. Nonetheless, their learning paths and creativity are seldom recognized among wider audiences. Second, by mining cryptocurrencies, these shehuiren miners participate in and experience the global financialization of people's everyday lives, while nonhuman actors such as mining rigs in a local context and the precarious crypto market at a global scale profoundly reshape these miners' living environments, everyday habits, and the dynamics of their emotions in return. Thirdly, the subaltern reconfiguration of the blockchain scene in China is specifically understood in a historical period when both the Chinese central government and its regional branches imposed stricter as well as convoluted restrictions regarding crypto mining and trading in 2021. By examining the differential aspirations of shehuiren miners who live at the margins of post-socialist China, I demonstrate the oversimplification of assuming that the subaltern-as a united social group with clear collective consciousness-could either be empowered by a decentralized blockchain to resist a repressive state or a ferocious neoliberal digital economy. Instead, shehuiren miners are actors in the subaltern blockchain scene who deliberately attached themselves to the larger technology-mediated networks in a post-socialist Chinese society that constantly marginalized them as the inferior other with different structural dynamics. --- AMATEUR CRYPTOCURRENCY MINERS AS NEW DIGITAL PROFITEERS ON BLOCKCHAINS Blockchain can be imagined as an open, distributed ledger where transactions between any two parties are recorded in a verifiable way (Iansiti & Lakhani, 2017). Rather than being stored and managed by some central authorities or trusted thirdparty intermediaries, such as banks, this public ledger is dispersed on a peer-to-peer network across the world (Kher et al., 2021). When each private computer in this network keeps a record of the public ledger and can verify its authenticity, it becomes extremely difficult for any single player to falsify or fabricate the already documented information. Though displayed publicly, each transaction is strictly encrypted through certain protocols and thus enabled without disclosing one's identity. Literally, the term "block" refers to each set of structured transaction information, whereas "miners" are those who constantly add new blocks to a "chain" to verify each new transaction. Though the concept of cipher block chaining sparked several pioneering attempts from the early 1990s, Bitcoin (proposed in 2008 by Satoshi Nakamoto, whose real-world identity is unknown) was the first success that led to a dramatic increase in both blockchain databases and cryptocurrencies (Kher et al., 2021). The number of cryptocurrencies based on different blockchains exceeds 9,000 by November 2022.1 If the technological characteristics function as the skeleton defining the framework of blockchain, then miners, or the people who record each transaction, serve as the flesh of the system providing essential content. However, who can become a miner, why are they willing to take responsibility, and how can a miner benefit from the process? Another distinct feature of many blockchain networks is their hash-based proof-of-work (hereafter PoW) challenge to enable crypto mining. For example, when a block needs to be added to the chain of Bitcoin, multiple miners wish to do the job as they can receive a transaction fee as well as a block reward once it has been accomplished. To identify a reliable miner, Bitcoin, in particular, requires its members to use their computers to solve specific mathematical puzzles as proof of their work. For each transaction, any miner who can correctly solve the mathematical problem at the fastest speed is granted the chance to add a new block to the chain and is thus rewarded. Therefore, to participate as a miner, one should not just accept the PoW mechanism but also demonstrate their computational capability to earn the chance to add a new block. Nonetheless, for each cryptocurrency, how PoW is specifically implemented varies widely. For example, Chia, a blockchain claiming itself to be greener Bitcoin, utilizes miners' hard drive space rather than computational power.2 Moreover, due to the high consumption of energy, Ethereum transitioned from PoW to an alternative mechanism, proof-of-stake (PoS), on 15 September 2022, giving mining power based on the percentage of coins held by a miner. 3 The dynamics and variations of these technological mechanisms have significantly affected how miners can participate in and seek profits from blockchains. Notably, the following steps that manifest how an individual miner could profit, for example, from mining Ethereum, were archival documentation of the time when I conducted the bulk of ethnography in 2021, when PoW still dominated Ethereum blockchain and crypto mining in general (Figure 1). Usually, a miner first purchased as many GPUs as possible to boost his or her computational power when addressing mathematical puzzles. With multiple GPUs, he or she could start building the mining rig, a specially designed computer, to more efficiently accommodate the mining process. Assembling a mining rig individually was usually a painstaking or even exasperating task, even though there were plenty of accessible tutorials online, as everyone would confront different problems, ranging from component mismatch to failures in optimizing system-especially for the socio-economically disadvantaged miners because, in many cases, they could only afford low-cost knockoffs or second-hand components. Moreover, the mining rig needed to be constantly maintained because their computational power as well as electricity consumption would always be affected by contextual factors such as interior temperature, ventilation, operating systems, GPU settings, etc. After addressing the hardware issues, one could choose either to mine solo or within a pool. Due to the increasingly intensive competition among miners, particularly because of the existence of large-scale mining farms, it had become more difficult for individual miners to win a full block reward. A mining pool thus distributed the mathematic puzzle among scattered miners, and according to each one's computational power, individual miners could share the block reward once they succeeded in collectively adding a new block. After receiving the crypto tokens as rewards, miners could utilize different re-investing strategies, for example, converting to fiat currencies such as USD or RMB, depositing cryptos in centralized exchanges such as Binance or FTX, trading non-fungible tokens (NFTs), and participating in the Initial Coin Offerings (ICO) of various projects and receiving airdrops to either consolidate or increase their gains. 4 The process created different types of economic costs for an individual miner, including but not limited to the purchase of computer components, constant maintenance of mining rigs, electricity bills, and the volatile prices of certain cryptocurrencies. Moreover, a Chinese individual miner also had to bear various social costs, particularly caused by the multiple levels of the Chinese government with their inconsistent and campaign-style policies (Zhou, 2022). Since the success of Bitcoin, scholarship on blockchain and cryptocurrencies has significantly increased. Nonetheless, we still have little knowledge about realworld miners, who they are, in what conditions they live, and whether and how they make money by being a node on a blockchain. Though some scholars have investigated the psychological dynamics among crypto traders and their impacts on, for example, Bitcoin prices (e.g., Aloosh & Ouzan, 2020), most economic studies still assume blockchain users, both traders and miners, to be homo economicus who can always fit into a generalized model or theorem despite different social and cultural conditions (e.g., Biais et al., 2019). However, such a universal assumption could offer little help in advancing our understanding of the reconfiguration of localized blockchain scenes as a technology, or as a cultural artifact in general, and its related circumstances always embody distinctive meanings, uses, and re-designs by populations of various backgrounds (Brock, 2020;Burrell, 2012). 4 Because non-fungible tokens (NFTs) contain references to digital files such as images, photos, audio, and videos, they are uniquely identifiable assets recorded in a blockchain. People can thus purchase, sell, and trade NFTs through blockchain networks. Initial Coin Offering (ICO) is a blockchain-based money raising strategy. Any entity (company, collective, or individual) can raise funds by creating new crypto coins, sharing the whitepaper to articulate their vision, and crowdfunding on blockchain. Interested investors can receive crypto token as a stake in the project. Due to the anonymity of the community, it is indeed difficult to localize blockchain users. Nonetheless, using quantitative data from public surveys and search engines, some sociologists tended to generalize blockchain users as techno enthusiasts, speculative investors, liberals, and criminals (Bohr & Bashir, 2014). Specifically, cryptocurrencies that are untraceable for authorized financial institutions are notorious in public discussions for being widely used by criminals to launder money or fund terrorism (Yelowitz & Wilson, 2015). By participating in offline conferences and workshops in Australia, Tana and her colleagues (2019) more specifically portrayed blockchain users as fortune-hunters, knowledge seekers, and visionary entrepreneurs. At the same time, apart from a few leading figures such as Vitalik Buterin, the founder of Ethereum blockchain, or Elon Musk, the centibillionaire who is also a cryptocurrency enthusiast, the ordinary miners who actually update new blocks to the chain rarely appear in the media. The attention to Chinese individual miners and traders is even less as media reports-both in Chinese and English-tend to depict cryptocurrency mining in China as a fullfledged industry where mining farm owners have already taken control of the 5 *HODL, an acronym for "hold on [for] dear life", is a memetic strategy among crypto investors, indicating that they do not believe in short-term trades amid the notoriously volatile crypto market. **APY, short for annual percentage yield, is a way of passive investing, sharing similarities with deposits in traditional financial intermediaries, such as banks, exchanges, and brokerages. ***De-Fi, short for decentralized finance, refers to financial instruments by using smart contracts on blockchain networks instead of financial intermediaries, either the traditional ones or centralized exchanges in crypto market. ****In the right part of the figure, I only enumerate the re-investing strategies frequently used or discussed among my interviewees based on Ethereum blockchain. This is thus not a comprehensive list, while these strategies are not mutually exclusive of each other either. purportedly decentralized blockchain networks by possessing enormous computational power, thus largely devaluing the role of scattered individual miners. The academic and public narratives together indicate that blockchain is actively mined and used by privileged elites either from a socio-economic, ethnic, or techno-cultural perspective. If the disadvantaged are ever to have any chance to benefit from blockchain, they can only wait to be taught, included, and rescued. However, in this study, I argue that some disadvantaged marginal others, specifically the subaltern shehuiren in China, have endeavored to survive in the increasingly precarious post-socialist Chinese society by actively adopting blockchains. Before going into their stories, I will first discuss the meaning of the subalternity of Chinese shehuiren to better understand the reasons as well as the social contexts for them to become amateur crypto miners. The terms "subaltern" and "subalternity" first gained significance as a substitute for "proletariat" after appearing in the writings of Antonio Gramsci, the Italian Marxist. In his view, the power of either the ruling class's repression or the subaltern's resistance is not decisive, but negotiable and reciprocal. An "expansive" hegemony always strategically acknowledges and partially incorporates the subaltern's aspirations into the worldview of a dominant group to effectively maintain its powerful status (Jones, 2007). The Subaltern Studies Group (SSG), a team of post-colonial scholars focusing on the South Asian social context, later carried forward the term through their attempts to re-narrate the region's history from the perspective of below. For example, according to Ranajit Guha (1982), "subaltern" refers to all Indian populations that are not elite, regardless of whether they are determined by class, caste, age, or gender. He also underlined a shared character across various subaltern groups: the impulse to resist domination from the elite (Louai, 2012). However, such a point received severe criticism from Gayatri Spivak, a feminist critic who also used to be an important contributor to SSG. In her well-known long essay, "Can the Subaltern Speak?" (1988), by pointing out that the female subalterns were more likely to be muted, excluded, and misunderstood, she revealed the absurdity of imagining a united, homogeneous subaltern subjective identity and questioned the possibility of subalterns' collective actions. Subaltern groups in China today share commonalities with these features, including that (1) the subaltern is highly heterogeneous, usually without shared interests; (2) subaltern consciousness thus does not necessarily exist, neither do these people necessarily act or politically engage according to an imagined collective class consciousness; (3) diversified subaltern groups could still negotiate with the interlocking matrix of oppression in a hegemonic structure. However, it must be noted that subalternity is always actualized in a local context through various mechanisms. For example, in contemporary China, some ethnic groups such as the Yao, Bai, Dai, and Yi people are assumed to be major members of subalterns for being the others of the dominant Han Chinese, as they often struggle with intersectional marginalization, including ruralness, poverty, disease, drug use, and cultural alienation (Liu, 2010;McCarthy, 2011). From the perspective of Marxist sociologists, such as Ngai Pun (2005), Chinese rural migrant workers, who trade their cheap labor to global capital producing shoes, toys, and electronics for the world, comprise "a specifically Chinese subaltern" (15). Although they work in sweatshops in the cities, most of the over 200 million Chinese rural migrant workers are only temporary urban residents according to the specifically designed household registration system (hukou in Chinese) (Chan & Seldon, 2014). Both the central and regional governments thus not only evade the responsibility to provide them with proper welfare benefits, but, more importantly, undermine the transition from peasants to the working class as an unfinished process (Pun, 2016). The sociopolitical remaking of rural migrant workers as a specific type of Chinese subaltern is further justified by the prevalent public discourses that usually label them as inferior others of low quality (suzhi) compared to their urban counterparts (Anagnost, 2004;Jacka, 2009;Kipnis, 2006;Yan, 2003). Briefly, subaltern groups, such as ethnic minorities and rural migrant workers, are determined by the intertwinement of socio-economic, political, and cultural factors in contemporary China. Nonetheless, due to the rapid changes of global capitalism and the reconfiguration of Chinese society, the meanings and compositions of subalterns have significantly expanded to broader social groups beyond the two most notable groups. The subaltern particularly includes those who do not fit within existing sociological categories, such as the second or third generation of rural migrant workers who used to be called "left-behind children" or "floating children" (Mu, 2018). With Little Gu being a typical example, many of them refuse to work in factories in adulthood like their parents or grandparents once did, but make a living in various temporary, part-time, low-wage jobs that can offer little occupational identity or work-based sense of belonging, or become vagabonds wandering between cheap internet cafés (Standing, 2016;Tian & Lin, 2020). Other subaltern groups who are not widely recognized among the wider public involve dropout teenagers or vocational school students who are viewed as losers by the formal education system and, therefore, as future unskilled workers (Willis, 2019;Woronov, 2015), early retirees with a small or even no pension, selfemployed workers, or small business owners like Brother Gu and Sister Wang (Qiu, 2009). Rather than determining one's subaltern position simply from a single dimension, such as ethnicity, rural/urban division, occupation, or income level, the mechanisms to identify and construct subalternity are particularly heterogeneous, complicated, and even inexplicable after the 2010s because of various structural dynamics, including but not limited to the recurrent global financial crises, the Sino-US trade war, the long-term impacts of the COVID-19 pandemic, and China's zero-COVID policies, as well as the deep embeddedness of various digital technologies, not just in social production, distribution, and consumption but also in people's everyday lives. Therefore, I propose shehuiren, a post-socialist term, as an alternative perspective for understanding subalternity in China today. Literally translated as "society people", the original meaning of the term refers to all the individuals who were beyond the scope of the previously ubiquitous socialist work unit systems in urban areas and the commune systems in the countryside (Xiang, 2018). These work units and rural communes, together with the enduring household registration system that strictly restricts population movements, have never been completely eradicated since the country's neoliberal economic reform in 1978, but only transformed into more subtle forms for generating social differentiation in postsocialist China (Afridi et al., 2015;Bray, 2005). Being identified as deviant in the household registration system (e.g., ethnic minorities and rural migrants), or excluded from either the formal educational system (e.g., floating children, dropout teenagers) or the authorized labor market (e.g., small business owners, laid-off and underemployed workers), the outsiders of these post-socialist institutions are all inevitably shehuiren. Lacking access to institutional resources and sufficient social support, shehuiren often gain knowledge and experience of the world by wandering from one place to another or switching from one job to another in precarity. In their own words, they depend on themselves to chuang shehui or hun shehui, to "loiter around and see life", as "the society people". The amateur miners I followed in this study live under such circumstances. As small business owners, dropout students, and part-time or contract workers, their unstable income means that they cannot fully make ends meet, and/or their day job exhausts them both physically and mentally, so they always have to look for alternative ways to survive. The term shehuiren thus connotes a marginal, subordinate, inferior, informal, and precarious social position. More importantly, shehuiren implies a grey or sometimes illicit position that is neglected, discouraged, or (nominally) prohibited in legitimate public accounts. For example, a widely known shehuiren image is that of Liu Huaqiang, a protagonist in Conquest ( 2003), a popular TV crime series, who not only earns money by leading a gangster in a survival-of-the-fittest scenario but also makes a name for himself by seeking revenge on the ones who once bullied him and his family members. The fictional figure assuages the frustrations of many real-world subalterns who feel powerless and deprived. In response, they learn and develop the practical value of being shehuiren, that one must depend on him or herself by whatever means-whether morally or legally controversial or not-to survive in a transitional post-socialist society that is marked by unequal opportunities, fragmented principles, and conflicting ethics. The term shehuiren implies not just gangster or street violence (Li et al., 2020), but also folk outlaws, petty crimes, and participation in any sectors beyond the Chinese government's administrative scope. To take crypto mining and trading as an example, the Chinese government released formal restrictions on crypto mining and trading respectively in 2013, 2017, and 2021. However, because of the ambiguous regulatory descriptions, technical difficulties, and economic costs in implementing these policies in practice, many individual crypto miners still anonymously contribute to the global crypto market by using various methods, such as virtual private networks (VPNs), which are also illegitimate but widely used among China-based internet users to access the internet beyond the Great Firewall (Roberts, 2018). On the other hand, whereas crypto mining and trading are strictly prohibited in China, some concepts such as blockchain and metaverse, which can hardly be separated from cryptocurrencies, are enthusiastically embraced as the new trends of the future digital economy both by government officials and industrial practitioners. 6 In sum, the grey and unstable positions of blockchain-related technologies in the sophisticated system of Chinese internet regulations also determine the subalternity of disadvantaged crypto miners or traders. Last but not least, as Spivak (1990) argues, if the subaltern can to some extent express themselves despite limited space and resources, they are partially incorporated into the hegemony by at least being heard, though in most cases imprecisely. For example, some members of the subaltern, particularly the rural migrant workers, never give up trying to "talk back" to the structures of power that erase or distort their subjectivities and realities by writing poems (Sun, 2010), creating documentaries (Sun, 2014), dressing with hairstyles and make-up that are inconsistent with mainstream aesthetic values (Sun & Qiu, 2015), mocking themselves as "pubic hair" (diaosi, which figuratively means "losers") (Cao 2017;Sum, 2017;Szablewicz, 2014;Witteborn & Huang, 2015), or expressing their frustrations through user-generated rap videos on specific platforms (Hou, 2021). Notably, when these various cultural practices may generate collective consciousness and mutual interaction among the subalterns themselves, they often trigger denunciations among the upper and middle class for being identified as morally and aesthetically problematic (Hou 2020), thus reinforcing the subaltern as both a position and a process of becoming the inferior and marginal other in China today. Despite having no intention of neglecting the subaltern position of the more widely acknowledged ethnic minorities or rural migrant workers, I underline the difficulty of speaking and naming the other diversified subaltern groups who have not yet entered the public discussion. The amateur miners in this study, as well as many other disadvantaged people, fall into this epistemic gap for being hard to name or categorize using existing sociological terminology. I, therefore, suggest shehuiren-the outsiders who have only themselves to depend on, using whatever means, in order to survive in the post-socialist Chinese dynamics that unequally marginalize them with interlocking socio-economic, political, and cultural forces-as a stopgap way to call for attention to disadvantaged individuals/groups who are still relatively silent and invisible. Acknowledging that the intellectuals' attempts to speak on behalf of the unnoticeable subaltern and name them with a fictional identity within their discipline creates "epistemic violence" and risks aggravating the silence of the disadvantaged (Spivak, 1988, p. 283), I still try to listen to, record, and interpret shehuiren miners' stories in my research. Nonetheless, instead of generalizing my interpretation of how subalternity has been actualized as a revelation of fact, I only demonstrate the existence of a pattern in which blockchain-related technologies, crypto markets, the regulations of the Chinese government, and the disadvantaged individuals' own desires together contribute to the reconfiguration of a subaltern blockchain scene in contemporary China through the case of shehuiren miners. Specifically, I pay attention to how these miners perceive technology, profits, and risks and the impacts they create, no matter how local in scale. Here, I follow Bruno Latour's (2005) definition of agency as "making some difference to a state of affairs" (p. 53). Rather than building on human beings' motivations, subjectivities, and intentionality, Latour's definition directs me to concentrate on the traceable impacts, particularly the dislocations these miners have made during their engagement in blockchain-related activities. If their adoption, innovation, or rejection of the dynamically changing blockchain technologies can create certain outcomes, at which level will these outcomes appear, and how will they in turn affect the miners themselves? Or, in other words, how did the subaltern blockchain scene take shape in China today, with specific forms of marginality and exclusion? The following sections will address these questions. --- METHODS I conducted ethnography tracing people, stories, artifacts, and connections across different sites both online and offline. Being an impoverished PhD student with economic struggles similar to those of other subaltern miners, I have attended several WeChat and Telegram chatting groups and several private offline gatherings about cryptocurrency since March 2021. Initially, I anticipated finding and entering a concrete field site, for example, the kind of mining farm usually depicted in news reports, where mining rigs were neatly placed on rows of shelves, or a single platform where amateur miners constantly interact with each other. However, there is no such isolated "field" and thus no "reality" about Chinese subaltern miners out there somewhere, waiting for me to step into it (Rabinow, 1986). Rather than one physical or virtual place existing in the first place, the field of this research is a set of emerging associations, or a network of different actors including but not limited to subaltern miners, their family members or friends, various second-hand computer components, mining rigs, cryptocurrency-related information (and disinformation), mining pools, trading platforms, and, of course, the blockchain itself. My ethnography here is consistent with the principles of actor-network theory, in that I followed different actors, investigated the traces they left when building and reshaping connections, and recorded my own interpretation as a participant and researcher (Latour, 2005). Specifically, I focused on five subaltern miners who engaged in mining two crypto coins, Ethereum and Chia, with multiple tools. 7 Launched in 2013, Ethereum is the second largest cryptocurrency after Bitcoin by market capitalization. With its smart contract functionality, it is characterized by affording a variety of decentralized finance applications and services. Chia is a more recent cryptocurrency, founded in 2017, which features the use of time and hard drive storage as its PoW mechanism instead of GPU computing. With this specific design, Chia is usually described as a greener alternative to Bitcoin or Ethereum because it consumes much less electricity power during mining. The market prices of both these two cryptocurrencies change drastically even within a single day. For this article, I used their prices on 1 September 2021 as a reference (for Ethereum: 1 ETH = 3,529 USD; and for Chia: 1 XCH = 218 USD). As cryptocurrency trading is now strictly supervised and regulated by Chinese authorities, all the interlocutors' identifiable information was intentionally anonymized to fully protect their identity. With their consent, I obtained data from the following sources. First, by frequently visiting their living areas and talking to them through video chats, I observed how their (our) everyday experiences have been interrupted and transformed by multiple activities related to crypto mining. I followed how they set up their own mining rigs, chose a specific mining pool, cashed out RMB, and generated alternative income from their Ethereum or Chia investment. I paid special attention to how they interacted and discussed crypto mining with friends, family members, and acquaintances. Second, these miners were very generous in sharing how and from where they accessed crypto-related information on multiple social media platforms. Creating my own accounts, I subscribed to exactly the same key opinion leaders, vloggers, group discussions, and channels on WeChat, Discord, Telegram, Bilibili, Weibo, and Douban to keep in step with them. Third, I collected information from news reports, policy documents, the cryptocurrencies' own whitepaper, technological and business analyses, etc. In doing so, I tried to position the subaltern miners' actions and opinions in a broader social context, taking into consideration how they are (un)perceived by others. The initial bulk of my ethnography was conducted from March 2021 to December 2021, while I also conducted occasional follow-up interviews and information collection afterwards. --- SUBALTERN MINERS' INVISIBLE LEARNING AND INNOVATION Rather than being passive and ignorant, the subaltern shehuiren are actually more than happy to accept not just new technologies but any new ideas that can make profits, because they have to survive under the post-socialist social structures that often place them in an inferior position. As long as they have reliable information and access to learning materials, and the cost is affordable, they never refuse any chances to solve their economic struggle, even just temporarily. For example, when Brother Gu was obsessed with learning to be a crypto miner, his wife, Sister Wang, took full responsibility for boosting the sales of their noodle restaurant during the post-pandemic downturn. By creating funny and inspirational stories about herself and her sons and sharing them on Douyin's Nearby channel (a location-based service of this mobile app), she tried to enlarge her Douyin fanbase and transform them into potential consumers. Sister Wang felt delighted with the outcome because she did not invest any money but created some new possibilities to profit "all by herself". While Douyin is designed to encourage all its users to post easily with mobile phones, there are greater technical obstacles to learning to be a crypto miner. Luckily, Brother Gu and Liang all found their own ways of learning. Brother Gu crossed the threshold led by his younger brother, while Liang's interest started by following several Bilibili tech channels, in particular some famous computer hardware bloggers on the platform (e

While public narratives indicate that blockchain is widely used in developed societies among privileged elites, either from socio-economic, ethnic, or techno-cultural perspectives, this study examines how some disadvantaged marginal others, specifically the subaltern shehuiren in China, survive in the increasingly precarious post-socialist Chinese society by engaging with blockchain and cryptocurrencies. Literally translated as "society people", shehuiren are the socio-economically and techno-culturally disadvantaged others who face marginality due to various postsocialist institutional inequalities. This study aims at unpacking how, on the one hand, the blockchain scene has been reconfigured by the disadvantaged in the local context, and on the other hand, how subalternity is actualized in post-socialist China, where blockchain-related technologies deeply intertwine with various forms of social inequalities. By tracing a group of shehuiren crypto miners through ethnography, I demonstrate that this subaltern scene of blockchain not just reshapes the shehuiren individuals' notion of time, space, and value and the social relationship among themselves, but also profoundly impacts the power dynamics between the subalterns, the more privileged others, and the state authorities. Specifically, I underline that, despite being treated as losers, outsiders, and potential wrongdoers due to the existing social structures, shehuiren miners are neither victims nor rebels opposing either the authoritarian state or the global neoliberal order. Instead, they are actors who harvest limited profits through their unacknowledged creativity, adeptly making use of various resources within their reach and weaving their differential aspirations by attaching themselves to the larger technology-mediated networks in an unequal post-socialist society where a united subaltern hardly exists.

them in an inferior position. As long as they have reliable information and access to learning materials, and the cost is affordable, they never refuse any chances to solve their economic struggle, even just temporarily. For example, when Brother Gu was obsessed with learning to be a crypto miner, his wife, Sister Wang, took full responsibility for boosting the sales of their noodle restaurant during the post-pandemic downturn. By creating funny and inspirational stories about herself and her sons and sharing them on Douyin's Nearby channel (a location-based service of this mobile app), she tried to enlarge her Douyin fanbase and transform them into potential consumers. Sister Wang felt delighted with the outcome because she did not invest any money but created some new possibilities to profit "all by herself". While Douyin is designed to encourage all its users to post easily with mobile phones, there are greater technical obstacles to learning to be a crypto miner. Luckily, Brother Gu and Liang all found their own ways of learning. Brother Gu crossed the threshold led by his younger brother, while Liang's interest started by following several Bilibili tech channels, in particular some famous computer hardware bloggers on the platform (e.g., Ancient Computer Builder). 8 Liang also emphasized that viewing online discussions about how the price of GPU has been affected by the crypto market only raised his interest in crypto mining. But if he had not met "Engineer" during an offline hotpot party, he would never have thought about mining Ethereum himself. "Engineer" was the nickname for Feng, who lived by repairing and recycling used computer components on Xianyu, the largest second-hand e-commerce platform in China backed by Alibaba. His prior knowledge of fixing and testing hardware made it easier for him to construct mining rigs. New miners like Liang consulted "Engineer" either remotely or during their irregular gatherings, while "Engineer" either helped them fix, for example, the GPU temperature problem himself or told them where they could find tutorial videos. "Engineer" always did these things for free, but by doing so he gained respect and trust from the others, so that when they needed computer components, they purchased them directly from Feng's Xianyu shop. As in Xiang's (2005, p. 14) finding among the Zhejiang rural emigrants working in the clothing business in Beijing, guanxi (which can be roughly translated as "networks") played a significant role in building connections within the subaltern crypto miner community. For an individual, the information coming from a networked and reliable source (family members, relatives, or friends of similar age) is worth much more attention than news reports or online discussions, especially when deciding whether to start a business or not. When Chia was about to launch in late April 2021, Little Gu and Liang gathered information from the internet, discussed their plans, and decided to seize the opportunity, buying as many hard drives as they could to mine the new coin. Liang said: I skimmed through their [Chia's] whitepaper, but I am not sure whether I can digest all this [information] or not. You know the field is full of scams, and there are so many projects. But if Little Gu thinks it's a good choice, I will follow him. He is an ace. I think this is really important, maybe the most important. While thinking about investment, you need to cooperate with a trustworthy person. However, unlike Zhejiang emigrants' use of the term guanxi, particularly regarding the ways in which people can actively mobilize their connections with privileged government officials or the wealth to look for money-making strategies (Xiang, 2005, p. 16), miners are inclined to reinforce or establish new guanxi with people who have expertise and knowledge. In other words, authority in the network is developed based on whether one has prior knowledge and, more importantly, whether one is not just a good learner himself or herself but also a potentially good teacher inspiring others to learn or even to innovate. Subaltern miners are not just quick learners but also creative innovators who are capable of making full use of any resources to which they have access. Being a rural migrant who never finished high school and has no previous knowledge about either finance or internet technologies, Brother Gu quickly adapted himself, learning how to identify the quality of a used GPU, replace a GPU's thermal paste, and connect four or five GPUs to one mainboard in order to assemble a DIY mining rig. At a time when high hashrate GPUs were in short supply, he even created a unique structure where a laptop mainboard was positioned on top of a PC cooler to decrease the GPU temperature from nearly 90 to 54 degrees Celsius, thus greatly enhancing the machine's mining efficiency (Figure 2).9 However, the learning and innovation of the subaltern are hardly visible in public discussion. In July 2021, when mining farms were expelled from Xinjiang and Sichuan Province for their excessive use of local electricity, Caixin, one of the few Chinese business media outlets still in favor of professional journalism, published a photo showing how a local female worker was recruited to clear out the place. 10 By portraying the dismantling of mining rigs by the poor as similar to harvesting cotton, flowers, or agricultural products, the picture indicated that the subaltern have no ability to understand the significance of the political or technological change but could only work as highly disposable generic laborers. A similar narrative can be found in Wang's (2020) exploration of how technology has transformed the Chinese countryside. When rural farmers devoted themselves to feeding chickens on a blockchain-based farm (where all chicken information was stored on blockchain to secure food safety), they showed no interest in the technology itself. Figure 2. The strange-looking mining rig created by Brother Gu joins a laptop mainboard with a PC cooler to efficiently decrease the GPU temperature. These portraits of the subaltern are typical in the world of representation across the globe, where they are seldom regarded as knowledgeable or innovative actors in the network and platform society (Castells 2011;de Kloet et al., 2019;van Dijck et al., 2018). On the one hand, Chinese subaltern-rural migrants, in particular-have been severely exploited by global capital as cheap labor, lacking a safe working environment or basic welfare support. On the other hand, the products they produce, re-design, and modify are usually perceived as either low quality or copycats. Moreover, the Chinese population in general is also confronted with the post-colonial debate about whether the Chinese are capable of innovation. Some scholars argue that Chinese people simply cannot innovate because the problematic Confucian philosophy does not allow students to act divergently or question any authority (Lockette, 2012), or because the Chinese Communist Party's institutional prohibitions constrain local companies from pursuing any type of breakthrough (Abrami et al., 2014). Neglecting the fact that the developed world is also complicit in taking advantage of Chinese subalterns' labor and creativity, these arguments transform Western society's superior position in defining innovation into essentialist discrimination against the subalternity of emerging markets. Numerous recent studies concentrating on shanzhai culture, especially shanzhai mobile phones, have expanded the concept of innovation to include incremental adaptions to address users' needs in a localized context (Cai, 2020) and the politics of hybridity (Chubb, 2015). In particular, Han (2017) reminded us that shanzhai products, though initially copycats or knockoffs, actually complicate the meaning of originality and fakeness. By exploring the transition of Shenzhen, the special economic zone in South China, from a site of copycat production into a legitimate and threatening rival of Silicon Valley, Lindtner (2020) argued that refashioned imperial power not only persists but also reverberates through technological innovations that claim to promise participation and agency. In short, rather than saying that Chinese subaltern cannot create, their innovations are hardly acknowledged either domestically or globally. The lack of textual or visual representation confined Brother Gu's creative low-budget mining rig to his own living room. Even if subaltern innovations occasionally enter the public discussion, they are either underrated or inappropriately exploited, in most cases. From the perspective of political representation, subaltern miners can hardly speak for themselves on the "decentralized" blockchain either. Thus, miners, whether subaltern or not, have little power to impact the technological features of blockchain. Similar to the model of social media platforms, core developing teams (in parallel to commercial platforms, such as Facebook or Google) decide the key features and structures for each transaction, while miners (similar to social media users in this analogy) often have to either accept them all or simply quit. In August 2021, Ethereum activated its London hard fork with a primary change in its mechanism for calculating transaction fees. To smooth the transaction process, part of the ethers generated during transactions would be burnt rather than awarded to miners. 11 That said, miners in general received fewer ethers as a reward for facilitating each transaction, but the developing team expected that the price of ethers would thus become higher and less volatile. Although the upgrade did coincide with a rise in the price of ethers, it is still difficult to estimate whether miners will benefit from such a change in the long term. For whatever the changes in the structure of blockchain, miners have few alternative options besides either accepting or quitting. To alleviate their perennial precarity, amateur miners could only practice the values of shehuiren: to rely on constantly equipping themselves with new knowledge and endless learning. Otherwise, they will no longer have the chance to profit from blockchains. Finally, I have to make it clear that all five miners observed during my ethnographical research were male. This is a direct result of my snowball sampling strategy, while it might also demonstrate a more general tendency for Chinese women to be less likely to participate in cryptocurrency mining, trading, or development. As a female, when I watch tutorial videos, follow social media updates, and participate in offline gatherings, I often encounter sexist comments against women. For example, in Laptop Repair Man's videos, the video creator always strangely stresses the phrase "plug in the charger and open the machine" to amuse his (mostly male) audience by suggesting sexual intercourse, because the phrase is homophonic with "insert" and "penis".12 On Xianyu, a second-hand GPU described as "used by girls" can be sold at a higher price than the others, because it is commonly assumed that women usually lack knowledge of computers, particularly hardware, and they will never use their personal computers to mine cryptocurrencies. The sexist atmosphere clearly makes the field unfriendly for women. If Little Gu and "Engineer" Feng can build their authority in the subaltern network by demonstrating their learning ability and knowledge, why cannot Sister Wang take a similar role, since all three are excellent learners of new digital technologies? Learning and creating regarding blockchains, the seemingly neutral factors, are, in practice, gender-divided. If, to some extent, a group of subaltern men can make profits by mining cryptocurrencies, "subaltern as female is even more deeply in shadow" (Spivak, 1988, p. 287). The subaltern innovation itself is also intertwined with existing social inequalities in various forms (Irani, 2019). In sum, blockchain-related technologies first redefine the network structure among shehuiren when assembling the blockchain scene in a Chinese local context. Subaltern individuals earn respect and trust from others depending on their ability to gather information, learn new technologies, and innovate, rather than whether or not they can mobilize connections with government officials, the rich, or the other privileged. Nonetheless, it must be noted that the seemingly neutral ability to learn and create is unequally distributed and gender-biased in practice. Compared to their male counterparts, subaltern women are less likely to be welcomed in the scene or to make a profit from blockchains, which again reinforces the nonexistence of shared interests or equal chances that can benefit the subaltern on the whole. Furthermore, in most cases, the learning, creating, and innovating of shehuiren miners are only acknowledged among themselves with a very limited scope. The proclaimed "decentralized" blockchain does not change the prevalent disregard for and inappropriate exploitation of the subaltern's technological efforts, for the discourses around it hardly challenge the public imagination towards the subaltern, nor does blockchain, as a set of technologies, offer alternative power for the subaltern to express themselves. In other words, the subaltern blockchain scene, at this stage, is still far from debunking the silence and invisibility of the subaltern in front of the socio-economically, ethnically, or techno-culturally privileged public audiences. --- FINANCIALIZING THE SUBALTERN MINERS' EVERYDAY LIFE The economic struggle for shehuiren as the subaltern is simultaneously influenced by two trends in post-socialist China. First, the income they achieve from precarious work is not enough to make ends meet, even though none of the miners in my study ever consume conspicuously. The collapse of traditional guaranteed welfare, such as pensions, education, and health care, adds further costs for individuals to secure a living (Hacker, 2019). At the same time, if recruited for a temporary job, Chinese subaltern are subjected to inhumane working conditions. In the tech industry, for example, the famous online protest "996, ICU" in 2019 opposed the notorious work schedule prevalent in tech enterprises. The ironic name of the movement indicates that an employee usually works from 9 am to 9 pm, six days a week, and he or she will consequently be burnt out, risking their health and perhaps needing to be treated in an Intensive Care Unit (ICU) someday. 13 Whereas tech professionals already enjoy a relatively prestigious position compared to the subaltern population, labor conditions for shehuiren are even worse. According to Pun's (2005) observation, long-term intensive labor and stress left almost every young female rural migrant worker with chronic pain such as headaches, backaches, and menstrual pain. Long working hours also make them vulnerable to occupational injuries because they can hardly concentrate when operating machines. The situation has not improved since digital platforms offer new working opportunities. For example, subaltern shehuiren frequently choose Didi drivers (Chen & Qiu, 2019) and food delivery couriers (Sun, 2019) as their job options. Lacking any state or institutional support, they not only suffer from long working hours and high risks of being injured; platform datafication and algorithms exercise additional power in disciplining their labor. Individuals are therefore expected to handle risks and make arrangements by themselves against unemployment, illness, and even macro financial crises due to this wide expansion of neoliberalism and a deteriorating work environment (Pellandini-Simányi, 2020). Utilizing various financial products became a necessary strategy to address an individual's economic struggles, particularly for the subaltern shehuiren. For example, during the state-led market transition and urbanization starting in the 1990s, both laid-off workers and peasants whose land had been expropriated could receive a certain amount of money as compensation, mostly ranging from 10,000 to 100,000 RMB. Despite debate as to whether the amount was reasonable or not, the money did serve as an essential starting point for a new calculative, responsible, and self-governing life. According to Maso (2015), the Chinese stock market could hardly prosper without the active participation of the scattered amateur investors, made up of the unemployed and early retired, who enthusiastically invested in response to their loss of secure labor, even though the chances of success were always dim. By simplifying the procedure and facilitating it on mobile phone applications, digital platforms such as Alipay became one of the world's top money market funds (MMF), managing 712 million Chinese users' 780.8 billion yuan of assets by the end of June 2021. 14 The easy access and everyday use of these digital tools not only enable ordinary people to actively engage with various financial products but also present it as a rational and promising activity to balance multiple risks. Financialization thus infiltrated the subalterns' everyday lives as a hegemonic mechanism because when managing their assets and risks individually, the subaltern reinforces the value of shehuiren by embracing a calculative and self-governing subjectivity and reclaiming autonomy, empowerment, and security (Langley, 2020). Nonetheless, with such governance through freedom, people not only buy into neoliberal logic, considering successful investment or management of money as essential for a meaningful individual life, but also neglect other alternatives and risks, exposing themselves to various latent socio-economic costs (Pellandini-Simányi, 2020). For the shehuiren miners, crypto mining is not an alternative but is consistent with the existing financialization of people's everyday lives utilizing blockchain. To proliferate, mining functions similarly to the purchasing of MMF or stock. However, it particularly attracts the subaltern by generating lucrative returns with relatively low economic costs. Four of the miners in this study put in 10,000 to 60,000 RMB as the initial investment to set up their own mining machines (except Little Gu, who is very good at saving money in his daily life and invested 120,000 RMB). By putting in 30,000 RMB, Liang provided 300Mh/s computing power to the mining pool he participated in, which meant he could receive about 0.25 ether in return per month. After deducting the maintenance costs, basically the electricity bills and transfer fees, he could still receive 4,000 RMB every month as a supplementary income. Even if unexpected macro changes happen -if, for example the Ethereum price collapses below the electricity bill, or the Chinese authorities ban individual crypto mining -Liang is seldom anxious because he can "just shut down the machines and it will cost nothing". And he believed that by selling all the second-hand GPUs, he could also partially recover the initial cost. "Regarding the money I have already earned, the worst situation is that I can no longer profit through it, but I won't lose my principal." Crypto mining's second attraction, especially compared to other potential working opportunities, is freedom and acceptable labor input. Brother Gu regards it as a much better choice compared to working as a courier, a common option for the subaltern to survive during and after the pandemic, or whenever they lost their original precarious job. After I set up a mining machine, I don't need to look after it all day. Maybe I check whether it is too hot or whether the software works well, but it is not a lot of work. Imagine if I delivered food for Meituan, I would be running outdoors all day, like ten hours or twelve hours, leaving Sister Wang alone to take care of the restaurant and the boys. But now I can earn about 5,000 or 6,000 yuan per month through mining, and I can continue to make noodles at our restaurant. The ways in which the lucrative potential and flexible conditions attract shehuiren to step into crypto mining is similar to the condition of other social groups who experience exclusion; for example, some Japanese women intentionally choose to participate in the sex industry to escape the broader societal constraints (Koch, 2020). Nonetheless, what is significant about the case of subaltern miners is that these financial practices thus deeply infiltrate their everyday lives, reshaping their ways of living. Whereas existing studies mainly understand the financialization of everyday lives from the subjective perspective, which means it functions through a calculative and self-governing subject (Pellandini-Simányi, 2020), I note that regardless of whether they have a conscious subjectivity or not, subaltern miners are profoundly impacted by the financial practices of mining cryptocurrencies at the material level. In other words, the system of mining, with both its hardware and software as non-human actors, does not just facilitate but also profoundly affects the subaltern miners' actions and emotions. Unlike mining farms, usually set up either in warehouses or refurbished abandoned factories, individual shehuiren miners could only place their DIY mining rigs next to their beds, around their desks, or in any available place in their personal everyday living environment (Figures 3 and4). Therefore, the constant heat and noise produced while the GPU computes cannot be ignored. One of the minor motivations Little Gu used to persuade himself to start building his first mining rig was that his room was freezing cold during the spring festival, and he thought that even if mining would not turn lucrative, at least he could use it as a heater. But the situation became unbearable in the summer. Heat dissipated from the running GPUs made every miner's home like an oven, so that they either chose to buy an air conditioner or had to change their room layout frequently, switching the positions of their mining rigs to find the place with the best ventilation. The problem for Brother Gu was even tougher, because he had to maintain multiple mining rigs while his two preschool kids played in the same cramped room. He therefore transferred some of his mining rigs to his parents' place in the countryside, but the 50-kilometer distance added time and energy costs when he needed to maintain these facilities. Compared to the heat in summer, the noise seemed much more tolerable, because the longer they mined, the more they got used to the whirring GPU fans. More importantly, without any additional noise, the whirring indicated that all the mining rigs were operating smoothly, and thus crypto coins were constantly awarded when new blocks were added to the chain. Rather than enduring the noise, they enjoyed it as a symbol of hope, because, whenever needed, the whirring can be exchanged for fiat currency to address their economic struggles. As they consumed so much electricity, mining rigs also greatly changed miners' everyday habits for the use of electric home appliances. For example, Zhao 16 Little Gu shared the picture with the author through WeChat on 15 August 2021. lived in a rented apartment with 30 amps as the maximum circuit limit. The rating is sufficient for ordinary use, but with mining rigs running in the home, Zhao had to calculate carefully when to use high-power electrical equipment to avoid circuit breaks. In the morning, he only used his microwave oven to heat up food after boiling water with an electric kettle. The circuit break itself did not matter, but every time his mining rigs restarted, especially after a forced shutdown, they encountered malfunctions in connecting different components, entering the system, or starting the mining software. After experiencing several breaks, which meant he had to reassemble the mining rigs from time to time, he became so stressed that he forced himself to give up drinking boiled water, even though tap water in China is generally not potable. To avoid the stressful situation, others tried to upgrade their household circuit breaker to 40 amps or even 60 amps. However, such action brought greater risks, including damage to the equipment, body injuries or even fire. Again, if these accidents happen, it is the subalterns' own responsibility to bear all consequences. More subtly, crypto mining reframed the miners' affective perceptions of time and value and the rhythms of their emotions. As a long-time video game player, the initial reason Little Gu tried to learn about computer hardware was to gain better game-playing experiences. Nonetheless, after starting to mine crypto, he gradually felt guilt rather than pleasure while playing. As all his equipment was assigned to mining crypto all day, stopping one of the machines to play games became a luxury. My game computer shares the same motherboard with one mining rig. So playing games just makes mining inefficient... I used to play every day after work, but now I only allow myself to play once a week, just three hours on Saturday afternoons. Even for these three hours, I give up earning tens of RMB. Doesn't it mean I'm actually paying a ticket to play video games? Each time I come up with this idea, I tell myself, go find something else for fun and leave the mining machines alone! They are making money for you! As mining rigs continuously work 24/7, the trading of cryptocurrency also never ends. Unlike the stock market, where prices only change within trading hours, miners' emotions can be interrupted at any time by volatile prices, technological changes (such as Ethereum's London hard fork), new ICO projects, and unstable policies. Every day, they were inundated in a sea of information (and disinformation), which took their time and energy to digest, categorize, and evaluate to anticipate future dynamics and manage their assets at the same time as managing their emotions. The time and energy they spent on cryptocurrency was much more than simply maintaining the mining rigs as equipment. They could not ignore all the updates, or miners would be continuously affected by the overwhelmingly numerous changes in the crypto market. Therefore, none of the subaltern miners could resist the temptation to check and even collect more information about cryptocurrency, because of the existence of money-making chances, no matter how small the probability of succeeding in the novel digital profiteerings. Either for those who hope to earn a sustainable income to better support their families or for those who expect sudden wealth, blockchain tempts them with promising opportunities and thus interpellates them as neoliberal, particularly financialized, subjects. In short, although it facilitated a novel set of blockchain technologies, crypto mining and trading is similar to, for example, investing in the stock market and buying MMF, or the prevalent trend of financialization which already infiltrates the everyday life of ordinary people and reshapes our neoliberal subjectivities. Compared to other strategies, crypto mining is feasible and attractive to the subaltern shehuiren due to its relatively low economic cost, acceptable labor input and promising returns. On the other hand, the materiality of blockchain-based financialization particularly generates different levels of consequences in the local scenescape. First, individual miners' perceptions of domestic space, time, labor, and value are deeply reshaped due to the existence of mining rigs and the dynamics of the global crypto market in their everyday lives. Second, blockchain-related technologies largely expand the boundary of the scene as an urban-centric concept. In other words, the blockchain scene constructed by and around Chinese shehuiren miners is an amalgam of a virtual landscape across global time zones based on blockchain networks and scattered domestic environments located not just in lowcost living areas in cities but also urban fringes and rural areas. Therefore, the subaltern blockchain scene restructures the assembling of a scene by incorporating previously inconsequential or peripheral actors/elements. --- 7 PURSUING DIFFERENTIAL "CHINESE DREAM(S)" ON BLOCKCHAIN AMID PRECARITIES The subaltern is not a united group with a clear collective consciousness. Even among the five miners of this study who all wish to make a living, their concrete aims and strategies for engaging in cryptocurrency significantly diverge from each other. I argue that they developed as different types of financialized subjects while investing in cryptocurrencies. Such a process has been deeply embedded in a highly precarious circumstance simultaneously determined by the volatile global crypto market and the Chinese governments' ambiguous and campaign-style policies regarding crypto mining/trading and blockchain. In other words, whether the shehuiren miners can succeed in making ends meet first depends on how well they can react to the changes in the mechanism of blockchain technologies, prevent themselves from being caught by all kinds of crypto-related frauds or scams, convert their mined Ethereum or Chia to other fiat or crypto currencies at proper prices, and use various strategies to safeguard their financial gains. For example, the transition of Ethereum from PoW to PoS made all the shehuiren miners in this study no longer useful to this blockchain network, as mining power was determined by the coins one could stake rather than the computational power one could contribute. They could do nothing but shut down their Ethereum mining rigs and sell off their GPUs and other components. Moreover, the crash of the Luna crypto network in the summer of 2022 significantly affected the price of TerraUSD, a selfproclaimed algorithmic stable coin, and nullified the crypto assets of those who were holding TerraUSD as the crypto equivalents of USD. Towards the end of the same year, FTX, the second largest centralized exchange in the crypto market, collapsed due to its fraudulent crypto scheme and liquidity crisis. Users of the platform either could not withdraw their deposits or these were directly stolen after the bankruptcy of FTX. These unpredictable dynamics of the crypto market turned out to be a heavy blow for Little Gu and Liang, causing them to lose not just tens of thousands of RMB, but also their confidence about whether they could still pursue profits by mining and trading on blockchains. Second, the precarity of the global crypto market is further exaggerated for Chinese miners in particular. However, rather than simply assuming that the Chinese authorities strictly forbade all blockchain-related activities from 2021 onwards, as the media often describe, I list some key governmental documents in Table 1, indicating the nuances and complexity of Chinese blockchain-related regulations. These public accounts first indicate that different governmental departments, particularly those of the finance sector, have already paid attention to managing and disciplining specific cryptocurrency (Bitcoin) or crypto activity (token financing) since 2013. The scope of regulations targeting crypto mining only significantly escalated in 2021, when not only the finance sector but also the State Council in general, the Ministry of Public Securities, the State Administration of Taxation, the National Energy Administration, and provincial governments also became crucial governing institutions. Crypto mining in particular has thus been officially identified as an illegal activity due to its potential use in criminal activities, high consumption of electricity, and negative impact on financial stability. Paradoxically, blockchain in general is actively supported by both national and regional governments, being widely regarded as the next pillar of the Chinese digital economy. The conflicting attitudes implied in these regulations thus gave much grey space to the unauthorized use of blockchains. Moreover, apart from the Inner Mongolian policy, which publicly claimed to penalize individual miners, these policies primarily concentrated on institutional entities-mining farms, trading platforms, exchanges, etc.-rather than individual miners. In practice, individual miners could easily anonymize themselves by using VPNs. Even though internet connections through VPNs might not always be stable, at the time this article was written, these shehuiren miners could still temporarily escape the nationwide internet surveillance with some technical tactics. Nonetheless, I do not mean that Chinese authorities had little or less impact on shehuiren miners compared to the volatile global crypto market. I will demonstrate in this section that the subaltern individuals' various yearnings and frustrations coexist in tension with the hegemonic Chinese mainstream political narrative of the "Chinese dream" when post-socialist institutional structures always treat them unfairly as losers, outsiders, or potential wrongdoers. Ever since the start of his presidency in 2012, Xi Jinping has proposed the term as the guiding vision of the new leadership. Specifically, the "Chinese dream" connotates three layers: the economic prosperity and strength of the country, the rejuvenation of the nation, and the happiness of the people. 18 Existing studies have focused on the concept's political implications at the macro level, such as its role in enhancing the Party's domestic legitimacy and the changes in the Chinese position in the international context (Mahoney, 2014;Wang, 2014). Others interpret the Core Socialist Values, proclaimed by the authorities, as detailed features for realizing the "Chinese dream" (Feng, 2015). Responding to the Chinese dream, the Core Socialist Values depict an idealized citizen as an individual with patriotism, dedication, integrity, and friendship who lives in a society with a bright vision. However, living in the shadow of these positive ideological discourses, shehuiren miners were profoundly impacted by both the direct restrictions on crypto mining and the precarious nature of the crypto market in reshaping their subaltern subjectivities. I roughly divide the subaltern miners' dreams into four types: financialized, entrepreneurial, downshifting, and speculative. Brother Gu's family belongs to the first type, which regards crypto mining as an additional source of income consistent with utilizing other financial products. By whatever means, Brother Gu and Sister Wang need a stable cash flow to support their family. In the increasingly precarious society, this simple aspiration becomes harder to achieve because as shehuiren, they can only depend on themselves to address all types of economic difficulties and carefully manage any potential risks. Nonetheless, risks beyond their control always exist. For example, Brother Gu regularly converted the Ether and Chia he mined into RMB, not because he lacked confidence in their long-term return, but simply because he needed cash to pay bills. In doing so, he was not only deprived of trading at a better price, but he also exposed himself to the legal grey area and the risk of financial loss. Even though Brother Gu can still rely on centralized exchanges registered outside China, such as Binance, nobody knows how long the government's current neglection on individual miners will last. Moreover, he lives in constant anxiety, imagining his bank account might be frozen or his GPUs could be expropriated someday, not just because of the ambiguous narratives in the state's blockchain-related regulations, but also as a result of wide-spread rumors among the online communities of shehuiren miners. Zhao and Little Gu represent the second and third types, who both hope to "lie flat" on the blockchain and perceive it as a long-term alternative path to achieving financial independence and exploring a more meaningful life. Lying flat is a defeatist lifestyle that gradually evolves into a non-cooperation movement among the Chinese younger generation, who refuse to surrender to the oppressive work culture where the rat race only yields vague chances for upper mobility. 19 Blockchain offers some shehuiren, who are excluded from the formal labor market, an additional way to pursue profits and imagine success amid socio-political precarities. Zhao explained that as a graduate student majoring in mechanical His full speech can be read at http://www.gov.cn/ldhd/2013-03/17/content_2356344.htm, accessed on 6 September 2021. 19 The "lying flat" lifestyle also attracted media attention, for example the BBC discussed the issues on https://www.bbc.com/news/world-asia-china-57328508, accessed on 3 September 2021. engineering, he used to think it worthwhile to pursue a career in his field, but after devoting himself to cryptocurrency, he totally changed his mind: No matter how hard I work for a boss, I always make more money for them than for myself. Even if someone pays me 100,000 yuan or 200,000 yuan a year, I need to make much more money for him (or her) in return. And I have to sacrifice my own health for them. What's the point? I would rather use that time and energy to develop myself. The aspiration to self-development is another feature of the neoliberal entrepreneurial subject that emphasizes the individual taking full control and responsibility for themselves. Though "lying flat" seems to contradict the dominant ideology, as the state authorities, for example, President Xi, emphasized in his New Year's speech of 2018 that happiness can only be achieved through great endeavors, 20 it at the same time connotates an entrepreneurial subject that coheres with the national policies to boost mass entrepreneurship and innovation, encouraging individuals to find and create opportunities by themselves and for themselves as a new engine for China's economic growth. 21 More radical than Zhao, Little Gu articulates his reflections on consumerism and anticipates utilizing cryptocurrency to achieve a kind of personal freedom. I don't think buying a lot of commodities is a meaningful way of living. Consumption only produces trouble. I still need to make money, but just to have more free choices for my own future.... You know, I saved plenty of money even when I worked part

While public narratives indicate that blockchain is widely used in developed societies among privileged elites, either from socio-economic, ethnic, or techno-cultural perspectives, this study examines how some disadvantaged marginal others, specifically the subaltern shehuiren in China, survive in the increasingly precarious post-socialist Chinese society by engaging with blockchain and cryptocurrencies. Literally translated as "society people", shehuiren are the socio-economically and techno-culturally disadvantaged others who face marginality due to various postsocialist institutional inequalities. This study aims at unpacking how, on the one hand, the blockchain scene has been reconfigured by the disadvantaged in the local context, and on the other hand, how subalternity is actualized in post-socialist China, where blockchain-related technologies deeply intertwine with various forms of social inequalities. By tracing a group of shehuiren crypto miners through ethnography, I demonstrate that this subaltern scene of blockchain not just reshapes the shehuiren individuals' notion of time, space, and value and the social relationship among themselves, but also profoundly impacts the power dynamics between the subalterns, the more privileged others, and the state authorities. Specifically, I underline that, despite being treated as losers, outsiders, and potential wrongdoers due to the existing social structures, shehuiren miners are neither victims nor rebels opposing either the authoritarian state or the global neoliberal order. Instead, they are actors who harvest limited profits through their unacknowledged creativity, adeptly making use of various resources within their reach and weaving their differential aspirations by attaching themselves to the larger technology-mediated networks in an unequal post-socialist society where a united subaltern hardly exists.

in return. And I have to sacrifice my own health for them. What's the point? I would rather use that time and energy to develop myself. The aspiration to self-development is another feature of the neoliberal entrepreneurial subject that emphasizes the individual taking full control and responsibility for themselves. Though "lying flat" seems to contradict the dominant ideology, as the state authorities, for example, President Xi, emphasized in his New Year's speech of 2018 that happiness can only be achieved through great endeavors, 20 it at the same time connotates an entrepreneurial subject that coheres with the national policies to boost mass entrepreneurship and innovation, encouraging individuals to find and create opportunities by themselves and for themselves as a new engine for China's economic growth. 21 More radical than Zhao, Little Gu articulates his reflections on consumerism and anticipates utilizing cryptocurrency to achieve a kind of personal freedom. I don't think buying a lot of commodities is a meaningful way of living. Consumption only produces trouble. I still need to make money, but just to have more free choices for my own future.... You know, I saved plenty of money even when I worked part-time as a student. Without those savings, I would not have been able to invest in cryptocurrency... Since my current income [in cryptocurrency] can already cover my daily necessities, I am thinking of moving to some very low-cost areas, like the Rust-Belt regions in Northeast China... It's meaningless for me to be cramped in big cities. Little Gu's lying down may be even flatter than Zhao's. He interprets freedom not just as independence from the labor market but also from consumerism and materialism by emphasizing frugality (Taylor & Davies, 2021). Such a pursuit of personal freedom is undoubtedly in contrast to the national endeavor to construct a prosperous consumer society, though nominally frugality is still a commonly praised virtue. However, it also needs to be noted that such freedom is achieved through investment and the full use of various financial instruments (Taylor & Davies, 2021). We can hardly imagine how in practice an individual can live as a recluse in contemporary consumer society. Liang and Feng represent the last category, of those who hope that cryptocurrency can be a shortcut to becoming super-rich one day. For example, during the early phase of Chia mining, Liang and Feng refused to use a mining pool, expecting to earn several full coins by themselves, especially when the initial trading price once peaked at nearly 2,000 USD. Pooled mining produces a constant revenue of smaller value, whereas sole mining is more like winning a lottery: the block reward tends to be more erratic, but once a miner successfully adds a block, he or she receives the full set of the block reward. Moreover, to maximize the reward, Liang also put all his gain from previous Ethereum mining into Chia, as he believed the latter's mechanism would become popular among crypto investors. Nonetheless, the price of Chia has decreased ever since its first trading, and we cannot predict when Liang will recover his all-in investment. The last speculative subjects internalized the neoliberal logic that the subaltern position is a consequence of personal bad choices. Therefore, what they anticipate is for some luck to escalate in the hierarchy so they can then enjoy some prestige, which they can hardly access as a subaltern shehuiren. Nonetheless, these high-risk investing strategies are also inconsistent with the state's expectations for social and financial stability. By describing the role of subaltern miners' own dreams in reconfiguring the blockchain scene in contemporary China, I try to step away from two common interpretations of digital technologies among Chinese internet users: one of an empowering digital technology that returns power to users and citizens, in particular affording them resistance to an authoritarian party-state; and the other of how powerful social sectors such as the government oppress, or commercial institutions and neoliberal market contaminate or co-opt a once authentic grassroots culture. Both narratives romanticize the democratic intervention of digital technologies and grassroots resistance (Lindtner, 2020). Just as Spivak (1988, p. 296) proposed, the metaphor "white men are saving brown women from brown men" is itself problematic because neither the imperialist subjects nor the local nativists actually listened to or even cared about the subaltern Indian women's voice. To adapt Spivak's analogy, I argue that it is biased and tricky to presume to ask whether the blockchain can save the subaltern from either the oppressive authoritarian state or the engulfing global neoliberalism. First, the two powerful social structures do not necessarily conflict with each other but coexist in a dynamic tension. At the same time, they are both able to exercise greater influence with technological elites to shape and reshape the features of a specific blockchain and thus affect the actions and aspirations of the subaltern. On the other hand, I also do not mean that the subaltern are only victims of the broader social structures who have no choice but to accept a structural position. Nor are they resistant subjects with clear consciousness about an imaginary foe. If the subaltern can, to some extent, benefit from their engagement with blockchains, harvesting some profits through their unacknowledged creativity, they adeptly make use of various resources within their reach, weave their differential aspirations, and become actors by attaching themselves to the larger blockchain scene that is simultaneously reshaped by various types of societal precarities (Latour, 2005, p. 217). During the process, they confront frustrations, powerlessness, and difficulties in a post-socialist society that never stops structurally positioning them as the subaltern through policies, institutional structures, hegemonic political discourses, nation-wide surveillance, unneutral technological designs, and global economic dynamics. In other words, though also influenced by the yearnings and actions of shehuiren miners, the subaltern blockchain scene is not yet or may never develop into a completely alternative grassroot-oriented scenescape, but again is always deeply intertwined with various existing forms of inequalities. --- CONCLUSION Over a year of ethnographic research, this study traces and records the actions, aspirations, and frustrations of a group of amateur cryptocurrency miners who inevitably fall into an unnamable subaltern position in contemporary China, due to their impoverished, precarious, and ambiguously illicit conditions. Specifically, I use shehuiren, a phrase I appropriate from the subaltern's everyday language, as a stopgap terminology to describe the heterogenous disadvantaged groups and their unacknowledged subordinate position in post-socialist China today. Because of being marginalized in existing social structures, shehuiren are more likely to adopt and make use of new technologies to overcome their financial struggles, even just temporarily. Engaging with blockchains and mining and trading cryptos has thus been not only a novel form of digital profiteering for them to make ends meet but also a way to negotiate with the larger social structures that constantly exclude them as the losers, outsiders, and potential wrongdoers. Shehuiren miners first played a key role in reconfiguring the subaltern blockchain scene in local context, incorporating previously inconsequential peripheral elements, including but not limited to their unnoticed and underrated knowledge and creativity, their domestic living environments and everyday habits, and their yearning and desires to the dynamically changing assemblage around blockchains. The subaltern blockchain scene also significantly redefined the network structure and social relationship among shehuiren, in return. Specifically, subaltern individuals earned respect and trust from others depending on their ability to gather information, learn new technologies, and innovate, rather than whether or not they can mobilize connections with government officials, the rich, or the other privileged. Moreover, with multiple non-human actors, such as mining rigs and the volatile global crypto market, the subaltern blockchain scene transformed these participants' perceptions of domestic space, time, labor, value, and future. Nonetheless, the subaltern blockchain scene never existed in a power vacuum, but was constantly intertwined with various forms of existing inequalities. In particular, my ethnography shows that, first, the seemingly neutral ability to learn and create is unequally distributed and gender-biased in practice. Compared to their male counterparts, subaltern women are less likely to be welcomed in the scene or to make a profit from blockchains, which again reinforces the non-existence of shared interests or equal chances that can benefit the subaltern on the whole. Second, the proclaimed "decentralized" blockchain does not change the prevalent disregard for and inappropriate exploitation of the subaltern's technological efforts, for the potential that subaltern can be knowledgeable and innovative does not cohere with the public imagination about the subaltern both in China domestically and abroad. Third, to manage risks and handle various forms of precarities simultaneously generated by the global crypto market and Chinese state authorities, shehuiren miners again have to embrace a calculative and self-governing logic in order to survive in the increasingly unequal world. By carefully weaving their financialized, entrepreneurial, downshifting, and speculative aspirations into the hegemonic narrative of "Chinese dream", I underline the non-existence of a united subaltern with a clear consciousness opposing either the oppressive authoritarian state or the global neoliberal order. Neither are they simply placeholders of the larger social structure. Instead, they are always actors, in Latour's sense, who left traces in reconfiguring the subaltern blockchain scene by adeptly making use of various resources within their reach, harvesting limited profits through their unacknowledged creativity, and attaching their differential aspirations to the larger amalgam of technologies, neoliberalism, and state authorities. --- FUNDING STATEMENT AND ACKNOWLEDGMENTS The author received no financial support for the research. --- 17 http://www.gov.cn/gzdt/2013-12/05/content_2542751.htm http://www.gov.cn/xinwen/2017-09/04/content_5222657.htm http://www.gov.cn/zhengce/zhengceku/2021-10/08/content_5641404.htm https://www.ndrc.gov.cn/xxgk/zcfb/tz/202109/t20210924_1297474_ext.html http://fgw.nmg.gov.cn/xxgk/zxzx/tzgg/202105/t20210526_1596731.html https://finance.sina.com.cn/tech/2021-06-09/doc-ikqcfnca0121533.shtml https://www.163.com/tech/article/GC9N1CLK00097U7R.html http://fgw.sc.gov.cn/sfgw/tzgg/2022/4/15/4d392a1bf7914e49afaeae2cce181dfa.shtml https://finance.sina.com.cn/china/dfjj/2021-07-14/doc-ikqciyzk5429321.shtml http://www.gov.cn/zhengce/zhengceku/2021-12/01/content_5655205.htm http://www.yn.gov.cn/zwgk/zcwj/yzf/202205/t20220510_241902.html 18 Xi Jinping articulated the "Chinese Dream" as a concept in his speech after being officially elected as the President of People's Republic of China by the National People' Congress in March 2013.

While public narratives indicate that blockchain is widely used in developed societies among privileged elites, either from socio-economic, ethnic, or techno-cultural perspectives, this study examines how some disadvantaged marginal others, specifically the subaltern shehuiren in China, survive in the increasingly precarious post-socialist Chinese society by engaging with blockchain and cryptocurrencies. Literally translated as "society people", shehuiren are the socio-economically and techno-culturally disadvantaged others who face marginality due to various postsocialist institutional inequalities. This study aims at unpacking how, on the one hand, the blockchain scene has been reconfigured by the disadvantaged in the local context, and on the other hand, how subalternity is actualized in post-socialist China, where blockchain-related technologies deeply intertwine with various forms of social inequalities. By tracing a group of shehuiren crypto miners through ethnography, I demonstrate that this subaltern scene of blockchain not just reshapes the shehuiren individuals' notion of time, space, and value and the social relationship among themselves, but also profoundly impacts the power dynamics between the subalterns, the more privileged others, and the state authorities. Specifically, I underline that, despite being treated as losers, outsiders, and potential wrongdoers due to the existing social structures, shehuiren miners are neither victims nor rebels opposing either the authoritarian state or the global neoliberal order. Instead, they are actors who harvest limited profits through their unacknowledged creativity, adeptly making use of various resources within their reach and weaving their differential aspirations by attaching themselves to the larger technology-mediated networks in an unequal post-socialist society where a united subaltern hardly exists.

BACKGROUND Patient-centredness has been advocated as a necessary element of high-quality healthcare. [1][2][3][4][5][6][7][8] The US Institute of Medicine endorsed patient-centredness in 2001 as one of six goals for improving healthcare and as a powerful answer to address deficits in health systems in responding to patient-specific needs, preferences and values. 9 Although a widely accepted definition of patientcentredness is lacking, [5][6][7][8] most studies focus on aspects of understanding and respecting the patients' individual values, needs and desires; involving patients and family members in the care process, patient education and creation of shared knowledge; and physical and emotional comfort and support. [10][11][12][13][14][15] Berwick described three maxims of patient-centredness: (1) 'The needs of the patient come first'; (2) 'Nothing about me without me' (ie, transparency and involvement of patients and family members in each clinical decision and in the design of the care process and services); and (3) 'Every patient is the only patient' (ie, a customisation of care at the level of the individual). 16 Patient-centred care is considered to be especially important during critical episodes in the care process such as during discharge from the hospital. The growing emphasis on shorter hospital stays demands more postdischarge care and creates an important coordinating and management role for patients and family members. 17 Often, patients and family members are the only common thread between hospital and community care services. 18 Patients and family members require skills, information and confidence to ensure continuity in postdischarge care. 18 Patients at discharge are often in a vulnerable state: they are anxious, have side effects from medication, and may have functional or cognitive impairment. [18][19][20] Discharge can also be an intense episode in the care process where patients and family members are not ready to care for the patient at home, and are confronted with difficult decisions and changes (eg, financially and emotionally) that impact their home setting and resources. Patients, despite the recently increased focus on patient-centredness, often leave the hospital unprepared for postdischarge demands. [21][22][23] A recent survey of patients with complex care needs in 11 countries reported that one in four did not receive instructions for follow-up nor did they receive clear medication directions. 24 Other studies have demonstrated that patients and family members express anxiety and a sense of abandonment after discharge. [25][26][27] Patient unpreparedness, anxiety and a misunderstanding of the full ramifications of their situation at discharge are believed to increase hospital readmissions and adverse events in the posthospital setting. This is especially the case for the elderly and those with chronic conditions who require frequent transitions between hospital and home care. [28][29][30][31] There is little understanding about the factors that facilitate or create barriers to patient-centred care at hospital discharge. Identifying the barriers and facilitators may help in the design of effective solutions for improving the discharge process. This may improve patients'/families' self-care skills (eg, improving medication adherence), mitigate patient anxiety, and reduce avoidable and costly readmissions. The aim of this study was to explore the barriers and facilitators to patient-centred care in the hospital discharge process. We elicited perceptions and experiences about the discharge process through interviewing patients, family members and care providers (in the hospital and the community). --- METHODS --- Study design and settings We conducted a qualitative study of patient handovers at hospital discharge in nine hospitals, and their respective primary and community care settings, as part of the HANDOVER project, which addresses patient handovers at the hospital to primary care interface in five European nations. 32 The countries involved in the HANDOVER project (The Netherlands, Spain, Poland, Italy and Sweden) represent a wide variety and types of European healthcare and funding systems. Four academic or teaching hospitals and five regional community hospitals representing all five nations were selected to ensure the sample reflected a wide variation in hospital type, size and structure. Hospitals varied in size from 127 to 1042 beds. --- Participants Participants in the study were stakeholders in the discharge process, including patients and family members (if available), and healthcare providers ( physicians, nurses) of the recruited patients at the hospital and community care settings. Patients recruited fulfilled both the general and country-specific inclusion criteria (table 1). We used purposive sampling to ensure diversity of patients (ie, age, gender, diagnosis, hospital setting and wards) and healthcare professionals. The patients or their proxy, if a patient was unable to --- GPs and community nurses Representing the communities to which the patients were discharged Exclusion criteria Patients referred to other care units within the hospital prior to their discharge home or discharge to another country participate personally due to his/her illness, were asked for written consent. Ethics approval was received at each of the five study sites. The providers were identified based on the patients they cared for and were then informed about the study and requested to participate. --- Development of interview formats The interview guides for the individual and focus group interviews were developed during several HANDOVER Research Consortium meetings. 33 The questions for the individual interviews were pilot-tested and refined in each country and the results were used to create the final guide. Topics that guided the question development were: <unk> Experiences with recent discharge processes (appreciative/problematic situations and consequences) <unk> Perceptions about the discharge process in general (ie, experiences, beliefs, norms, assumptions, methods, tools, barriers, facilitators) <unk> Perceptions about role taking, tasks and responsibilities <unk> Thoughts and suggestions for improving the discharge process. --- Data collection The individual interviews were conducted with patients recently discharged from the hospital to the community (ie, nursing home or home) and with their hospital physician, hospital nurse, general practitioner (GP) and community nurse involved in the discharge process. Patients were approached before their discharge from hospital, and provided with information about the project, and the interviews were performed 3-4 weeks after discharge by two local research team members. All interviewers had experience and/or background in healthcare as researchers or as healthcare providers. The focus group interviews were conducted separately with each stakeholder group, and varied in size from three to nine participants. The interviews were led by a trained moderator and one or two observers that completed field notes and added question prompts as needed. At the end of each focus group, the moderator summarised the discussion and allowed the participants to reflect and comment on the accuracy and validity of the information. 34 All interviews were audio-taped and transcribed in the native languages according to a standardised format. --- Data analysis The analysis consisted of two parts: the general analysis at the national level of the interviews and a subanalysis of the cross national data (figure 1). --- General analysis The transcribed interviews were analysed using Grounded Theory, a qualitative research method focused on the identification of concepts that emerge from study interviews or observation. 35 Two researchers in each country independently coded the transcripts to minimise subjectivity. Atlas.ti software V.6.0 (ATLAS.ti Scientific Software Development Company, GmbH, Berlin, Germany) was used to facilitate the coding process. Coding is the interpretative process in which conceptual labels are given to the data. 35 The generated codes were circulated between researchers in all countries and the list of codes was developed into a shared codebook, during a face-to-face meeting, conference calls and electronic mail correspondence (available upon request). Agreement about the meaning of the in English developed codes was achieved before the analysis stage. Regular conference calls were held to refine the codebook as codes arose during the analyses and to group the codes that were related to the same phenomenon into unique categories. Country-specific codes were used as needed. The same two researchers further analysed the data in each country until conceptual saturation was reached for that country, that is, no new codes or categories were generated. 35 --- Synthesis of local analysis Local analyses were used to report on patient-centred care and the culture 36 and to explore the barriers and facilitators to patient-centred care in the discharge process. Three researchers (GH, HW and MF) synthesised these findings. 37 The categories and themes identified across the different settings were verified with the researchers from each country and an additional number of quotes from each country were provided to illustrate the findings. Finally, new hypotheses emerged as a result of the data from the local analyses. 34 Figure 1 Procedure: from data collection to the subanalysis. --- RESULTS Overall, 192 individual interviews and 26 focus group interviews were analysed regarding patient-centred care in the discharge process of the five countries. Individual interviews were conducted with 46 hospital physicians, 38 hospital nurses, 39 GPs and 16 community nurses. 53 patients and/or family members were interviewed. Of the patients recruited, 39 could not be interviewed for various reasons. The individual interviews were evenly distributed across the countries (table 2) and across age and gender groups. The analysis resulted in 15 categories from which four themes emerged: (I) health provider prioritisation of discharge consultations; (II) decision-making within the discharge process; (III) care provider anticipation of patient-specific needs and preferences; and (IV) organisational factors (table 3). --- Theme I: care provider prioritisation of discharge consultations There are three categories within this theme: (1) lack of time; (2) giving priority to delivering medical or nursing care; and (3) lack of a standard discharge consultation. --- Lack of time The main concern for hospital physicians is delivering optimal medical care to patients, either for inpatients or outpatients. Hospital care providers, patients and their family members considered it important to complete the discharge consultations with the patient and family members during the hospitalisation period, and to discuss patient preferences and follow-up needs. Healthcare providers indicated that a barrier to optimal discharge consultations with patients and family members is a lack of time, with discharge often delegated to nurses or junior physicians. The consultations also take place at times that are convenient for the physicians, and these times often conflict with family member availability, which prevents them from being sufficiently informed. --- Giving priority to delivering medical or nursing care The responsibility to provide medical and nursing care to many patients and the interruptions by emergency admissions often leave care providers with insufficient time to talk with patients before they leave the hospital. Hospital nurses expressed that discharge consultations are frequently held in a rush just before patients leave the hospital, increasing the risk that important patient follow-up needs are missed or insufficiently addressed in the discharge process and the handover documentation prepared for community physicians and nurses. Patients then leave the hospital with incomplete information about care following the hospitalisation, including instructions for self-management. --- Lack of a standard discharge consultation Hospital physicians, nurses and GPs, frequently noted that at times a standard discharge consultation with patients and family members is not performed at all, especially for patients on surgical wards. Instead, the discharge information is provided piecemeal and in between other care activities. Consequently, patients, especially the elderly, often are not aware of the importance of the information provided, unable to remember the information and overwhelmed when they are suddenly told they have to leave the hospital. --- Lack of a standard discharge consultation Hospital nurse: There is no specific discharge consultation with the patient. (...) Nurses talk a lot with patients during the whole day, but there is no specific moment when one says to the patient: "listen, I organised this and that". GP: There are patients that are discharged and start complaining to me that they did not see the physician for two weeks and suddenly were informed with: "you can leave tomorrow". And on the next day there was no consult with the physician on duty. Nothing, but: "you can pack your belongings". --- II. Decision-making within the discharge process Involving patients in decisions regarding their follow-up Patient: Three physicians arrived at my bed. My physician, the physician at the ward, and...then it is like: "your treatment here is over. We found a follow-up location for you. You can go." Actually, they force you (...) they are a bit authoritarian. Community nurse: It is important to be sensitive to patient needs (...). But there is rush and insensitivity. It would be better if everyone, starting with the hospital physician, would ask the patient about what is needed. --- Dealing with competing interests Hospital physician: I will never keep the patient here against its will. If a patient does not want to go to a nursing home and even though the family (...) and nurses say: "he does not take care of himself and he will fall at home" (...) this person has the right to go home with the possibility to fall. (...) That the patient's autonomy. Hospital nurse: I understand when a patient says: "I will not take these medicines". (...) But that is his own responsibility. Unfortunately we often see such patients returning to the hospital and unfortunately this happened in this case as well, because the patient did not take is blood thinning medicines... that's his own choice. (...) It [influence] stops when they leave the hospital door. --- III. Care provider anticipation of patient-specific needs and preferences Estimating patients' resources, capabilities and skills Patient: After the amputation of my toes I was sent home with two sets for wound care dressing and told to treat this by myself. (...) I got one bleeding after the other. Community nurse: In several occasions patients have been discharged without us being informed about their insulin treatment, resulting in patients not receiving insulin after discharge. Sometimes it seems that the ward personnel thinks that these patients can manage everything by themselves and that they are all well functioning while, in reality, they suffer from dementia. --- Patient emotions and emotional support Relative: It was clear that my mother was frightened to go home. A little more compassion and understanding would have made it much easier (...) Well, there was a consultation just before discharge, but it was a real technical-medical conversation. Not in the sense of "are you looking forward to go home?" Patient: It was not possible to ask something because all the time you got the answer..."no this is not the right moment, later...". Patient preparedness for discharge GP: I often hear from patients that they were overwhelmed by the discharge, like: "suddenly I have to go home". Hospital nurse: As soon as we talked about going home we saw that he panicked and got another asthma attack. We strongly had the feeling this was correlated with the fear to go home. You often see these patients quickly return to the hospital. I think: "this patient was not capable to go home" (...) apparently not with the right preconditions. For example, it would be better to Theme II: decision-making within the discharge process Two categories emerged under this theme: (1) involving patients in decisions regarding their follow-up and (2) dealing with competing interests. --- Involving patients in decisions regarding their follow-up Comments on the involvement of patients in discharge handover decisions and decisions concerning follow-up varied widely. Some patients expressed that they had a --- Quality of information provided at discharge to patients and family members Relative: We came back home with all this drugs without the slightest idea of how long the therapy was supposed to last. GP: The hospital does not understand that information to the patient should be restricted to one page. I see patients arriving here with a complete set of brochures. (...) That is no information. (...) It only confuses or scares them. You should explain the few essential things. Patient: So, the cardiologist stood next to me and said all sorts of things in Latin. (...) I do not speak Latin! Exchange of patient-specific information between hospital and community care providers Community nurse: A hospital should inform us about patient discharge in case when a patient lives alone. These are elderly, sometimes with dementia. The doctor tells him things in the hospital, but the patient has already forgotten half of that when he gets home. Hospital physician: We sometimes give information to the community nurse too late, really close to discharge and the community nurse does not have the time to organise the handover. Community nurse: We see patients leaving the hospital with the medical report and they can have four ulcers...and not a soul knows about that! Until you visit them at home. That is very heavy. --- Community care providers' role in monitoring patients after discharge Patient: To be honest I did not receive any calls from my GP and I would have appreciated it. --- IV. Organisational factors --- Shift work structures of hospital care providers Hospital physician: The lack of consultations with patients and family at discharge has to do with work schedules of the attending physicians at the ward. (...) We have evening shifts, night shifts, weekend shifts. (...) The physician who takes over also needs time to get to know the patient. (...) This means that the information exchanged is not sufficient, because you do not know the patient well. Patient: You constantly see new physicians (...) it makes you crazy, because at a certain moment you do not know who you need. Accessibility of hospital care providers to patients GP: I think a patient should have better access to the physician who still treats that patient. I mean, when this patient is recently discharged and still has a question related to his hospitalisation I think it is odd that it he is advised to contact the GP. At the outpatient clinic they say: "no, you cannot speak to the physician". --- Pressure on available hospital beds Hospital nurse: Sometimes you feel that the hospital physicians have made a decision about discharge, and then you feel that it is actually a little bit too early, actually. But you don't have that much of a choice since the pressure is high. Hospital nurse: If a physician needs a hospital bed during the weekend, he or she will discharge the patient without any notification. --- Discharges on weekends Patient: At Friday they told me that I could go home the next day. But the offices are closed on Saturdays and they could not give me all the proper discharge information and equipment. (...) That was not pleasant. (...) So I did the medication and all other things on my own. voice in the choice of a nursing home or rehabilitation centre, whereas others felt they were ignored and only asked to follow their physicians' and nurses' instructions. Patients experienced the decision about the timing of the discharge in varied ways. Several patients expressed that when they expressed that they did not feel ready to go home, they were allowed to stay in the hospital. Others felt they did not have any say in this matter or their requests were ignored. Patients and GPs mentioned instances of sudden and abrupt discharge that overwhelmed patients. --- Dealing with competing interests Physicians and nurses reported they face situations where patient preferences (eg, remaining in the hospital, not wanting to go to a nursing home) are in conflict with their medical, nursing needs or the administrative pressure of vacating hospital beds for other patients. Hospital physicians and nurses indicated that these problems may result in avoidable readmissions. Theme III: care provider anticipation of patient-specific needs and preferences Six categories emerged around this theme: (1) estimating patients' resources, capabilities and skills; (2) patient emotions and emotional support; (3) patient readiness for discharge; (4) quality of information provided at discharge to patients and family members; (5) exchange of patient-specific information between hospital and community care providers; and (6) community care providers' role in monitoring patients after discharge. --- Estimating patients' resources, capabilities and skills Patients and community care providers commented that patient-specific resources, self-management capabilities and skills are often overestimated or not critically assessed. As a result, patients may be discharged without sufficient medications or other supplies, or without detailed instructions to the patient or carers for how to perform simple procedures such as changing a wound dressing. --- Patient emotions and emotional support Hospital nurses in particular recognised the need for emotional support for patients at discharge. In contrast, patients and family members mentioned that there was little awareness of the patient's emotional status and needs by care providers, who rarely demonstrated compassion, efforts to listen to the patient, and to reassure patients and families about their concerns. Patients and family members perceived this as a small timeinvestment from care providers and commented that hospital physicians and nurses appeared to focus primarily on medical or nursing needs. Care providers commented on lack of time and normal care routines as barriers to more effectively addressing the emotional needs of patients and family members. --- Patient preparedness for discharge Care providers commented on the value of preparing patients for discharge, particularly those who need to perform more complex or technical care at home, and that more attention should be paid to encouraging patients to effectively perform monitored self-care activities in the hospital before discharge. However, patients and GPs also mentioned examples of sudden and abrupt discharge that overwhelmed patients. On the other hand, healthcare providers mentioned situations where they tried to prepare patients for discharge by informing them early in the day or hospitalisation about the expected discharge date or, if possible, by prolonging the hospital stay. --- Quality of information provided to patients and family members Hospital and community nurses, GPs and patients indicated that patients often receive insufficient instructions concerning their follow-up. For example, a patient who was required to inject a medication at home noted that no instructions or demonstration of how to inject the medication had been given before discharge. Information provided at discharge is often perceived to be unclear or it is given too fast with no time for questions or clarifications. Patients reported that healthcare professionals often used medical-technical jargon they were unable to understand, and community care providers reported that patients received an overload of nonprioritised written and verbal information at discharge, which lead to confusion and prevented patients from remembering key aspects of their follow-up care. Hospital nurses described various approaches to improve clarity of information and to ensure patients understood the most important aspects relevant to follow-up, including involving family members in discharge process, demonstrating and monitoring self-care activities, checking if patients understood the information and highlighting the important information in a discharge letter. --- Exchange of patient-specific information between hospital and community care providers Community care providers noted that the timely exchange of patient-specific information is important and supports anticipating patient preferences and needs at discharge. Descriptions of patients' social and emotional status (ie, living alone, dementia symptoms, depression, agitation) were reported to be important in addressing specific follow-up care needs. Several community care providers noted that this type of key information often is not present or deficient. Community care providers' role in monitoring patients after discharge Finally, patients and GPs believe it is important that community care providers check with patients whether there are unresolved issues to be dealt with. Patients indicated that this frequently does not happen and GPs concurred. GPs admitted this likely has to do with a lack of time and resources. Theme IV: organisational factors Four categories related to this theme: (1) shift work structures of the hospital care providers; (2) accessibility of hospital care providers to patients; (3) pressure on available hospital beds; and (4) discharges on weekends. --- Shift work structures of hospital care providers Hospital care providers indicated that the lack of discharge consultations with patients and family members relates to the structure of hospital physicians' and nurses' work shifts. Patient discharge is often performed by physicians and nurses who do not have an ongoing relationship with the patient or family. Care providers and patients described patients being discharged by care providers who just started their shift or rotation and were not acquainted with the patient's history, needs for community services or preferences. The involvement of multiple personnel sometimes also causes confusion at discharge as patients received contradicting information from different members of the healthcare team. --- Accessibility of hospital care providers to patients Hospital nurses, patients and GPs mentioned difficulties in identifying and contacting the physician or nurse who treated them in the hospital. Patients are often advised to contact their GP, while GPs are not always up-to-date with the treatment that was provided and the follow-up that was advised during the hospitalisation. --- Pressure on available hospital beds One factor reported by hospital care providers in pushing for early discharges was financial drivers and the lack of available hospital beds that requires patients to be discharged, even when the patients may not be ready to go home. --- Discharges on weekends A particular problem involved patients discharged just before or during the weekend. Although hospital care providers expressed these discharge situations require specific attention, patients and their GPs experienced problems with receiving immediate home care, equipment and medication during out of office and weekend hours. Moreover, the window of opportunity to arrange the necessary community care is small as discharge planning is decided or conveyed very late during the patient's hospitalisation. --- DISCUSSION To our knowledge, this is the first study that investigated patient-centred practice at hospital discharge based on the perceptions and experiences of patients, family members and care providers in the hospital and community. Patients, family members and care providers report various factors that facilitate or present barriers to patient-centred care in the hospital discharge process. Four themes emerged from this study: care provider prioritisation of discharge consultations; decision-making within the discharge process; care provider anticipation of patient-specific needs and preferences; and the role of organisational factors. Our findings indicate that to a considerable extent patient-centred care is influenced by the behaviours of the health professionals and by organisational aspects beyond the direct influence of these professionals (ie, organisational factors). Our results suggest that both domains are intertwined. In the context of the three maxims of patient-centredness, 16 our findings indicate that in the discharge process the needs of the patient do not often come first. Discharge planning occurs hurriedly just before the patient leaves the hospital, and a standard discharge consultation with the patient appears to be largely lacking. Interviews suggest this occurs due to a lack of time and the prioritisation by healthcare providers on providing urgent medical or nursing care to the patient or more likely to other patients. Second, decisions about the patient are not always made with the patient. Decisions concerning discharge date and follow-up are made by healthcare providers without input of the patient or carers, often due to a lack of time and the pressure on available beds and available resources in the hospital and community. This likely is another important area for improvement, as studies demonstrate that the quality and safety of care and patient satisfaction increases, and healthcare costs decrease, when providers, patients and family members work in partnership. [38][39][40][41] Third, many patients are discharged without specific information, instructions and without postdischarge care being tailored to their individual preferences and needs. This is due to an over or lack of estimation of the patient's capabilities, their degree of informal support and emotional needs. As a result, patients leave the hospital uninformed about the details of their posthospital care, and may feel unprepared and anxious. The patient's preparedness for discharge involves more than physical function readiness 42 and should include also emotional, cognitive and psychosocial readiness, 43 44 as well as the readiness of family members who will be caregivers. Many of the care providers recognise the importance of these aspects, but are often frustrated by their inability to discharge patients at the optimal moment, due to hospital bed availability for new patients and the limited availability of community care resources. Healthcare providers need to deal with conflicting pressures. 45 Care providers informing patients about discharge repeatedly and in multiple-steps, providing information to patients about the expected discharge date early in the hospitalisation, and checking if patients understood the information were perceived as important facilitators to patient-centred care in the discharge process. Finally, patient and healthcare provider experiences demonstrate that it is essential that the GP and community nurses are informed well before the actual discharge date about the patient's hospitalisation history, home setting, emotional needs and eventual discharge plan. This will help ensure continuity of care with community care providers able to provide postdischarge care that helps to reduce the likelihood of unnecessary hospital readmissions. Our study has several limitations. Patient-centred care was analysed and compared between the five countries that have their own distinct healthcare delivery and funding systems. These systems have unique legislative and organisational characteristics, and perform within different constraints while serving different patient populations. Not all findings were found across all five study sites. For example, we did not find comments on patient involvement in decision-making in the data from Spain. Spanish patients participating in the study were members of ethnic minority groups with low health literacy, which may contribute to differences in the desire for involvement. Second, the interviews were transcribed in the native languages of the five countries, which may have increased the chances of errors and variations in the interpretation of the data. 46 All efforts were made to ensure the methodological rigour and validity of the translations from English to the native languages as well as back to English across the study sites by using a standardised code book, meeting frequently, sharing and comparing our results, and by performing a pilot analysis. Finally, local influences on the quality of patientcentred care may be underappreciated and our findings may not be generalisable to other healthcare systems. Future interventions at enhancing patient preparedness for discharge should be directed both at the level of the care provider's attitudes and at their organisational level, with a focus on improving the interactions among care providers, patients and family members, as well as to improving the interactions between hospital and community care providers. One intervention to be tested is a standard discharge handover protocol to offer patients and healthcare professionals a well thought out approach to these handovers. Additional promising interventions consistent with our findings include: educating and training care providers on aspects of patient-centred care, 47 48 and a formalised face-to-face discharge consultation, in an interruption-free location, for patients who are about to be discharged. The patients should be assessed for their level of understanding and to repeat or elaborate information. [49][50][51] Specific tools to facilitate the information exchange to patients and family members might include the use of pictures, video and storyboards. 52 53 Electronic notifications can be used to communicate the patient's medical and psychosocial information, in time, to community care providers. 54 55 These initiatives can improve patient preparedness, reliability of patient care and greatly enhance the value of healthcare. 56 57 --- CONCLUSIONS This study considerably improves our understanding of barriers and facilitators that can help or compromise patient preparedness for the discharge process. The use of individual and focus group interviews provided valuable insights into attitudinal and external aspects that influence patient-centred care during the discharge process. Overlooking these facilitators and barriers can often undermine the success of clinical interventions that have been used to address handover inefficiencies. 58 59 Patient-centred discharge care processes should address two types of interactions: interactions among the care provider, patient and their family members, and the interactions between the hospital and community care providers. We hypothesise that the quality of these interactions is determined by the extent to which care providers, driven by their attitudes and their organisation of care, are willing and able to accommodate patient-specific needs and preferences. --- Competing interests None. Ethics approval Ethics approval provided by an Ethics Committee within each participating country. Provenance and peer review Not commissioned; externally peer reviewed. Data sharing statement Data are available on request from the corresponding author.

Background: Advocates for quality and safety have called for healthcare that is patient-centred and decision-making that involves patients. Objective: The aim of the paper is to explore the barriers and facilitators to patient-centred care in the hospital discharge process. Methods: A qualitative study using purposive sampling of 192 individual interviews and 26 focus group interviews was conducted in five European Union countries with patients and/or family members, hospital physicians and nurses, and community general practitioners and nurses. A modified Grounded Theory approach was used to analyse the data. Results: The barriers and facilitators were classified into 15 categories from which four themes emerged: (1) healthcare providers do not sufficiently prioritise discharge consultations with patients and family members due to time restraints and competing care obligations; (2) discharge communication varied from instructing patients and family members to shared decision-making; (3) patients often feel unprepared for discharge, and postdischarge care is not tailored to individual patient needs and preferences; and (4) pressure on available hospital beds and community resources affect the discharge process. Conclusions: Our findings suggest that involvement of patients and families in the preparations for discharge is determined by the extent to which care providers are willing and able to accommodate patients' and families' capabilities, needs and preferences. Future interventions should be directed at healthcare providers' attitudes and their organisation's leadership, with a focus on improving communication among care providers, patients and families, and between hospital and community care providers.

Introduction Fatal interactions between police and the public became the subject of increased scrutiny following the 2014 shooting of Michael Brown in Ferguson, Missouri, and several subsequent controversial police shootings. These fatal interactions are objectively rare in the context of all contacts between police and the communities they serve, but they can evoke strong emotional reactions from the public. They are typically complex and dynamic events, the details are slow to emerge, and to the public the legal structure and process surrounding these events are confusing, if not frustrating. Police use of deadly force is perhaps the most powerful expression of state authority and it can be equally powerful in undermining the public perception of police legitimacy. The Black Lives Matter (BLM) movement, which emerged after the shooting of Trayvon Martin by Florida resident George Zimmerman, has seen an increased profile since the shooting of Michael Brown and related public demonstrations and riots. The developing narrative reflects a belief that police officers are more likely to kill minorities, all else being equal, and that the law insulates law enforcement from accountability. As a movement there is little evidence that BLM supporters endorse retaliatory violence against the police. However, several police leaders have publicly expressed their opinion that BLM clearly does endorse such violence. This narrative includes claims that the police are under attack and that there is a "war on cops." The killing of five Dallas police officers in 2016 is a particularly troubling touch point in this regard. While there has been debate over the nature of the threat, it can be said that the number of shootings of police during 2016 has exceeded the number recorded in 2015 [1]. Conservative political commentator Heather MacDonald is often credited with articulating the "Ferguson Effect" hypothesis, asserting that police officers respond to their fears of increased scrutiny by engaging in less proactive policing, leading to increased crime [2]. The hypothesis has been extended to encompass a more general hesitancy to act, leading to decreased officer safety, as well as increases in retaliatory lethal attacks on police to avenge what are seen as racially-motivated killings of blacks. One anecdotal example of this phenomenon was the stated refusal of a Chicago police officer to draw her weapon while being beaten because she feared the media coverage if she shot and killed her assailant, who was an African-American male [3]. This situation has led several scholars to investigate whether there were changes in proactive policing reflected in increased crime [4], and debate whether violence by and/or toward the police has increased, decreased, or stayed the same in the wake of these events. Recent research has examined whether there was a detectable increase in killings of police post-Ferguson (through March, 2016) and found no evidence to support the hypothesis [5]. While it is important to assess the effects of Ferguson and BLM as a historical turning point in perceptions of police legitimacy, as well as subsequent police and public behavior, the broader and arguably more important question that this research addresses is the general process question: whether the taking of life by law enforcement is associated with retaliatory lethal violence against law enforcement and whether the reverse may also be true, that lethal violence against law enforcement is associated with increased killings by police. In fact, signals of perceived culpability for this violence and who is responsible can be found in other areas of our criminal justice system. In the courts, representatives of the law enforcement community have sued the Black Lives Matter movement and other organizations, claiming they are responsible for violence against officers. In one instance, the father of a Dallas Police Officer killed in an ambush by an offender specifically targeting law enforcement, sued the Black Lives Matter movement and others, who the complainant argues "have convinced their supporters that there is a civil war between blacks and law enforcement, thereby calling for immediate violence and severe bodily injury or death" [6]. A similar suit "claims Black Lives Matter leaders incited others to harm police in retaliation for the death of black men killed by police" [7]. The United States has a long history and tradition of local control over law enforcement; this has manifested in nearly 18,000 state and local law enforcement agencies that operate outside of any unified command and control structure. As such, the best way to model public and law enforcement knowledge of lethal interactions-a prerequisite to retaliatory violence-is through media coverage. Over the last two years the media in general, and social media in particular, have been increasingly used to inform the public of violence between law enforcement and the public. In a more recent editorial, Heather MacDonald quotes New York Police Commissioner James O'Neill as stating that a suspect who killed a police officer "'hated the police'-...because he had heard and read 'countless times' in conversation, on television and in the newspapers that cops were the 'bad guys."' [8]. This reference to the perceived power of the media, and given the rise of social media and its centrality to organizing movements such as BLM, demonstrates why it is important to assess the role of media, if any, in these fatal interactions. This research examines these relationships, and seeks to answer the questions of whether there is any evidence of retaliatory violence between the two groups of victims, and to what extent social media plays a role in inciting these acts of violence. --- Fatal law enforcement & civilian encounters Research focused on police shootings and criminal homicide is limited. A literature search yielded about a dozen published studies that have empirically assessed this relationship since 1970. A significant problem that persists to the present day is the lack of adequate data about police shootings. While the government has invested in collecting detailed information about officers killed in the line of duty, there has been less investment in collecting data on police use of force and justifiable and non-justifiable homicides by police. This has led to recent data collection efforts by media organizations such as The Guardian and The Washington Post, as well as crowd-sourced efforts such as www.killedbypolice.net, to enumerate individuals killed by law enforcement. The utility of these data collection efforts is demonstrated by the Justice Department's recent reliance upon them to improve the validity and reliability of their own data [9]. The earliest reported U.S. studies relied on either Vital Statistics data or administrative data for either a single agency or a small collection of agencies, and typically used cross-sectional designs and bivariate analytic methods (see [10][11][12][13][14][15]). These early studies were fairly consistent in finding a relationship between police shootings and criminal homicide, but were unable to draw conclusions about the direction of the relationship. The first reported longitudinal analysis, conducted in 1986 using NYPD data, concluded that the bivariate relationships reported in the literature were likely spurious [16]. In the early 1990's, researchers turned their attention toward the FBI's Supplemental Homicide Reports (SHR) and subsequent research has consistently reported finding a relationship between various measures of community violence and police shootings (see [17][18][19][20]). One longitudinal study, conducted in 2001 using SHR data, reported a temporal relationship between predatory homicides and police shootings at the national level [21]. However, it is important to note that the time-series analysis used to model the relationship implicitly assumes that there is no feedback between variables. Specifically, it models police shootings as a function of predatory homicides, ignoring the fact that police homicides can, in turn, impact levels of predatory homicide. This is an inherent problem with this type of time-series analysis and in most instances represents a misspecification of the model [22]. In sum, the current state of knowledge about the temporal relationship between police shootings and criminal homicide is extremely limited. While there is evidence of a bivariate relationship between violence and police shootings across time, location, levels of analysis, data sources, analytic methods, and theoretical frameworks, absent from the literature is a longitudinal study that accounts for the cyclical relationship between the variables under study as well as competing explanatory variables, such as media coverage as contagion. --- Social media as contagion There is evidence that the media can act as a contagion, not only spreading ideas and information, but also emotions. For this study, we reason that for there to be retaliatory violence, citizens and law enforcement must be aware of the initial acts of violence. If a minority citizen is shot and killed by police and there is no media coverage of the event, it is difficult to argue that the killing of a law enforcement officer a day or a week later is driven by the prior fatal encounter. It is therefore important to understand how social media coverage of such events might communicate information about deadly encounters across social networks. Both traditional and social media can act as an emotional contagion, spreading fear, anger and other negative affects in addition to pure information. Social media has been shown to directly impact the emotions of those consuming it. For example, looking at the social media activity of millions of Facebook users, it has been demonstrated that rain decreased the frequency of posts with a positive connotation while increasing those with a negative connotation [23]. Importantly, the researchers also found that an increase in user's negative posts significantly decreased the frequency of positive posts by individuals within their social networks, even though those friends were not physically located in areas with inclement weather. An experimental study that manipulated the Facebook content provided to hundreds of thousands of users found that reducing the number of positive posts to which users were exposed significantly decreased the frequency of positive words they used in subsequent posts, and a similar effect was found for decreasing posts with a negative connotation leading to the use of fewer negative words [24]. These studies provide empirical support that a person's emotional state and, subsequently, how they express themselves can be directly impacted by their social media networks. In addition, research has demonstrated that tweets with a negative or positive sentiment are retweeted more often and faster than tweets with a neutral message [25]. This behavior could impact the breadth and speed of dissemination of social media messages related to fatal encounters between law enforcement and the public. Due to the emotionally charged nature of BLM for supporters and non-supporters alike, one would expect that tweets referencing the movement would be anything but neutral in their content. This has implications for the contagion of social media and could explain why #BlackLivesMatter was one of the top hashtags used in 2015, a period that encompasses almost two-thirds of the time period under study for this research [26]. This evidence of social media contagion and the spread of negative emotion is important when viewed through the lens of General Strain Theory (GST) [27][28][29][30]. From this perspective, fatal law enforcement-citizen encounters perceived as illegitimate are a source of strain (negative stimuli) generating negative emotions (primarily anger). Due to the particularly unjust nature and high magnitude of this strain (as spread through social media), it is likely that these negative emotions will catalyze negative behaviors (such as retaliatory aggression) in order to reduce the strain. Individual traits and group pressures may also amplify the likelihood that this strain leads to retaliatory aggression. While tests of GST are somewhat mixed, there is ample support for these mechanisms. Although research on media effects has not specifically examined the relationship between social media and fatal law enforcement-citizen encounters, it does provide evidence that social media coverage of these events could potentially increase the likelihood of future events. To further our understanding of the phenomenon, we explore whether there is evidence that violence between law enforcement and the public is retaliatory in nature and whether there is a media contagion effect that heightens the risk of further violence. --- Research design & measures We use a structural vector-autoregressive (SVAR) model to analyze the contemporaneous, cyclical and dynamic relationships between variables. The SVAR model controls for temporal ordering and accounts for the relationship that these variables have on each other during the same day (i.e., without a lag). For additional background and technical detail on SVAR models, please see the Supporting information section. Although the SVAR model is considered by some to facilitate drawing causal inferences from time series data, we caution readers that the strongest causal arguments are drawn from experimental methodologies and therefore our results should be interpreted as associations between variables, not causal relationships. For our analysis, we examined four variables across two models. • LAW: The number of law enforcement officers shot to death per day • MINORITIES: The number of minorities shot to death by law enforcement per day • WHITES: The number of white non-Hispanics shot to death by law enforcement per day • TWITTER: The number of tweets with #BlackLivesMatter or "Black Lives Matter" that were posted per day The number of law enforcement officers shot in the line of duty was taken from data provided by the Officer Down Memorial Page [31], which is made publicly available through their website under fair use for educational purposes. This database allows us to identify the number of officers who were killed by non-accidental gunfire from January 1, 2015 through September 30, 2016, the time period under study for this research. We focus specifically on the number of officers shot to death to mirror the data we used for citizens killed, which also focuses specifically on interactions where individuals are shot during fatal law enforcement-citizen encounters. The number of individuals killed by law enforcement was taken from The Washington Post database tracking citizens shot and killed during interactions with law enforcement in the United States [32], which is made publicly available on their website under a creative commons license. The data are collected through news reports, Internet reports, and public records. In addition to identifying those killed, The Washington Post also collects data on victim demographics, most important to this research being race and ethnicity. This variable was used to divide the list of victims into two categories-minorities shot and killed by law enforcement and white non-Hispanics shot and killed by law enforcement. If the race or ethnicity was unknown, these individuals were counted as white non-Hispanic, as the lack of an identifiable minority status would in theory be treated by the BLM movement similarly to the shooting death of a white non-Hispanic. The number of minority victims and white non-Hispanic victims were then aggregated to a daily count for the analysis. For both datasets, it is important to acknowledge the limitations. Each dataset collects data solely on individuals who are shot and killed, which will not represent non-shooting deaths that also may have had a high profile. For example, the deaths of Freddie Gray and Sandra Bland who died while in custody of state actors in the criminal justice system. These deaths were acknowledged by the Black Lives Matter movement, but yet are not represented in our data. To measure social media exposure, we used Twitter data as a proxy for immediate, social media reaction to law enforcement/citizen violence. Twitter was chosen over other social media services, such as Facebook, as all tweets are accessible to the public, regardless of whether someone is a "friend" or "follows" a user. We used Google advanced search to identify tweets that included either the the entire phrase "Black Lives Matter" or the hashtag #BlackLi-vesMatter. The advanced search allowed us to focus only on results that were connected to www.twitter.com, had the word "status" in the URL (limiting the results to posts), and occurred on a specific day using Twitter's date abbreviation format (e.g. "1 Jan 2015" or "30 Sep 2016"). The final search string resembled the following: ("1 Jan 2015") AND ("blacklivesmatter" | "black lives matter") AND (site:twitter.com) AND (inurl:status) Each search resulted in a count (provided by Google) of results returned based on the advanced search string. These tweets could support, oppose, or be neutral of the Black Lives Matter movement. They are best thought of as a proxy for the amount of social media attention focused on law enforcement and citizen encounters that end in a death, especially where the citizen was a racial or ethnic minority. The results were disaggregated into a single count for each day under study. However, as one reviewer pointed out, the data we use weighs all tweets the same, regardless of the number of consumers for each tweet. For example, an individual with five followers who tweeted using #BlackLivesMatter has the same effect on the model as a twitter handle who tweeted using the same hashtag that had five million followers. Similarly, our measure of social media does not control for the frequency of tweets by each twitter account and therefore prolific tweeters will have a larger impact on the model, regardless of their reach. Finally, our data does not measure whether the tweets are actually about the death of a citizen through lethal use of force or the death of an officer in the line of duty. These are inherent limitations to the data we collected. Table 1 shows the summary statistics for the variables used in the analysis. One can observe that the data is dominated by zeros. To deal with this issue we follow the approach proposed by Burbrdge, Magee and Robb (1988) [33], who expand on Johnson (1949) [34], and perform an inverse hyperbolic sine (IHS) transformation on each of the homicide count variables, as follows: g t 1<unk>4 ln<unk>yY t <unk> ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ffi 1 <unk> y 2 Y 2 t q <unk>1<unk> where g t is the transformed variable and <unk> is set equal to one. The IHS transformation is used "... to reduce the influence of extreme observations of the dependent variable on the regression" [33]. Therefore, we can run linear regression models on the transformed data and interpret the coefficients as if we were using a natural log transformation (i.e., in percentages). This transformation was applied to all data series, including Twitter data, to maintain consistency. Table 2 shows the summary statistics for the transformed variables. The following plots show that the IHS transformation of homicide rate preserves the properties of the original data. --- Stationarity tests To appropriately estimate time series models, particularly the one proposed in this research paper, it is imperative to work with stationary series. To test whether each time series is stationarity, we used an Augmented Dickey-Fuller (ADF) test and a KPSS test [35]. The null hypothesis under the ADF test is non-stationary, and we look for evidence to reject such a claim. It is a well known fact that the power of such test is relatively low because it is biased toward not rejecting the null even if the data generating process is stationary. Also, the power of this test diminishes even more when deterministic components such as intercept and trend are added to the model [36]. Therefore, we use the KPSS test as a robustness check. On the contrary, the null hypothesis under the KPSS test is stationarity. Table 3 shows the results from both tests. All series are stationary except for Twitter data. Because the Twitter series is nonstationary, it needs to be transformed (i.e., differenced). --- Econometric model estimation and results To examine the relationship between law enforcement killed by citizens, citizens killed by police (minorities and whites) and "Black Lives Matter" (BLM) twits, we start with the following reduced-form model: law t 1<unk>4 a 10 <unk> P p k1<unk>41 a 2k law t<unk> k <unk> P p k1<unk>41 a 3k ctz t<unk> k <unk> P p k1<unk>41 a 4k twt t<unk> k <unk> e law;t ctz t 1<unk>4 b 10 <unk> P p k1<unk>41 b 2k law t<unk> k <unk> P p k1<unk>41 b 3k ctz t<unk> k <unk> P p k1<unk>41 b 4k twt t<unk> k <unk> e ctz;t twt t 1<unk>4 g 10 <unk> P p k1<unk>41 g 2k law t<unk> k <unk> P p k1<unk>41 g 3k ctz t<unk> k <unk> P p k1<unk>41 g 4k twt t<unk> k <unk> e twt;t<unk>2<unk> where law is the number of law enforcement killed by citizens per day, ctz = (minorities, whites) is the number of citizens killed by law enforcement per day, twt is the first difference of the number of "Black Lives Matter" tweets per day, and e law,t, e ctz,t and e twt,t are the reduced-form residuals. In matrix form, system (2) can be re-written as: Z t 1<unk>4 D 0 <unk> D 1 Z t<unk> 1 <unk>... <unk> D p Z t<unk> p <unk> e t<unk>3<unk> where Z t 1<unk>4 and p is the lag order selected based on the Akaike Information Criterion (AIC). The problem of working with a reduced-form model is that the effect of a one-time shock to any of the variables in the system does not convey any information about the dynamics of the variables under study because reduced-form shocks are correlated. That is, they are composites of the structural shocks. The structural shocks, on the other hand, are orthogonal and therefore uncorrelated by design. This relationship is represented as e t = A -1 <unk> t. In matrix form: e law; where <unk> law,t, <unk> ctz,t and <unk> twt,t are the corresponding structural shocks, and A <unk> 1 1<unk>4 1 d 12 d 13 d 21 1 d 23 d 31 d 32 1 2 4 3 5 is the matrix of contemporaneous effects. To disentangle the effects of structural shocks, which are uncorrelated, it is necessary to recover the elements of A -1 (this is commonly referred to as the identification problem). The identification approach used in this study, which was first introduced by Rigobon [38] and is based on the heteroskedasticity of structural shocks, allows as to achieve this goal by identifying regimes of high and low volatility in second moments. Under the assumption of homoskedasticity, the variance-covariance matrix derived from Eq (4) can be specified as follows: var<unk>e law <unk> 1<unk>4 var<unk> law <unk> <unk> d 2 12 var<unk> ctz <unk> <unk> d 2 13 var<unk> twt <unk> cov<unk>e law ; e ctz <unk> 1<unk>4 d 21 var<unk> law <unk> <unk> d 12 var<unk> ctz <unk> <unk> d 13 d 23 var<unk> twt <unk> cov<unk>e law ; e twt <unk> 1<unk>4 d 31 var<unk> law <unk> <unk> d 12 d 32 var<unk> ctz <unk> <unk> d 13 var<unk> twt <unk> var<unk>e ctz <unk> 1<unk>4 d 2 21 var<unk> law <unk> <unk> var<unk> ctz <unk> <unk> d 2 23 var<unk> twt <unk> cov<unk>e ctz ; e twt <unk> 1<unk>4 d 21 d 31 var<unk> law <unk> <unk> d 32 var<unk> ctz <unk> <unk> var<unk> twt <unk> var<unk>e twt <unk> 1<unk>4 d 2 31 var<unk> law <unk> <unk> d 2 32 var<unk> ctz <unk> <unk> var<unk> twt <unk>5<unk> 8 > > > > > > > > > > > > > > <unk> > > > > > > > > > > > > > > : Notice that system (5) has 6 equations and 9 unknowns: <unk> law, <unk> ctz, <unk> twt, <unk> 12, <unk> 13, <unk> 21, <unk> 23, <unk> 31, and <unk> 32. Therefore, it cannot be consistently estimated. By identifying more than one regime in the variances of structural shocks, it is possible to solve system (5) without additional restrictions. That is, we can estimate the following system, where i = 1, 2 denotes the regime: var<unk>e <unk>i<unk> law <unk> 1<unk>4 var<unk> <unk>i<unk> law <unk> <unk> d 2 12 var<unk> <unk>i<unk> ctz <unk> <unk> d 2 13 var<unk> <unk>i<unk> twt <unk> cov<unk>e <unk>i<unk> law ; e <unk>i<unk> ctz <unk> 1<unk>4 d 21 var<unk> <unk>i<unk> law <unk> <unk> d 1;2 var<unk> <unk>i<unk> ctz <unk> <unk> d 13 d 23 var<unk> <unk>i<unk> twt <unk> cov<unk>e <unk>i<unk> law ; e <unk>i<unk> twt <unk> 1<unk>4 d 31 var<unk> <unk>i<unk> law <unk> <unk> d 12 d 32 var<unk> <unk>i<unk> ctz <unk> <unk> d 13 var<unk> <unk>i<unk> twt <unk> var<unk>e <unk>i<unk> ctz <unk> 1<unk>4 d 2 21 var<unk> <unk>i<unk> law <unk> <unk> var<unk> <unk>i<unk> ctz <unk> <unk> d 2 23 var<unk> <unk>i<unk> twt <unk> cov<unk>e <unk>i<unk> ctz ; e <unk>i<unk> twt <unk> 1<unk>4 d 21 d 31 var<unk> <unk>i<unk> law <unk> <unk> d 32 var<unk> <unk>i<unk> ctz <unk> <unk> var<unk> <unk>i<unk> twt <unk> var<unk>e <unk>i<unk> twt <unk> 1<unk>4 d 2 31 var<unk> <unk>i<unk> law <unk> <unk> d 2 32 var<unk> <unk>i<unk> ctz <unk> <unk> var<unk> <unk>i<unk> twt <unk>6<unk> 8 > > > > > > > > > > > > > > > > <unk> > > > > > > > > > > > > > > > > : In this case, system (6) has 12 equations and 12 unknowns, which allows us to solve for the structural parameters (contemporaneous coefficients and variances). This method is similar to using instrumental variables to solve for the endogeneity problem. The difference is that it is applied to the variance-covariance matrix of reduced-form residuals [38]. Here, an instrument is the additional heteroskedasticity regime that has been identified. The next step in the estimation procedure is to identify regimes in which the relative variances of the structural shocks have changed over time. To do so, we study the behavior of historical volatilities since they are expected to reflect such changes. In this case, the weekly historical volatility was calculated using daily data with 20-day windows. To systematically find a regime change, structural break tests are conducted in the historical volatility of Twitter data. We used the [39] test to find multiple breaks, allowing up to 5 breaks, and used a trimming of at least 0.15, so that each segment has a minimum of 15% of the observations in the sample. The best number of breaks was selected based on the Bayesian information criterion (BIC). Results are depicted in Fig 4. The dotted line indicates the break date, and the horizontal red lines represent the 95% confidence bands for the identified break. The high volatility regime for the Twitter data occurs after July 1, 2016. Therefore, the period before this date is defined as the low volatility regime. To make sure we have correctly identified high and low volatility regimes, we can test whether the variances of <unk> law, <unk> ctz and <unk> twt in the high volatility regime are systematically larger than the corresponding variances in the low volatility regime. Results of this test are presented below. Once the regimes have been identified, we proceed with the estimation of two different structural models. Model 1 includes law enforcement killed by citizens, number of minorities killed by police, and BLM tweets. Model 2 includes law enforcement killed by citizens, number of white non-Hispanics killed by police, and BLM tweets. By estimating these models we can test if there are differences in police reactions following a one-time structural shock to each group. Note that this procedure is carried out in four steps. In the first step, the reduced form VAR model is estimated as described in system (2). Based on the Akaike Information Criterion (AIC), the lag length of 2 weeks (p = 2) was selected. In the second step, model residuals are obtained and used to construct the variance-covariance matrix for both high and low volatility regimes. In the third step, these variance-covariance matrices are used to estimate system (6). Results from the estimation of this system are the contemporaneous coefficients and structural shock variances. The standard errors are calculated using a fixed-design wild bootstrap with 500 replications. Finally, after recovering structural parameters, we are able to conduct the analysis of impulse response functions. Results from the estimation of contemporaneous parameters and structural shock variances are presented in Tables 4 and5. Recall that the difference between model 1 and 2 is the racial/ ethnic background of the citizens killed by police. Model 1 uses minorities, while model 2 uses white non-Hispanics. First, we focus on the ratios of the estimated variances of structural shocks from system (6). These are used to verify we achieved identification as the variances in the high volatility regime are expected to be greater than those in the low volatility regime. Therefore, p-values for the tests of the null hypotheses H 0 : var<unk> <unk>1<unk> g <unk>=var<unk> <unk>2<unk> g <unk> 1 for g = law, ctz, twt, are included. The bootstrapped p-values are less than 0.01 in all cases, except for minorities in model 1. This result is expected because the high volatility regime for this variable was regime 2. In both models, the variance of structural shocks for the Twitter data is three times larger in regime 1 (high volatility) compared to regime 2 (low volatility). This is to be expected since public opinion post July 1, 2016 is captured by an increased variation of BLM tweet changes. In model 1, the variance of law enforcement killed is 66% higher in regime 1 than in regime 2 (0.0970 vs. 0.0582). This means that post July 1, 2016 events are associated with a higher variation in the number of officers killed. Given that this series (law enforcement killed) is stationary with a zero lower bound, an increase in the variation can only come from the increased killings of police officers. This claim is supported by the Dallas shootings in July 7, 2016. In the same model, the variance of minorities killed by police is 23% smaller in regime 1 compared to regime 2 (0.3303 vs. 0.4317). This indicates that the events post July 1, 2016 are associated with a decrease in the number of minorities killed by police. Again, this series is stationary with a zero lower bound, therefore a decrease in variance can only come from the decrease in the number of minorities killed. This indicates that the low volatility regime for minorities shot and killed by law enforcement corresponds to the high volatility regime for Twitter and police officers shot and killed by citizens. In model 2, the variance of law enforcement killed is 74% higher in regime 1 than in regime 2. This is consistent with model 1. In the same model, the variance of white non-Hispanic citizens killed by law enforcement is 5% higher in regime 1 than in regime 2 (0.2672 vs. 0.2547). Even though the ratio is statistically significant, it is small from a practical point of view. This tells us that the relative frequency of law enforcement officers shooting white non-Hispanics did not substantially change in the post July 1, 2016 time frame even though the number of minorities killed in the same period decreased, on average. Overall, these results indicate that the large increase in the variances of the structural shocks in the selected high volatility regime, specifically the BLM twitter activity, is sufficient to achieve identification. Following Lanne, Lu <unk>tkepohl and Maciejowska [40] we also tested for the uniqueness requirement to check if identification has been achieved. It implies that the change in the relative variance should not be homogeneous across variables in the system. The null hypothesis tested is: H 0 : var<unk> <unk>1<unk> j <unk> var<unk> <unk>1<unk> k <unk> = var<unk> <unk>2<unk> j <unk> var<unk>2<unk> k <unk> 6 1<unk>4 1 for j 6 1<unk>4 k 2 1<unk>2law; ctz; twt and was conducted using the bootstrap results. The results confirmed that we have achieved identification. Continuing with Table 4, we now focus on the estimates of contemporaneous coefficients (off-diagonal elements of matrix A -1 ). The p-values for the tests of statistical significance of contemporaneous effects H 0 : <unk> jk = 0 for j = 1, 2, 3 and k = 1, 2, 3 such that j 6 1<unk>4 k are also reported. All parameters, with exception of the effect of a shock to minorities killed on the number of BLM tweets, are statistically significant at the 0.01 level. • On average, a 1% increase in the number of minorities killed (MINORITIES) is associated with a 0.09% decrease in the number of law enforcement deaths (LAW) the same day the shock occurs. The same shock has no effect on the growth rate of BLM tweets (TWITTER). • A 1% shock (increase) to LAW increases MINORITIES by 0.63%, and decreases the growth rate of TWITTER by 27% the same day the shock occurs, on average. • On average, a 1% shock (increase) to TWITTER increases LAW by 1.25%, and increases MINORITIES by 0.82% the same day the shock occurs. Focusing on the contemporaneous coefficients in model 2 (Table 5), we can observe that all of the parameters, with the exception of the effect of a shock to the BLM tweets on the number of white non-Hispanics killed by law enforcement, are statistically significant at 0.01 level. One can observe that some shocks have different effects either in magnitude or sign than in model 1. • On average, a 1% increase in the number of white non-Hispanics (WHITES) is associated with a 0.2% increase in LAW on the same day. Compare this to model 1 where the same 1% shock to MINORITIES reduces the number of dead police officers by 0.09%. • A 1% shock to LAW decreases WHITES on the same day by 0.83%, on average. This is different from model 1 where the same shock increases MINORITIES by 0.63%. • A 1% shock to TWITTER has no effect on WHITES on the same day (coefficient is statistically insignificant), yet the same shock increases the MINORITIES by 0.82% in model 1. • A 1% shock to WHITES causes a 0.04% drop in TWITTER, yet the same 1% shock to MINORITIES killed has no

We examine whether retaliatory violence exists between law enforcement and citizens while controlling for any social media contagion effect related to prior fatal encounters. Analyzed using a trivariate dynamic structural vector-autoregressive model, daily time-series data over a 21-month period captured the frequencies of police killed in the line of duty, police deadly use of force incidents, and social media coverage. The results support a significant retaliatory violence effect against minorities by police, yet there is no evidence of retaliatory violence against law enforcement officers by minorities. Also, social media coverage of the Black Lives Matter movement increases the risk of fatal victimization to both law enforcement officers and minorities. Possible explanations for these results are based in rational choice and terror management theories.

exception of the effect of a shock to the BLM tweets on the number of white non-Hispanics killed by law enforcement, are statistically significant at 0.01 level. One can observe that some shocks have different effects either in magnitude or sign than in model 1. • On average, a 1% increase in the number of white non-Hispanics (WHITES) is associated with a 0.2% increase in LAW on the same day. Compare this to model 1 where the same 1% shock to MINORITIES reduces the number of dead police officers by 0.09%. • A 1% shock to LAW decreases WHITES on the same day by 0.83%, on average. This is different from model 1 where the same shock increases MINORITIES by 0.63%. • A 1% shock to TWITTER has no effect on WHITES on the same day (coefficient is statistically insignificant), yet the same shock increases the MINORITIES by 0.82% in model 1. • A 1% shock to WHITES causes a 0.04% drop in TWITTER, yet the same 1% shock to MINORITIES killed has no statistically significant effect on TWITTER in model 1. --- Impulse response analysis After identifying the contemporaneous effects in each system, we are now interested in evaluating the total effect, contemporaneous and lagged, of a 1% shock to each of the endogenous variables on itself and on the rest of the endogenous variables in the system. To do this, we focus on the calculation of impulse response functions (IRF). Figs 5 and 6 present the IRFs that were calculated based on the identification through heteroskedasticity scheme described earlier. This allows us to run through a sequence of scenarios to examine, for example, what would happen to the number of minorities killed the day of, or any reasonable arbitrary number of days after, an unexpected increase in the number of law enforcement officers killed by citizens. Or we can ask, what effect a shock to BLM tweets will have on the number of law enforcement killed by citizens and the number of citizens killed by law enforcement? We plot the IRF based on the original estimation from the data (solid line) as opposed to the median or mean IRF from the simulated data (in both cases the results are very similar), as well as one and two standard deviation bands represented by dashed and dot-dashed lines, respectively. The X-axis represents the number of days from the initial shock to the variable of interest. Here, we plot impulse responses up to 7 days after the shock. An effect is considered statistically significant for the period of time in which the upper and lower 95% confidence bands are either above or below zero. If the 95% confidence interval includes zero, the response of the variable in question is statistically insignificant, meaning that the response of that variable to a particular structural shock is null. Since the TWITTER variable is in first differences, while the rest of the variables are in levels, we plot the cumulative IRF of this variable to a 1% shock to each of the endogenous variables in the model to be consistent with the interpretation of the IRF of the variables that are in levels. --- Fatal law enforcement & minority civilian encounters The first relationship of significance from Fig 5 includes LAW, which has an immediate and significant positive association with MINORITIES that becomes insignificant after the first day. This means that an unexpected 1% shock to the number of law enforcement officers shot to death in a day is associated with a 0.63% increase in the number of minority citizens shot to death on the same day, on average. Alternatively, a 100% increase in LAW is associated with a 63% increase in MINORITIES, net any effect attributed to the number of tweets that reference Black Lives Matter. In practical terms, if the number of law enforcement officers killed in one day doubles from the average, there are an additional 0.8 minorities shot to death for one day. MINORITIES has an immediate and significant negative association with LAW that becomes insignificant after the first day, which is associated with a 0.09% decrease in the number of law enforcement officers shot to death. In practical terms, if the number of minorities killed in one day doubles from the average, there are in 0.01 fewer law enforcement officers shot to death for one day. TWITTER has an immediate and significant positive association with MINORITIES that becomes insignificant after the first day, which is associated with an 0.82% increase in the number of minority citizens shot to death on the same day. In practical terms, if the number of tweets related to Black Lives Matter doubles from the average, there are an additional 1.02 minorities shot to death that day. Similarly, TWITTER has an immediate and significant positive association with LAW that becomes insignificant after the first day, which is associated with an increase in the number of law enforcement shot to death in a day by more than 1.25%. In practical terms, if the number of tweets related to Black Lives Matter doubles from the average, there are an additional 0.16 law enforcement officers shot to death that day. --- Fatal law enforcement & white-non Hispanic civilian encounters Fig 6 mirrors the model presented in the previous subsection, however, the number of minorities shot to death by law enforcement is replaced with the number of white non-Hispanics shot to death by law enforcement (WHITE). LAW has an immediate and significant negative association with WHITE that becomes insignificant after the first day. An unexpected 1% shock to the number of law enforcement officers shot to death in a day is associated with a 0.83% decrease in the number of white non-Hispanic citizens shot to death on the same day. Or, a 100% increase in LAW is associated with an 83% decrease in WHITE, net any effect attributed to the number of tweets that reference Black Lives Matter. In practical terms, if the number of law enforcement officers shot to death doubles from the average, there are 1.2 fewer white non-Hispanics shot to death that day. WHITE has an immediate and significant positive association with LAW that becomes insignificant after the first day, which is associated with a 0.2% increase in the number of law enforcement officers shot to death on the same day. In practical terms, if the number of white non-Hispanics shot to death doubles from the average, there are an additional 0.03 law enforcement officers shot to death that day. Moreover, TWITTER has an immediate and significant positive impact on LAW that becomes insignificant after the first day, which is associated with an increase in the number of law enforcement shot to death in a day by more than 1.2%. In practical terms, if the number of tweets related to Black Lives Matter doubles from the average, there are an additional 0.16 law enforcement officers shot to death that day. Also of interest, was the relationship between these shooting deaths and both the social media and general media coverage of law enforcement/citizen fatal encounters. An unexpected shock to law enforcement killed is associated with a significant, immediate and prolonged decrease in the amount of media content published in both models. This same media suppression pattern appeared when white non-Hispanics was shocked. A shock to the number of minorities shot to death had no relationship with the number of tweets referencing Black Lives Matter. These results demonstrate that law enforcement and white deaths are associated with less coverage within all types of media, while minority deaths had no relationship. --- Results & implications Using a structural vector-autoregression framework, we analyzed daily data between January 1, 2015 and September 30, 2016, modeling the contemporaneous, cyclical relationship between the number of law enforcement officers shot to death in the United States, the number of citizens shot and killed by law enforcement in the United States, and the number of tweets that included #BlackLivesMatter or the term "Black Lives Matter." Two models were run, separating citizens killed into minorities and white non-Hispanics (See the Supporting information section for additional model information). Our results provide evidence of a retaliatory, violent relationship between law enforcement and citizens. Unexpected shocks to the number of law enforcement officers killed are associated with more minorities killed and fewer whites killed on the same day. In addition, our models found that unexpected increases in citizen deaths increased the number of law enforcement officers killed if the citizens were white non-Hispanics, and decreased the number of law enforcement officers killed if the citizens were minorities. These relationships held regardless of how much social media attention was focused on the Black Lives Matter movement. In an attempt to understand our results, we present two possible explanations for these homicide patterns taken from the economics and psychology literature. The rational choice perspective (see [41,42]) is the simplest and most direct explanation for the reduction in the number of officers shot and killed in the line of duty after a minority citizen is shot and killed. Based on the assumption that humans are rational beings who engage in cost-benefit analyses of their behaviors, rational choice theorists would argue that, when controlling for the amount of social media exposure, minority citizens would be cognizant of the high cost of an encounter with law enforcement officers after learning of the deaths of other members of the public who are minorities. In turn, this would alter their behaviors to reduce the likelihood of contact with law enforcement and, if contacted, increase behaviors that would reduce the risk of the encounter turning deadly. This would reduce the risk of routine contacts between law enforcement and the public escalating into a situation where an officer is killed in the line of duty. For a possible explanation of the relationship between law enforcement killed and minorities killed, we turn to the field of psychology and terror management theory, which posits that when individuals are death primed-that is, their mortality is either consciously or subconsciously salient-they are more likely to support the predominant cultural worldview of the society in which they live and react positively to those associated with ingroups of that worldview, and negatively to those who they associate as being part of outgroups [43]. This worldview defense has also been shown to increase levels of punitiveness [44]. Mortality salience does not have an equal impact on all individuals, but its effects have been shown to be more pronounced on those with lower self-esteem [45]. Experimental research has also shown that ingroup/outgroup identification extends to race as, in one study, whites were more likely to view white racists more positively when mortality was salient [46]. Law enforcement officers are hired and trained to support the dominant cultural worldview of the communities they serve through the enforcement of codified legal norms. Any increase in mortality salience should increase their defense of that worldview. In addition, the Black Lives Matter movement (and minorities through association) could be viewed as an outgroup, threatening the predominant worldview and the established culture of the criminal justice system. Terror management theory would assert that if law enforcement officers are made aware of the homicides of their colleagues, this death prime would increase their mortality salience and alter the ways in which they engage with individuals from perceived outgroups in order to defend their cultural worldview. This effect would only be temporary and would explain why the increase in the number of minorities killed is only significant on the same day in our models. In addition, officers who are death primed may underestimate the risk posed by those from their perceived ingroup (such as whites) and be less prepared to use fatal force against these individuals if a contact requires. This would explain the significant decrease in the number of white non-Hispanics killed after an officer is killed in the line of duty. We also found evidence of social media incitement. In both models, an unexpected shock to the number of tweets referencing the Black Lives Matter movement is associated with a significant and immediate increase in the number of law enforcement officers shot to death. The results measuring the relationship between social media and shootings of citizens were not as robust as an unexpected shock to the number of tweets referencing Black Lives Matter, which was associated with an immediate increase in the number of minorities killed by law enforcement, but had no relationship with the number of white non-Hispanics killed. --- Conclusion This study set out to examine whether there was evidence of retaliatory fatal violence between law enforcement officers and the public, while controlling for the prevalence of social media connected to the Black Lives Matter movement. The results show that there does appear to be retaliatory violence; specifically, that an unexpected shock to the number of law enforcement officers shot in the line of duty is associated with a significant increase in the number of minorities killed in the same day. However, unexpected shocks to minorities shot by law enforcement actually are associated with a significant decrease in the number of law enforcement officers shot, while shocks to white-non Hispanics shot by law enforcement are associated with increases in law enforcement officers killed. We frame these results through both terror management theory and rational choice theory although, to be clear, we did not explicitly operationalize and test these theories. Also, we acknowledge that our theoretical explanations are not definitive and competing explanations are plausible. For example, as one reviewer noted, police violence against citizens could be a sign of civil unrest, which law enforcement officers may interpret as an increase in risk to themselves and their colleagues, leading to a heightened use of defensive tactics that explains why no pattern of retaliatory violence was identified against law enforcement when a minority member of the public was shot. Specific to social media as a contagion, we found that an unexpected shock to tweets related to Black Lives Matter are associated with increases in both the numbers of law enforcement officers and minorities shot and killed. These results can be framed through research demonstrating that social media can spread negative affect and can do so quickly depending on the nature of the communication's message. While we would hesitate to draw firm policy implications until replication of the core findings as well as testing of policy options can be undertaken, our results suggest some potential directions that might be investigated in future research. First, although we do not claim that the observed increase in law enforcement shootings of minorities are non-justifiable uses of deadly force, this relationship between minorities and law enforcement signals the possibility of a disproportionate reaction to public killings of law enforcement officers based on race, especially when compared to the observed contrary relationship between whites and law enforcement. Future research might consider these results and how to address them in the context of: • Training: for example, experimentally manipulating mortality salience in order to explore its effect on trainee performance, and exploring training curricula that make officers aware of these patterns and provide guidance on how to mitigate the effects of social media contagion • Policies: for example, testing whether an agency's current systematic communications about officers killed in the line of duty across the country (which might unintentionally and needlessly increase the mortality salience of officers) could be limited, and with what effect, unless a specific threat to their agency and personnel exists • Levels of community engagement: for example, experimenting with providing officers opportunities to engage in meaningful outreach with minority communities to limit officer perceptions of minorities as being part of an outgroup. Second, although the First Amendment to the U.S. Constitution guarantees all Americans the freedom of speech, those who employ social media to advocate on behalf of, or against, social movements should also be cognizant of the real world impact of their communiques. While we would not suggest any undue restrictions on free speech, we note that similar to the oft-invoked example of yelling "Fire!" in a crowded theater where no fire exists, there are common sense limits to free speech that may apply to ill-considered social media declarations of a "war on cops" or of "racist" police. Those who have used the Black Lives Matter hashtag or terminology in ways meant to either empower or disenfranchise the movement may have brought along with their messages a heightened awareness of the life endangering conflict that occurs between law enforcement officers and minority communities and, in doing so, appear to increase the risk to both. --- All relevant data are within the paper and its Supporting Information files.

We examine whether retaliatory violence exists between law enforcement and citizens while controlling for any social media contagion effect related to prior fatal encounters. Analyzed using a trivariate dynamic structural vector-autoregressive model, daily time-series data over a 21-month period captured the frequencies of police killed in the line of duty, police deadly use of force incidents, and social media coverage. The results support a significant retaliatory violence effect against minorities by police, yet there is no evidence of retaliatory violence against law enforcement officers by minorities. Also, social media coverage of the Black Lives Matter movement increases the risk of fatal victimization to both law enforcement officers and minorities. Possible explanations for these results are based in rational choice and terror management theories.

Introduction Enterprises have to make differentiation strategies to better cope with market competition and provide social support to their stakeholders (Zhou et al., 2022). For example, some enterprises developed new social media technology and adopted online technology to meet the changing needs of stakeholders during the epidemic to reduce the economic losses under the crisis (Yu et al., 2022). More critically, the growing external stakeholder pressure has raised requirements higher for corporate social responsibility (Lu and Abeysekera, 2017). Generally, CSR is regarded as a more competitive strategy to promote firms' pro-environmental behaviors, and helps firms to obtain good reputations and enhance their relationships with stakeholders (Tang et al., 2021), thereby promoting firms' sustainable business performances (Mubeen et al., 2021). Hence, how to promote CSR strategy is of great importance in helping enterprises maintain sustainable development in the postepidemic era. The driving factors of corporate social responsibility (CSR) strategy have received wide attention from both academic and practical fields. Among them, executives' traits are an important dimension to explain the choice of CSR strategy. Extant studies mainly focus on executives' demographic characteristics, educational background, and working experiences on corporate social behaviors (McCarthy et al., 2017;Tang et al., 2018;Al-Shammari et al., 2019). Little attention has been paid to the impact of executives' early family experiences on their behaviors in the CEO suit. And the childhood family experiences may greatly affect individuals' cognitive formation, personal preferences, and behaviors. Birth order is a natural difference that would influence individuals' early family interactions, which may predict individuals' psychological behavior (Taubman-Ben-Ari, 2018), and persist for the longest duration during adulthood (Whiteman et al., 2011). Previous research about birth order mainly involved the sibling rivalry perspective, and explored the impact of birth order on individuals' risk-taking behaviors, such as smoking behavior (Slomkowski et al., 2005) and driving style (Taubman-Ben-Ari, 2018). Meanwhile, a few studies show that executives' birth order may also influence the firm's risk-taking behaviors where they work (Campbell et al., 2019). For example, Zheng L. J. et al. (2021) proposes that founders' birth order positively affects firms' innovation activities, which is usually known as one of the risk-taking behaviors. However, few studies have paid attention to sibling prosocial behaviors in addition to sibling rivalry, such as sharing, compassion, and help, especially in the business context. Considering that corporate social responsibility (CSR) behavior is usually seen as a typical prosocial behavior, this paper attempts to examine how executives' birth order affects corporate CSR behavior by considering their family traits. In order to answer the above question, this paper takes Chinese non-financial private listed companies from 2010 to 2017 as the research samples, and employs a fixed effect model of panel data to empirically test the relationship between CEO birth order and the firms' CSR behaviors. We also examine the moderating effects of the presence of a female sibling and the age gap between CEO and the closest sibling. The empirical results show that there is a significant negative relationship between CEO birth order and corporate CSR behaviors. The results of further studies suggest that the presence of a female sibling weakens the negative impact of CEO birth order on firms' CSR behaviors. And the relationship between CEO birth order and CSR behaviors would also be weakened when the sibling age gap is larger. This paper mainly contributes to three aspects: First, it enriches the studies of corporate social responsibility by exploring a new driving factor of CSR behavior from the perspective of CEOs' family traits. This paper explores how CEO birth order influences firms' CSR behaviors, and provides a new explanation of corporate CSR behaviors from executives' early family domain. Second, this study extends the research on the moderators of CEO birth order and CSR behaviors. To be specific, we mainly examine the moderating effects of the presence of a female sibling and the age gap between the CEO and the closest sibling and find that both the presence of a female sibling and a greater age gap would weaken the relationship between CEO birth order and CSR behaviors. Third, this paper advances the birth order research from sibling rivalry to sibling prosocial aspects. Previous studies mainly analyze the sibling effect on executives' behaviors based on the sibling rivalry view, while this paper integrates sibling prosocial tendencies and sibling rivalries into the same framework and proposes that sibling interaction may also shape executives' prosocial recognition and prosocial behaviors at their jobs. The research arrangement of this paper is as follows: The second part is the literature review and hypotheses. The next part proposes the data and methodology. The fourth part reports the empirical analysis results, and the last part is the research conclusion and discussion of this paper. --- Literature review and hypotheses Sibling a ection: Associate birth order with prosocial behaviors Sibling relationship is an important motivator in shaping children's social recognition and behavioral tendencies persisting into their adulthood. Sibling interaction is characterized by affection, companionship, sharing, and helping, so that positive interaction with siblings may be conducive to form young children's prosocial preferences and then prosocial behaviors (Hughes et al., 2018). Through continual sibling prosocial interaction, children tend to imitate their elder siblings or parents' behaviors (Dunn and Munn, 1986), which enables children to learn how to share, cooperate, and help each other. These behaviors are prone to provide a behavioral mode for prosocial behaviors with others. Sibling differences determine how children perceive the affection, warmth, competition, and conflict between siblings, which typically differ in age. Such age differences suggest that the elder children are more likely to express prosocial tendencies to their younger siblings by sharing, helping, and caretaking. Generally, when parents are busy with work and do not have enough time and energy to take care of the younger children, the elder children naturally take the responsibility for the younger siblings (Salmon et al., 2016). In this case, the elder siblings adopt more other-regarding behaviors toward the younger siblings, such as affection, help, and sympathy (Recchia and Howe, 2009). The early family experience of caring for younger siblings in childhood makes earlier-born children more likely to consider the feelings of others with empathy and affection (Otterbring and Folwarczny, 2022), and promotes their self-regulation and prosocial behavior (Padilla-Walker et al., 2010). By contrast, later-born children are more likely to form a self-interest tendency and less other-regarding or prosocial preferences, because they are often taken care of by others (Campbell et al., 2019). --- Sibling rivalry: Associate birth order with prosocial behaviors Sibling interaction might also be full of rivalries. Faced with sibling competition over family resources, children would try their best to show their own unique abilities and characteristics, so as to get special attention and treatment from parents and improve their ability to acquire family resources (Wang et al., 2009). Because children have individual differences, parents tend to adopt differential treatment and unequally allocate family resources according to their children's individual characteristics (Tucker et al., 2003). This differential treatment negatively affects the quality of interaction between siblings and reduces their prosocial tendency (Shanahan et al., 2008). Birth order is a natural difference that enables children to maximize family resources and parental investment in different ways (Blake, 1981), and would also influence children's attitude toward family members and others (Harper et al., 2016). Those early family sibling experiences determine individuals' behavioral decisions during childhood and thus the whole life span (Suitor and Pillemer, 2007). Birth order greatly influences sibling rivalry. For earlierborn children, parents have enough time and energy to care for them, and the household resources would also be relatively sufficient. Under this circumstance, sibling rivalries over family resources are relatively weaker (Booth and Kee, 2009). Moreover, elder siblings usually have a stronger ability of competition for resources (Freese et al., 1999), thus they easily get more household resources (Hotz and Pantano, 2015) and involve less in sibling rivalries. However, the amount of family resources available to each child would gradually decrease with the increase of the sibling number (Zheng M. et al., 2021). Meanwhile, the competition and conflict for parents' attention and family resources may be more intensified (Weng et al., 2019). Therefore, later-born children have to compete for parents' attention, time, and household resources with their elder siblings (Whiteman et al., 2011). Later-born children tend to be more competitive and unfriendly, which in turn stimulates individuals' short-term self-interest and makes them pay more attention to their own interests, thereby leading to more risky behaviors (Menesini et al., 2010;Solmeyer et al., 2013), antisocial behavior (Buist, 2010;Ensor et al., 2010) and fewer prosocial behaviors (Kretschmer and Pike, 2010;Buist and Vermande, 2014). --- CEO birth order and corporate social responsibility behavior Family factors, such as family size, play a crucial role in entrepreneurship performance (Ge et al., 2022). Birth order is an important factor in personal early family life, and may shape individuals' recognition formation and behavioral tendencies (Zheng M. et al., 2021). Based on sibling affection literature, earlier-born siblings tend to exhibit more prosocial behaviors, while later-born individuals are usually engaged in less prosocial behaviors (Hughes et al., 2018). Birth order shapes individual's prosocial or antisocial preferences, so that executives' birth order may be closely related to the social responsibility behaviors of the company where they work. Therefore, we propose that CEOs' birth order negatively affects their prosocial behaviors and consequently firms' CSR behaviors. According to sibling interaction research, earlier-born individuals usually have a higher sense of family responsibility. And they are more likely to care for their younger sibling(s) and sympathize with others through their other-regarding tendencies (Salmon et al., 2016). This childhood affection experience shapes earlierborn individuals prosocial preferences and enables them to have a stronger motivation to participate in prosocial activities (Otterbring and Folwarczny, 2022). These findings suggest that earlier-born CEOs have a greater tendency to adopt prosocial behaviors toward employees, the public, and other stakeholders, and may implement more CSR behaviors through their business decisions. By contrast, later-born CEOs are often attendee and have fewer family responsibilities, so they are prone to engage in less prosocial behaviors. In terms of sibling rivalry literature, CEO birth order affects parents' investment and the allocation of family resources; this early experience of sibling interaction was internalized into the CEOs' prosocial or antisocial bias. Earlier-born CEOs suffer less sibling rivalries and take much more family responsibility, which helps to form CEOs' prosocial orientations. This prosocial orientation improves the CSR behaviors that CEOs take in their executive suits. On the other hand, later-born CEOs have to compete more for family resources with their elder siblings, so they tend to form a sense of self-interest to maximize their own interests and less other-regarding preferences to others. This early family experience shapes CEOs' short-term selfinterests and weakens their prosocial preferences, which would also reduce their attention on corporate social responsibility behaviors in the companies they occupy. To sum up, the companies with the earlier-born CEOs might implement more social responsibility behaviors than those with the later-born CEOs. Based on the above analysis, this paper proposes the following hypothesis: Hypothesis 1: CEO birth order is negatively correlated to firms' CSR behaviors. --- Moderating e ect of the presence of a female sibling Prior studies in sociology posit that women usually exhibit much stronger other-regarding preferences than men (Andreoni and Vesterlund, 2001;Dufwenberg and Muren, 2006;DellaVigna et al., 2013). And women often show a greater willingness and responsibility to help others (Kamas et al., 2008;Willer et al., 2015). Research on feminine ethics in the business field also indicates that women entrepreneurs often attach more importance on household affairs (Ge et al., 2022), and women executives focus more on stakeholders' interests and working relationships. Moreover, female directors or executives pay more attention to corporate social responsibility (Post et al., 2011;Atif et al., 2020) and charitable donations (Einolf, 2011). Sibling interaction is a major family experience before adulthood, so the prosocial tendencies of female siblings could easily affect other siblings. The other-regarding preferences of women would be internalized into other siblings' behavioral tendencies through the family sibling interaction. When a CEO has an elder or little sister, the female sibling's otherregarding preferences are more likely to increase the focal CEO's prosocial orientation. Therefore, the presence of a female sibling moderates the relationship between CEO birth order and firms' CSR behaviors mainly through improving CEOs' prosocial preferences in their early family life, and weakens the negative influence of CEO birth order on firms' CSR behaviors. Hence, we posit the following hypothesis: Hypothesis 2: The relationship between CEO birth order and corporate social responsibility behaviors would be weakened when the focal CEO has a female sibling. --- Moderating e ect of sibling age gap Since CEO birth order shapes their behavior tendencies during childhood (Sulloway, 2009), and sibling rivalry is one of the key mechanisms behind birth order effects (Wan et al., 2021), it follows that the factors which influence sibling rivalry may inevitably influence birth order effects and individuals' behavioral preferences. Accordingly, we suppose that the negative effect of CEO birth order on corporate social responsibility behaviors would be strengthened when the sibling rivalry is greater. Instead, if an individual's early family experience had less sibling rivalries, the differential treatment generated by birth order might also accordingly reduce, thus the relationship between CEO birth order and CSR behaviors would also be weakened. Relevant research has shown that age gap influences the extent of sibling rivalry (Sulloway and Zweigenhaft, 2010). A smaller age gap indicates that siblings have to compete more fiercely for the scarce family resources and parents' attention (Badger and Reddy, 2009). And the elder siblings are less likely to care for the younger siblings under the conditions of a smaller age gap. But when the age gap is larger, siblings may have less rivalries for family resources, and parents also have more time and attention for their children over a greater age space (De Haan, 2010). Moreover, it is much more likely for the elder siblings to support their younger sibling when the age gap is larger, and the later-born siblings may also easily exhibit affection for their elder siblings (Dunn and Munn, 1986). Above all, a closer age gap intensifies sibling rivalry and makes siblings compete more for family resources and parents' time. In this case, there is less siblings' prosocial behaviors and more siblings' competition. Conversely, a larger age gap reduces sibling rivalry and increases siblings' other-regarding preferences by taking care of other siblings. It suggests that the negative effect of CEO birth order and corporate social responsibility behaviors would be weaker when there is a larger age gap between CEOs and the closest siblings, and stronger when the age gap is smaller. Then we assume the following hypothesis: Hypothesis 3: The relationship between CEO birth order and corporate social responsibility behaviors would be weakened when the age gap between a CEO and the closest sibling is larger and strengthened when the age gap is smaller. --- Theoretical framework of research model This study proposes a theoretical framework of the research model. This study investigates the relationship between CEO birth order and CSR behaviors of Chinese private firms, and further explores how the presence of a female sibling and age gap moderates the above relationship. Figure 1 describes the theoretical framework of the key factors. In this framework, CEO birth order is the independent variable, and CSR behavior is the dependent variable. Additionally, the presence of a female sibling and the sibling age gap are incorporated as the moderating variables. This study employs the fixed effects model of panel data to examine the impact of CEO birth order on CSR behaviors. --- Materials and methods --- Data and samples In this paper, the Chinese A-share private listed companies on the Shanghai Stock Exchange and Shenzhen Stock Exchange from 2010 to 2017 were taken as data samples. Due to the fact that the corporate social responsibility of state-owned enterprises is largely subject to government administrative intervention, it is hard to investigate the relationship between CEO personal traits and CSR performance. Therefore, we chose Chinese private enterprises as the research samples. Then we excluded ST and ST * samples, which refers to the companies that have been granted special treatment because of two consecutive years of losses, to avoid financial abnormality. The financial listed companies were also eliminated because of their high level of leverage. And samples with missing data of CEO birth order and other control variables were also excluded. Finally, we obtained 817 valid samples. The data of corporate social responsibility (CSR) behaviors was obtained from the HeXun website. Considering that Huxun began to disclose the CSR Ratings of Chinese listed companies from 2010, we chose 2010 as the starting point of empirical samples. The original data of CEO siblings was obtained from the China Stock Market and Accounting Research (CSMAR) Database, which contains the detailed information about the gender and age of CEOs' relatives. Since the CSMAR database no longer discloses the executives' kinship data after 2017, this study sample period ends by 2017. Other control variables were all from the CSMAR Database except industry data from the WIND database. In order to avoid the influence of extreme values, all the continuous variables were winsorized at the 1% level. --- Variable definition Dependent variable --- Corporate social responsibility behaviors According to Long et al. (2020), CSR behaviors are determined through the CSR ratings developed by HeXun, which has disclosed the social responsibility ratings of Chinese listed companies for many years and is usually used by Chinese scholars for CSR research. This CSR rating includes five aspects: responsibility for shareholders (30% weight), employees (15% weight), supply chain (15% weight), environment responsibility (20% weight), and social responsibility (20% weight). The HeXun CSR rating is mainly based on the corporate social responsibility reports and annual reports of Chinese listed companies, and could objectively and comprehensively measure CSR performance even for companies without disclosing the CSR report. The RKS CSR rating mainly targets Chinese listed companies that have disclosed corporate social responsibility reports, but cannot assign a CSR Rating of listed companies that have not disclosed CSR reports. However, the proportion of social responsibility reports disclosed by listed private enterprises is relatively low in China, and only 128 sample companies with CEO sibling data disclosed CSR reports from 2010 to 2017. Hence, we used HeXun CSR Ratings to measure firms' CSR behaviors instead of RKS CSR Ratings to ensure a relatively large sample size and objective research conclusion. --- Independent variable CEO birth order We first obtained the CEOs' names from the position information of Top Management Team (TMT) of listed companies in CSMAR Database. Then we further acquired the CEOs' sibling data from the TMT relatives database and dropped the samples without siblings. Based on the age of the CEOs and their siblings, the data of CEO birth order and the age gap between CEOs and their closest siblings were gleaned. Following extant studies, CEO birth order is ranked as the order CEOs were born. More precisely, the value of 1 was assigned to CEOs who are the first-born, and 2 for the second-born, etc. With reference to De Haan (2010) and Campbell et al. (2019), the CEO birth order was treated as a continuous variable in the regression models. In addition, we excluded the samples where CEOs were the only child. --- Moderating variables Presence of a female sibling On the basis of the gender information of CEO siblings, we determined whether there was a female sibling for the focal CEOs. The presence of a female sibling was measured by a dummy variable that assigned a value of 1 when the focal CEO has a female sibling, otherwise 0. --- Age gap The variable of age gap between CEOs and their closest siblings was measured as the absolute difference value of the age between focal CEOs and their closest siblings (e.g., Buckles and Munnich, 2012). For example, when a CEO is first-born, the immediate second-born sibling is the closest sibling. --- Control variables With reference to prior studies on CSR behaviors, we introduced a list of CEO-level and firm-level control variables to avoid the regression bias. Relevant studies on birth order suggest that the number of siblings is inevitably related to birth order (Booth and Kee, 2009), so it was necessary to control CEOs' number of siblings in the regression models. Meanwhile, previous studies have shown that CEO personal traits may influence corporate social responsibility behaviors (Cronqvist and Yu, 2017;Hao et al., 2019). Thus, we controlled for CEO degree, CEO gender (1 for female CEOs and 0 for male CEOs), and CEO overseas background (coded as 1 when the CEO had overseas study or work experience, otherwise 0). Second, we included several firm-level control variables into the regression models. Firm size was measured as the natural log of total assets. Financial leverage was calculated by the ratio of total liability to total assets. Return of Equity (ROE) was measured by the net income over average equity (Shaukat et al., 2016). Growth was measured as the growth rate of sales income. Additionally, we also controlled for governance-level variables. Board size (number of board directors), ratio of female directors (the proportion of female directors on board) (Landry et al., 2016), and ratio of directors with overseas background (the proportion of directors who have overseas study or work experience). The institutional shareholding ratio was measured as the number of institutional shareholders divided by the total number of shares (Dyck et al., 2019). H10 was calculated as the sum of the shares held by the top ten shareholders. Industry fixed effects and year fixed effects were all included in the regression models. --- Models According to the research hypothesis, we established Model (1) to test the impact of CEO birth order on firms' CSR behaviors. Model (2) and (3) were established to examine the moderating effects of the presence of a female sibling and age gap between a CEO and the closest sibling, respectively. Birthorder * Femalesib denotes the interaction term of CEO birth order and the dummy variable of the presence of a female sibling. Moreover, Birthorder * Agegap is the interaction term of CEO birth order and age gap between the focal CEOs and their Where <unk> is the residual error, <unk> i denotes the coefficient of control variables. Where Controls includes CEO degree, CEO gender, CEO overseas background, firm size, financial leverage, Return of Equity, Growth, Board Size, ratio of female directors, ratio of directors with an overseas background, Institutional shareholding ratio, and H10. --- Results analysis Descriptive statistics and correlation analysis Table 2 reports the descriptive statistics of the main variables. The average CSR score of the sample companies is 24.85, the standard deviation is 13.77, indicating that the performance of different companies in terms of CSR behaviors varies greatly. The mean of CEO birth order is 1.53, and the standard deviation is 0.68, showing that there is a small gap in CEOs' birth order among different companies. From the descriptive statistics of the control variables, the average sibling number of the focal CEOs is 1.27. The average degree of CEOs is 3.60, indicating that more than half of the CEOs have a bachelor degree or above. And 94% of the CEOs are male, and the proportion of female CEOs is very small. The percentage of female directors and directors with an overseas background on the board is 17 and 11%, respectively, indicating that the proportion of female directors is relatively low in the sample companies. The mean of H10 is only 0.18, which shows that there is still a high level of equity concentration. Descriptive statistics of all variables are shown in Table 2. Table 3 reports the correlations and the variance inflation factor (VIF). The average VIFs is <unk>2.0, far below the threshold of 10, so there is no serious multicollinearity problem in the regression process. --- Regression results analysis Table 4 reports the multiple regression results of CEO birth order and the firms' CSR behaviors. Hypothesis 1 assumes that CEO birth order is negatively correlated to CSR behaviors. The results of Model 1 show that the estimated coefficient between CEO birth order and CSR is -4.5781, and significant at the confidence level of 5% (b = -4.5781, p <unk> 0.05). Therefore, CEO birth order has a negative and statistically significant impact on firms' CSR behaviors. That is, earlier-born CEOs pay more attention to CSR than later-born CEOs. This conclusion also holds in Model 2 and Model 3 even when including the interaction terms. Hypothesis 1 is thus confirmed. In Hypothesis 2, this study predicts that the presence of a female sibling would weaken the negative relationship between CEO birth order and CSR behaviors. The results of Model 2 report that the estimated coefficient of the interaction term of of a female sibling significantly weakens the negative impact of CEO birth order on firms' CSR behaviors. Hence, Hypothesis 2 is supported. Hypothesis 3 theorizes the moderating effect of age gap on the relationship between CEO birth order and CSR behaviors. To examine this hypothesis, we introduce the interaction term of the age gap and CEO birth order in Model 3. The results of Table 3 suggest that age gap positively moderates the relationship between CEO birth order and CSR behaviors (b = 1.0217, p <unk> 0.10). Specifically, the negative impact of CEO birth order on firms' CSR behaviors would be weakened when the sibling age gap is larger, and strengthened when the age gap is smaller. The above results statistically support Hypothesis 3. With reference to Li et al. (2022), we further compare two figures to display the moderating effect of the presence of a female sibling and the age gap. Figure 2 shows the moderating role of the presence of a female sibling. It is easy to see that the presence of a female sibling would weaken the relationship between CEO birth order and corporate social responsibility behaviors. Figure 3 represents the moderating effect of sibling age gap. It indicates that the relationship between CEO birth order and CSR behaviors is weaker when the age gap between a CEO and the closest sibling is larger and stronger when the age gap is smaller. --- Robustness and endogeneity According to Campbell et al. (2019), we treat CEO birth order as three categories: first-born, middle-born, and lastborn, and then generate three dummy variables when CEOs are first-born, middle-born, and last-born, respectively. Column 1 of Table 5 reports the regression results including the dummy variable when CEOs are first-born, which shows that the firstborn CEOs are positively influenced toward CSR behaviors (b = 6.9568, p <unk> 0.05). Column 2 reports the result of the dummy variable of middle-born CEOs. The estimated coefficient of the dummy variable of middle-born CEOs is negative but not significant, which may be the result of the limited samples. Column 3 in Table 5 displays the impact on CSR behaviors when CEOs are last-born. The result indicates that the last-born CEOs are a significantly and negatively impacted toward CSR behaviors (b = -4.7025, p <unk> 0.10). The above results suggest that later-born CEOs would exhibit less CSR than earlier-born CEOs. In order to test the robustness of the moderating effect of the presence of a female sibling, we further divided the sample companies into two groups according to whether the focal CEO has a female sibling or not, to implement the regression process. Table 6 reports the grouped regression results. In Column 1, the result shows that when the focal CEO has a female sibling, the negative impact of birth order on CSR behaviors is relatively weakened. However, the result in Column 2 indicates that CEO birth order has a much stronger influence on CSR behaviors when the focal CEO is without a female sibling (b = -4.6836, p <unk> 0.05). Therefore, the negative relationship between CEO birth order and CSR behaviors is weakened when a CEO has a female sibling and strengthened when a CEO is without a female sibling. Based on the study of Baer et al. (2005), we further used a discrete measurement of age gap to test the moderating effect of the closest sibling age gap. Specifically, we created a dummy variable and code as 1 when the age gap between a CEO and the closest sibling is more than 3 years. Column 1 of Table 7 reports the result including the dummy variable of the closest age gap, which shows that a larger age gap weakens the negative impact of CEO birth order on CSR behaviors (b = 5.7597, p <unk> 0.01). The result also statistically supports Hypothesis 3. Moreover, we divided the samples into two groups on the basis of the age gap dummy variable to repeat the regression process of Model 1. The grouped results also indicate that a smaller age gap would strengthen the negative relationship between CEO birth order and CSR behaviors (b = -7.1490, p <unk> 0.01). According to Weng et al. (2019), we used a two-stage Heckman selection model and two exogenous variables to tackle the possible endogeneity bias caused by sample selection. The first one was sex of first child. In Chinese traditional cultural context, when the first child is a girl, parents are more likely to have more than one child to ensure that there is a boy to maintain the family. Therefore, sex of first child may influence the number of siblings and then birth order. The second exogenous variable is the family planning policies. based on the birth quota. Therefore, we marked the four phases as 0-3 corresponding to CEO birth year, to reflect the degree of government control for birth quota. Table 8 shows the results with Mills generated by the two exogenous variables, which are still in line with our main conclusion. --- Conclusions and implications --- Conclusions and discussion Enterprises are practicing CSR, business modes, and entrepreneurial networks with innovation and knowledge sharing to improve business performance (Rahmat et al., 2022;Zhou et al., 2022). Among the above activities, CSR is often considered as the basis of competitive advantages and an important way to increase firms' value (Tang et al., 2021). CEOs are highly correlated with firms' CSR activities (Mubeen et al., This paper constructs a theoretical framework to explore how CEO birth order influences corporate social responsibility behaviors. The study takes Chinese A-share private listed companies from 2010 to 2017 as data samples, to empirically test the relationship between CEO birth order and firms' CSR behaviors. The empirical results show that there is a significant and negative relationship between CEO birth order and firms' CSR behaviors. In other words, earlier-born CEOs tend to implement more CSR than later-born CEOs, while the laterborn CEOs are inclined to take less CSR behaviors. The findings of this paper are basically consistent with the previous literature of sibling prosocial behaviors and sibling rivalry (Zheng L. J. et al., 2021;Zheng M. et al., 2021). It suggests that earlierborn individuals are more likely to exhibit prosocial behaviors to their siblings and others. By contrast, later-born individuals are generally the ones being cared for, so they are more selfconcerned and have less prosocial preferences. This study further investigates the moderating role of the presence of a female sibling and sibling age gap on the relationship between CEO birth order and firms' CSR behaviors. The results show that the influence of CEO birth order on CSR behaviors will be weakened when the focal CEO has a female sibling. The above results support the view of female socialization, which proposes women usually have higher social preferences and tend to positively influence their family members' prosocial behaviors (Cronqvist and Yu, 2017). Moreover, the negative relationship between CEO birth order and firms' CSR behaviors would be weaker when there is a larger age gap between a CEO and the closest sibling, and stronger when the age gap is smaller. The conclusion indicates that a smaller age gap intensifies the sibling rivalries and reduces siblings' prosocial bias, which is primarily in line with the study of Campbell et al. (2019). --- Implications Theoretical implication This paper has three theoretical implications for the existing literature: First, the research on family sibling effect is extended from the field of social psychology to the business context. This paper enriches the studies on the influence of executives' early life experience on corporate strategic decision-making. The research on family sibling effect in the field of social psychology mainly focus on the influence of sibling effect on an individual's internal psychology or external behavior. As an individual, a CEO's early family life inevitably affects their cognitive formation and behavior preferences, which will be brought forward to the strategic decision of the enterprises they manage. Second, this study enriches the research on the driving factors of CSR and finds a new driving factor of CSR behaviors. Existing research has explored the driving factors of firms' CSR behaviors from the perspective of CEO traits and adulthood experiences (McCarthy et al., 2017;Tang et al., 2018;Hegde and Mishra, 2019), but few studies focus on the influence of CEOs' early family life experiences on CSR. From the perspective of CEOs' early family traits, this paper investigates the influence of CEO birth order on the CSR behaviors of the company they serve in the adulthood. Our research shows that CEO birth order shapes their personal prosocial tendency by influencing the sibling rivalry and prosocial preferences, which directly influences the firms' CSR behaviors. Third, this paper expands the upper echelon theory by examining the effect of executives' family traits and childhood experiences on corporate social responsibility behaviors. Many studies based on the upper echelon theory have focused on the impact of CEOs' demographic characteristics and work experience on CSR behaviors (McGuire et al., 2003;Deckop et al., 2006;Tang et al., 2015Tang et al.,, 2018)), neglecting the important role of early family experiences on CEOs' behavioral preference and corporate decision-making. From the perspective of CEOs' early family experiences, this paper studies how birth order affects corporate social responsibility behaviors by influencing CEOs' prosocial tendencies, which is conducive to a profound understanding of the influence of CEOs' early experiences on their business behaviors and decision-making. --- Policy recommendations There are also two main practical implications: First, it provides a further reference for listed companies that are concerned about corporate social responsibility to consider individuals' early family context when recruiting executives. For listed companies that pay attention to CSR, the number of siblings, birth order, and other early family environment should be taken into consideration when selecting CEOs, so as to ensure the effective performance of corporate social responsibility and maintain firms' sustainable development. Second, CEOs should be aware of the impact of birth order and other early family traits on their decisionmaking. Earlier-born CEOs tend to engage in more prosocial behaviors and take more appropriate social responsibility strategy. In contrast, later-born CEOs are more likely to adopt less CSR behaviors at their job. Therefore, CEOs need to acknowledge the association between birth order and firms CSR performance when making strategic decisions. Third, the study encourages enterprises to establish effective corporate governance structure and mechanisms to supervise the behaviors of executives and make corporate decisions free from the influence of executives' personal preferences.

Corporate social responsibility (CSR) is one of the most important business strategies which helps enterprises obtain competitive advantage and improve performance. Scholars have conducted many beneficial studies on the driving factors of CSR behaviors from the perspective of CEO traits, but rarely focus on the impact of the CEO's early family experiences. This study aims to fill this research gap by investigating the influence of CEO birth order on firms' CSR behaviors, and further exploring the possible moderating e ects of the presence of a female sibling and the age gap between the CEO and the closest sibling. This study takes Chinese non-financial private listed companies from to as the research samples, and empirically tests the relationship between CEO birth order and a firm's CSR behaviors. The empirical results show that CEO birth order negatively influences corporate social responsibility behaviors, and this relationship would be weakened when the CEO has a female sibling or the age gap between CEO and the closest sibling is larger. This paper extends the research on personal family factors from the field of social psychology to the business field and finds a new driving factor of corporate social responsibility behavior from the perspective of the CEOs' early family factors.

social responsibility behaviors by influencing CEOs' prosocial tendencies, which is conducive to a profound understanding of the influence of CEOs' early experiences on their business behaviors and decision-making. --- Policy recommendations There are also two main practical implications: First, it provides a further reference for listed companies that are concerned about corporate social responsibility to consider individuals' early family context when recruiting executives. For listed companies that pay attention to CSR, the number of siblings, birth order, and other early family environment should be taken into consideration when selecting CEOs, so as to ensure the effective performance of corporate social responsibility and maintain firms' sustainable development. Second, CEOs should be aware of the impact of birth order and other early family traits on their decisionmaking. Earlier-born CEOs tend to engage in more prosocial behaviors and take more appropriate social responsibility strategy. In contrast, later-born CEOs are more likely to adopt less CSR behaviors at their job. Therefore, CEOs need to acknowledge the association between birth order and firms CSR performance when making strategic decisions. Third, the study encourages enterprises to establish effective corporate governance structure and mechanisms to supervise the behaviors of executives and make corporate decisions free from the influence of executives' personal preferences. The absence of effective supervision mechanisms increases executives' opportunism, which enables executives to make decisions based on personal preferences rather than corporate interests. Hence, it is necessary to improve corporate supervision mechanisms through the optimization of corporate governance structure and governance mechanisms. --- Research limitations This study mainly has the following limitations: First, we theorized that CEO birth order influences firms' CSR behaviors through affecting sibling rivalry and shaping otherregarding preferences, but we cannot directly examine the birth order effect of the past sibling rivalry and family life experience. Although we further tested the hypothesis through moderators to provide additional evidence to our conclusion, there is still a need to explore a proper way to deeply investigate the internal mechanism behind CEO birth order effect. Second, we only chose Chinese private enterprises with CEO sibling data as research samples, there may be endogeneity problems especially caused by sampleselection bias. Although we have used a Heckman twostage model to deal with the endogeneity problems, future studies are still needed to further investigate CEO sibling effect with more comprehensive samples. Third, this paper only studies the influence of CEOs' sibling effects on firms' CSR behaviors, but does not consider different situational contexts. Future research can further investigate the influence of regional economic development level, cultural factors, and other factors on CEOs' sibling effects and business behaviors. Fourth, due to the limitations of the research sample, this paper only uses the data from 2010 to 2017 for empirical analysis. Future research can further expand the research sample and examine the influence of situational factors, such as the COVID-19 epidemic. --- 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/s. --- Author contributions MZ provided the overall conceptual model and wrote the original manuscript. GR modified the manuscript and provided ideas and suggestions for revision. SW and ZJ provided supplementary data and analysis for the revision. All authors contributed to the article and approved the submitted version. --- Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Corporate social responsibility (CSR) is one of the most important business strategies which helps enterprises obtain competitive advantage and improve performance. Scholars have conducted many beneficial studies on the driving factors of CSR behaviors from the perspective of CEO traits, but rarely focus on the impact of the CEO's early family experiences. This study aims to fill this research gap by investigating the influence of CEO birth order on firms' CSR behaviors, and further exploring the possible moderating e ects of the presence of a female sibling and the age gap between the CEO and the closest sibling. This study takes Chinese non-financial private listed companies from to as the research samples, and empirically tests the relationship between CEO birth order and a firm's CSR behaviors. The empirical results show that CEO birth order negatively influences corporate social responsibility behaviors, and this relationship would be weakened when the CEO has a female sibling or the age gap between CEO and the closest sibling is larger. This paper extends the research on personal family factors from the field of social psychology to the business field and finds a new driving factor of corporate social responsibility behavior from the perspective of the CEOs' early family factors.

Background Mental health is a pressing issue among the estimated 2.5-3 million migrant farmworkers in rural America [1][2][3][4][5]. Studies have found that up to 45% of migrant farmworkers have reported moderate levels of depression [4,[6][7][8] and up to 18% have reported impairing levels of anxiety [4,8,9] compared to the general United States (U.S.) population with 4.2% experiencing moderate levels of depression and 2.7% experiencing severe anxiety [10]. However, there are various barriers for migrant farmworker families to access mental healthcare. These barriers might include costs of care, uninsurance, lack of transportation, language difficulties, cultural differences, limited knowledge about services, transient and migratory lifestyles, and stigma and fear of deportation and fear of law enforcement agencies [3,4,6,7]. There has not been adequate longitudinal research on mental health, mental healthcare use, and related factors among migrant farmworkers to fully explore these issues. One major challenge to conducting longitudinal research with migrant farmworkers is the migratory nature of their work and lifestyles as well as limited-English proficiency and limited access to technology and internet services in remote regions. There are various validated tools that have been developed to measure mental health of migrant farmworkers, such as the Spanish versions of the Center for Epidemiologic Studies Depression Scale (CES-D; [3]) and the Patient Health Questionnaire-9 (PHQ-9; [4]). However, it is largely unknown to what extent administration of these measures and other data collection methods, such as online surveys and phone apps, are feasible and usable among migrant farmworker populations. These issues became particularly salient during the Coronavirus Disease-2019 (COVID-19 pandemic) which involved social distancing measures to be put in place and prohibited many in-person interactions like conducting in-person interviews, focus groups, and surveys. While there have been few cross-sectional reports indicating migrant farmworkers faced heightened vulnerabilities during the COVID-19 pandemic [11,12], to date, there has been no published longitudinal study of the mental health of migrant farmworkers in the U.S. during the pandemic. Even beyond the pandemic, there is great utility in understanding the best methods to survey this important vulnerable working population. In the current study, we conducted a small randomized controlled trial to test three different remote data collection methods with migrant farmworkers in South Texas with a 2-month follow-up period. The three remote methods were: telephone interview, online survey, or mobile app. To contribute to knowledge gaps on the mental health of U.S. migrant farmworkers during the COVID-19 pandemic, we also examined the mental health and well-being of the sample over time. The results will inform design and planning of future studies with this subpopulation as well as provide insights on the mental health of this subpopulation. --- Methods This study invited over 200 migrant farmworker family members residing in Texas and participating in the Education Service Centers (ESC) Migrant Education Program (MEP) between June 2021 and April 2022. The purpose of MEP is to "design and support programs that help migrant students overcome the challenges of mobility, cultural and language barriers, social isolation, and other difficulties associated with a migratory lifestyle" [13]. One feature of this program is the Parent Advisory Committee, which is comprised of migrant farmworker parents, schoolteachers, and other community partners, that meets throughout the academic year at ESC regions across Texas. Recruitment for this study occurred through the MEP and the Parent Advisory Committee. A total of 75 farmworker families agreed to participate and were randomly assigned to one of three groups to complete surveys by: (1) telephone survey; (2) online survey through Qualtrics, or (3) mobile app called LifeData. Participants were provided $10 compensation per assessment. Research personnel randomized assignments by family unit; therefore, there were a different number of individuals assigned to each group. Out of a total of 150 individuals who were assigned, there were 109 adults and 41 adolescents. This study only included the adult participants. Of the 109 adults that were assigned to groups, there were 39 adults in the telephone group, 39 adults in the online survey group, and 31 adults in the mobile app group. To maximize data collection, research personnel invited participants who dropped out of their assigned group to continue the study by switching to a different data collection group of their preference. We conducted separate analyses on participants across groups after they had switched. No phone carrier charges for data or study application use were incurred by participants. All study procedures were approved by the institutional review board at the University of Texas Health Science Center at Houston (HSC-SPH-20-0756). --- Measures Across all groups, data were collected through a battery of self-report measures. These measures were made available in both English and Spanish depending on participant choice. Sociodemographic and background characteristics were collected at baseline through a questionnaire that asked about age, gender, nationality, education, income, marital status, children, current housing situation and housing history, and employment. Psychological stress was assessed with the Migrant Farm Worker Stress Inventory (MFWSI; [4]), a 39-item self-report, validated instrument that assesses the quality and severity of stress in migrant farm work. Participants are asked to rate how stressful they find statements on a five-point Likert scale from 0 (Have not experienced) to 4 (Extremely stressful). Responses are summed for a total score ranging from 0 to 156, with a threshold score of 80 or higher indicating relatively high levels of migrant farmworker stress (i.e., representing upper 25% of scores) [4]. Symptoms of major depressive and generalized anxiety disorders were assessed with the two-item Patient Health Questionnaire (PHQ-2; [14]) and the two-item Generalized Anxiety Disorder-2 (GAD-2; [15]), which are each highly correlated with the longer versions of each respective measure (PHQ-9 and GAD-7). Both measures have been utilized in previous studies of Spanish-speaking populations [16]. Items on both the PHQ-2 and GAD-2 were summed with scores of <unk> 3 indicative of a positive screen for each respective disorder [17]. Symptoms of posttraumatic stress disorder (PTSD) were assessed with the Posttraumatic Stress Disorder Checklist, Version 5 (PCL-5; [18]), which asked participants to refer to a "very stressful experience" in their life and to rate 20 symptoms of PTSD on the degree to which they experienced each symptom in the past year on a five-point Likert scale from 0 (Not at all) to 4 (Extremely. The PCL-5 has been well validated and tested on English and Spanish-speaking populations [19]. Responses were summed for a total score that ranged from 0 to 80 considered as <unk> 33 to be indicative of a positive screen for PTSD [20]. Symptoms of alcohol use disorder were assessed with the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) with a score <unk> 4 indicative of a positive screen [21]. Somatic symptoms were assessed with the Somatic Symptoms Scale-8 (SSS-8; [22]) which consisted of eight items that asked participants to rate how much they were bothered by common somatic symptoms within the past 7 days on a five-point Likert scale from 0 (Not at all) to 4 (Very much). Responses were summed for a total score that ranged from 0 to 32. Social support was assessed with the Multidimensional Scale of Perceived Social Support (MSPSS; [23]) which is a 12-item measure of perceived adequate of social support from three sources: family, friends, and significant others. Participants were asked to rate items on a seven-point Likert scale from 1 (Very strongly disagree) to 7 (Very strongly agree). Responses were summed for a total score that ranged from 12 to 84. --- Data analysis First, descriptive statistics were conducted to characterize the total sample and then the three groups at baseline. Bivariate analyses using t-tests and chi-square tests compared characteristics of the three groups at baseline. Second, frequency analyses were conducted to examine the level of study participation among the three groups over time. All these analyses were based on participants in their original group assignment. Third, repeated measures analysis of variance (rANOVA) for continuous variables and Cochrane's Q test for categorical variables were conducted to examine changes in psychological stress, mental health, substance use, social support, and quality of life of the total sample longitudinally. This last set of analyses were based on the total sample irrespective of group and included participants who switched groups. Statistical analyses were performed using Stata version 17.0. --- Results As shown in Table 1, the majority of migrant farmworkers were aged 30 s (age range = 18-59), female, reported family annual income below $30,000, had lived in the U.S. an average of 18 years (range = 1-42 years), and lived with family with an average of five other household members (range = 2-7). In addition, 17% of participants reported they had experienced homelessness in adulthood with a total average of 195.8 days homeless in their lifetime (range 2-720). In terms of employment, participants reported they had worked an average of 13 years in agriculture (range = 1-45 years) and most worked in some type of produce harvesting as a migrant farmworker. Some participants held other jobs in addition to being migrant farmworkers, with the most common being jobs in the service industry. In comparing the telephone, online survey, and online app groups, participants in the telephone group were significantly more likely to be from the U.S., had higher levels of education, and had fewer children compared to the other two groups. There were no other significant group differences on sociodemographic or background characteristics. Table 2 shows the level of completion among the three groups over the 2 months of the study. Across groups, 50 migrant farmworker adults completed the baseline survey. There was differential attrition between groups starting at baseline, with 22 participants completing baseline in the telephone group (56.4% completion from initial assignment), 22 in the online survey group (56.4%), and 6 in the online app group (19.4% completion or 80.6% dropout). At 1 month, there was substantial attrition across groups as 30.8% of participants in the telephone group from initial assignment were retained, 25.6% retained in the online survey group, and 12.9% retained in the online app group. Finally, at 2 months, 66.6% of participants in the telephone group were retained from 1 month (or 20.5% retained since initial assignment), 70.0% retained in the online survey group (or 17.9% retained since initial assignment), and 25.0% retained in the online app group (or 3.2% retained since initial assignment). Among those who dropped out, eight participants in the mobile app group dropped out and indicated their preference to be moved to the online survey group at baseline or 1 month; and one participant in the mobile app group dropped out and was moved to the telephone interview group. Across groups and after switches, a total of 50 participants completed the survey at baseline, 26 participants at 1-month follow-up, and 16 participants at 2-month follow-up. Table 3 describes the mental health of participants across the three groups over the 2-month study period. Overall, the total sample reported relatively lower migrant farmworker stress; few symptoms of depression, anxiety, PTSD, and psychosomatic symptoms; and moderate levels of social support. Over 2 months, there was a significant increase observed in migrant farmworker stress and alcohol use problems, but declining anxiety and PTSD symptoms. --- Discussion This study contributes to research about the mental health of migrant farmworkers and strategies to overcome data collection challenges due to their migratory lifestyles and reservations about sharing personal health information. Through a small randomized trial, we tested three different remote data collection methods with a sample of U.S. migrant farmworkers and found that mobile phone apps like LifeData were not as effective in engaging migrant farmworkers as a survey method than traditional methods such as through phone interviews or online surveys. Only a handful of participants in the mobile app group completed the baseline assessment, so it is not that many were willing to use it and attrition occurred over time. Rather, it seems at least in our sample, most migrant farmworkers were reluctant to -$60,000-$69.000 even start using the mobile app despite research personnel offering technical assistance on how to use the mobile app. It is not clear whether U.S. migrant farmworkers tend not to use mobile apps in general, or specifically mobile apps for health surveys. Regardless, our findings suggest mobile apps may not be the best remote data collection method for migrant farmworkers. There are known barriers that may explain this, such as cultural differences, privacy concerns, fear of deportation and law enforcement, and lack of access to technologies and internet services in remote locations [3,4,6,7]. Instead, we found that the highest rate of study participation was among migrant farmworkers who were engaged through traditional telephone interviews. Study participation by online survey was not far beyond telephone interviews (4% lower participation rate). These findings inform design and planning of future studies with U.S. migrant farmworkers on which remote data collection methods may be most fruitful, sample sizes needed, and the level of attrition that may be expected with each method. Our sample of migrant farmworkers reported relatively low levels of farmworker stress (i.e., average score 35-39 out of 156) and did not report particularly high symptoms of depression, anxiety, or PTSD that warrant clinical attention during the COVID-19 pandemic. For example, 8% of our sample screened positive for major depression and 6% screened positive for PTSD at baseline, which is comparable or lower than the estimated point prevalence of major depression and PTSD in the U.S. adult population [24,25]. Moreover, migrant farmworker stress increased slightly over the 2-month study period, symptoms of depression, anxiety, and PTSD declined over time. Since we used a convenience sample, it is not clear how generalizability our findings are. However, our findings suggest U.S. migrant farmworkers have been quite resilient in their mental health during the COVID-19 pandemic, which accord with recent studies that have found veterans with severe mental illness or recent homelessness have fared better in their mental health than those in the general population [26,27]. Migrant farmworkers, along with other subpopulations, who have experienced considerable adversities in their lives may have developed a certain level of resilience that mitigated and protected psychological impacts of the COVID-19 pandemic. One area that may deserve clinical attention is the level of alcohol use reported in our sample. In our small sample size, we observed increases in reported alcohol use problems over time with about 19% of migrant farmworkers screening positive for alcohol use problems which is higher than the 10-13% prevalence of high-risk drinking found in the general U.S. adult population [28]. Several studies over the past decade have reported high alcohol consumption among farmworkers in general, and the negative health and social consequences of their heavy drinking [29,30]. Increased problems with alcohol use have been consistently reported in the general U.S. population during the COVID-pandemic [31][32][33] and further study is needed to determine whether this was this "COVID-19 effect" on alcohol consumption disproportionately impacted migrant farmworkers. This is an area that needs follow-up evaluation to observe whether alcohol use problems remain elevated in the population or return to baseline levels in the aftermath of the COVID-19 pandemic. There were several limitations of this study worth noting. We had a small sample size so our findings should be interpreted with caution and study replication with a larger sample size is needed. We followed migrant farmworkers for a duration of 2 months; a longer follow-up period may yield further insights about our different data collection methods and richer data about their mental health. Our data was based on self-report and subject to recall and respondent bias, especially since there is social stigma around mental health status that may have affected the openness of migrant farmworkers from sharing information about their mental health. We did not assess level of acculturation/assimilation which are important constructs related to psychosocial functioning [34][35][36]. The COVID-19 pandemic was a complex event that involved not only disease transmission but social distancing measures, city lockdowns, restrictions on international travel, and social strife-all of which may have impacted the results in unmeasured ways. Last, we focused on migrant farmworkers in the U.S. who lived in Texas who were predominantly Mexican-American adults and it is unknown whether these findings would be generalizable to other Hispanic subgroups or migrant farmworkers outside the U.S. --- New Contribution to the Literature Limitations notwithstanding, this study contributes to knowledge about effective remote data collection methods to assess the mental health of U.S. migrant farmworkers. This study provides needed information to guide future design of migrant farmworker studies by finding phone interviews and online surveys are much more effective in engaging and obtaining data from migrant farmworkers than mobile apps over multiple follow-up periods. Mobile apps may not be as readily adopted by migrant farmworkers, migrant farmworkers may be reluctant to share personal information on mobile apps, and mobile apps may not yield completion rates as high as traditional data collection methods. More work is needed to encourage adoption of mobile apps or develop ways to maximize traditional data collection methods to conduct beneficial research for the migrant farmworker population. Remote data collection methods were useful and necessary during the COVID-19 pandemic, which revealed migrant farmworkers in our study were resilient in their mental health over time during the pandemic. Further study is needed to understand the psychosocial and cultural factors underlying the resilience of migrant farmworkers and under what circumstances are remote data collection methods best to use for this population. --- Declarations Conflict of interest None of the authors report any conflicts of interest with this work. 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.

There has been limited longitudinal study of the health of migrant farmworkers due to their migratory lifestyles and there are opportunities to test new remote data collection methods in this subpopulation. A small randomized controlled trial was conducted with 75 migrant farmworker families who were randomly assigned to one of three groups that participated by (1) telephone interview, (2) online survey, or (3) mobile app between June 2021-April 2022. Of 50 farmworker adults who completed the baseline survey, there was differential attrition with 21% of the telephone interview group, 18% of the online survey group, and 3.2% of the online app group completing the 2-month follow-up. Over this period, migrant farmworkers reported relatively few mental health problems but notable alcohol use problems. Online apps were less effective than traditional methods for remote data collection. Alcohol use problems among migrant farmworkers in the U.S. may be an issue that deserves further study.

Introduction Corresponding with the increased availability and use of digital technologies in many societies, there is increasing concern regarding the safety, behaviour, understandings and wellness of digital technology users who use these technologies to engage with digital content and participate within digital environments [1,2]. The New Zealand Ministry of Education recognise both the pivotal role digital technologies have transforming teaching and learning in New Zealand schools [3] and the imperative for the education sector to ensure students are equipped to engage effectively and safely when using these technologies [4]. The term'safety' is often used to describe things that afford security and protection from danger. Maurice at al [5] define safety as "a state in which hazards and conditions leading to physical, psychological or material harm are controlled in order to preserve the health and well-being of individuals and the community" (p.234). The notion of 'risk' is always associated with safety. Cibbora [6] describes risks as actions that included an element of uncertainty, that have a probability of occurrence and that could potentially have undesirable outcomes or consequences. Staksrud and Livingstone [7] classified three types of risks associated with children's participation in online activities using digital technologies (p. 368); • Content risks: where children are the recipient of often mass-produced images and text (child as recipient); • Contact risks: where children participate in adult-initiated online activities (child as participant); and • Conduct risks: where children participate in peer to peer exchanges (child as actor) Each of these risk categories have been identified in New Zealand, with associated issues such as cyberbullying [8,9,10], information disclosure [11,12], overuse [13,14] and unsafe use [15] now impacting primary school-aged students. All schools in New Zealand have a legal responsibility to ensure the safety of students during school hours. To minimise the risks associated with digital safety, schools may implement strategies to ensure the safety of students within the school environment, for example blocking access to websites and monitoring digital technology use by students. However, many of these strategies have little impact when the students leave the school grounds. Thus, the Ministry of Education identify digital fluency and ensuring safe online learning environments as priorities for New Zealand schools [16], proposing that equipping learners with 21st century skills and digital competencies requires a cohesive, coordinated, cross-sector and multi-stakeholder approach to change within the New Zealand education system. Key organisations with an interest in 'Internet Safety' in New Zealand [17, 18,19] support this assertion, one stating that there has never been a greater need for schools and communities to work together as young people in New Zealand access the internet with increasing frequency via multiple access points, with a continuing trend towards mobile access. Although one New Zealand school-based case study [20] has investigated the implementation of digital citizenship, a concept often associated with digital safety, within a secondary school setting, there are major gaps in research relating to primary school contexts and more notably, research investigating the ways teachers and schools work with parents/wh<unk>nau and members of the wider educational community, who also reside within the educational ecosystem in New Zealand. The case study described in this thesis is intended to address this issue. The overarching question guiding this thesis is: How does a primary school approach digital safety and responsible use within their school ecosystems community? The following subquestions will focus the investigation. With regard to school leaders, teachers and school support staff: a) What perceptions do they have about digital safety and responsible use? b) How are digital devices used by students? c) How is risk constructed and managed? d) How is digital safety and responsible use encouraged? e) How do they work together, and with parents/wh<unk>nau and members of the wider school community, to support digital safety and responsible use by their children? Bronfenbrenner's 'Ecological Systems Theory' [21] and Davis' 'Arena with Change with Digital Technologies' [22,23] will provide the theoretical frameworks for this study. Notions of'space and place' [24] and 'networks', increasingly relevant to research involving digital technologies, will also be examined. --- Methodology Case Study methodologies as proposed by Stake [25] and Merriam [26] both resonate with me as a researcher as they closely align with my epistemological (social constructivist/ social-cultural) orientation. They also provide best fit with the study as a naturalistic, interpretative inquiry. The case study will conducted in a primary school in the local region and undertaken over a one-year period. Purposive sampling will been used to identify potentially suitable schools for the study, the criteria being; age band coverage (spanning ages five-thirteen), high usage of digital technologies and collaborative teaching approaches, and evidence of a BYOD, a 'bring your own device', policy within the school. Although the unit of analysis will be the school and the parental community within this school, the interactions with external networks across other layers of the ecosystem will also be also considered. Ethical considerations will be identified and discussed with the school, and ethical clearance gained prior to the study commencing. Qualitative data will be collected utilising a range of appropriate data gathering techniques including interviews, observations and document review/analysis. Data analysis will be conducted recursively in association with data collection, and will involve forms of analysis that may include categorical aggregation, content analysis, analytical induction and direct interpretation. Strategies to enhance credibility and trustworthiness will include reflective commentary, triangulation (data/theory), member checks, and multiple observations conducted over the period of one year. Researcher positioning, and disclosure of bias will be declared and discussed to enhance data dependability. This research and the resulting thesis will draw upon my individual [27,28,29,30,31] and collective [32,33,34] experiences as a researcher of digital technologies, digital environments and online communities, many years of experience as an educator working in and with primary schools in New Zealand, and my enduring fascination and critical appraisal of the ways digital technologies and environments are impacting the way people live, learn and communicate in society. It is intended but not assured that the findings exemplify the myriad of ways digital safety and responsible use are being addressed across the educational ecosystem, thus potentially providing insights for the reader that could inform future policy directions in New Zealand and school practices beyond New Zealand. It is highly likely the findings will expose questions and issues that justify further examination in future studies. As such, this thesis will make a valuable contribution to research and literature in this field. Importantly, it also makes a valuable contribution to the development of this author as a quality researcher.

With the New Zealand Ministry of Educations' emphasis upon e-Learning in educational settings, and the correlating increase in approaches to learning with digital technologies in New Zealand primary schools, primary school-aged students in New Zealand are increasingly using digital devices in school settings and at a progressively earlier age. As availability of digital devices outside of school also increases and the boundaries between usages blur, there is an imperative to prepare primary them to use digital devices safely and responsibly across multiple contexts, and for multiple purposes. Implementing a school-wide, cross-sector, multistakeholder approach has been proposed as the most effective way to prepare young people in this area. However, little is known about how such an approach is actualized in primary school settings, and the benefits and challenges associated with its adoption. Drawing upon ecological systems theory, this interpretive case study will examine how one New Zealand primary school addresses digital safety and responsible use within the school ecosystems community, how they engage with individuals, groups or organizations situated within other ecosystem communities, and the drivers, enablers, barriers and tensions they experience within these endeavours.

Introduction The practice of incest has been on the increase globally in recent past, and different people have different meanings as to what constitute incest based the culture and civilization of the people. According to Funmilayo & Francis (2019), incest is human sexual activity between family members or close relatives. The phenomenon of sexual relationships and practices among family members around the world have raised concern over the years. Incest is being more widely recognized as one of the world's biggest issues. However, since incest is considered taboo, it remains a neglected societal issue. Incest instances are growing at an alarming pace from time to time. It is not a new phenomenon; it has been around for over 4,000 years (Ojo and Olufemi, (2013). Although some individuals or cultures feel that incest is socially acceptable, particularly between two consenting adults, an incestuous act is morally wrong since it contradicts the nature of moral guidance. Incest is despised as inhuman conduct since it is widely acknowledged that having sex with a child is completely unacceptable (Testoni, et al., 2018). In Africa, Tidefors, et al. (2019) citing Parlor (1996) explain that during the era of the Roman occupation of Egypt there was a rise in brother-sister marriages. The reason adduced for this form of incest was to promote what was termed as own and "pure" people and to control the distribution of land for agriculture. This was because their daughters who got married to outsiders also had a share of the family land. In Ghana, incest is religiously sinful, morally tabooed, and legally criminalized by the Criminal Code (Act 29, 1960) as a second degree felony and punishable by a jail term between 3 and 25 years. However, owing to the scandal, shame, and stigma attached to incest, many families are unwilling to report members who perpetrate the act to avoid bringing the name of the family into disrepute (Osam, 2004). In Nigeria, the issue of incest is one of the most prevalent forms of unreported crime (Yusof et al., 2015). Due to the effect of both implicit and explicit pressure for concealment, emotions of guilt, humiliation, shame, being accused, or fear of any potential bad repercussions or threats, exposing it demands a careful and sensitive approach (Millan et al., 2017). This is because the majority of incest victims are youngsters who are fragile and rely on the offender for day-to-day survival. Only one of three instances of an incestuous incident is reported to authorities, with the other two cases staying between the culprit and the victim. Incest incidences are constantly influenced by concerns such as denial, ignorance, awareness, societal stigma, and prejudice. Apart from that, a few incestuous acts are reported to authorities, and few individuals are prepared to recognize them for fear of losing the family's honour and disgrace (Yusof et al., 2015). Nevertheless, it is important to note there are some exceptions and variations in cultural practices across different ethnic groups in Nigeria. In many cultures, certain types of cousin relations are preferred as sexual and marital partners whereas, in others these are taboos. That is, some cultures permit sexual and marital relations between aunts/uncles and nephews/nieces. However, parent-child and sibling-sibling unions are almost universally taboo (Akpoghome & Nwano, 2016). Despite the fact that most cultures disapproved sexual relationships amongst family members, some culture practice it till date. Conversely, some cultures proscribe sexual relations between clan-members, even when no traceable biological relationship exist, while members of other clans are permissible irrespective of the existence of a biological relationship. --- Statement of Problem Incest practices across culture has been on the increase in recent time and this phenomenon is one of the major challenges that poses threat and is affecting marriage and family institution in Nigeria as well as the health and wellbeing of the victims. Incest and sexual abuse of minors are social problems that directly affect the moral, social, legal and physical aspect of the society (Yusof et al., 2015). However, these two have to be clinically defined to properly distil the issues involved in order to consequently find solutions. At this point, it is important to assert that, a relationship that involves a child who cannot consent will be considered as a rape or sexual abuse by the perpetrator against the victim, whether such victim is a minor or adult but in the case where the victim is an adult and consented to the sexual relationship, he or she will be considered an accomplice to the crime of incest (Akpoghome & Nwano, 2016). In Nigeria, children are sexually abused by both adults and other children (who are by virtue of their age or stage of development) in a position of responsibility, trust or power over the child victim. According to Aruna, (2018), this act of incest, unarguable and persistently plagues childhood worldwide. That is, this typical sexual activity between people in consanguinity (blood relations), and sometimes those related by marriage or step family adoption, or lineage. It is strictly prohibited and considered immoral in most societies, and can lead to psychological trauma in children and family disintegration. On the other hand, most contemporary societies strongly condemn incestuous relationships due to moral, ethical, and legal reasons. These societies consider such relationships as taboo due to the potential for genetic disorders, the violation of familial bonds, and the potential for power imbalances or exploitation within family units (Aruna, 2018). --- Objective of the Study i. To ascertain the forms of incest practices in Karu local government Area Nasarawa state, Nigeria. ii. To determine the factors influencing incest practices among some ethnic groups in Karu local government Area Nasarawa state, Nigeria. iii. To identify effect of incest practices among some ethnic groups in Karu local government Area Nasarawa state, Nigeria. --- Conceptual clarification Incest The concept of incest which has been defined as sexual contact that occurs between family members. It is a sexual activity with a person from within the immediate family. Incest generally consists of a person's having sexual intercourse or performing an act of deviate sexual conduct with another person whom he or she knows to be his or her mother or son or brother or sister either of the whole blood or the half-blood (Akpoghome & Nwano, 2016). Incest is the sexual conduct between family members too closely related to be married, such as sexual conduct with a child, sibling, parent or grandparent. Millan, et al., (2017) note that incest relates to sexual activity between two people who are related through blood linkage. Incestuous relationships include those between sister to brother, father to daughter, uncle to niece, cousin to cousin, son to mother, among others. It can include touching, kissing, masturbation, oral sex and penetrative sex. Non-touching sexual abuse may involve introducing a much younger child to pornography, forcing them to watch a perpetrator masturbate or watching the victim in the shower or during other private moments. Although, sociologists and anthropologists have identified that marriage between certain immediate family members should be prohibited, and there are widespread rules (of lineage and clan exogamy) that forbid marriage and any form of sexual union between members of the same descent group (Nukunya, 2011). Incest is thus seen as "an offence or sin committed when certain categories of close relations indulge in sex" (Nukunya, 2011, p. 44). The exact meaning of incest varies from culture to culture, although it is proscribed by every human society. According to Lukianowicz (1972), incest can be placed into three categories: sexual relations between parents and their children, among siblings, and among other blood relations (grandfather-granddaughter, uncle-niece, and aunt-nephew). --- Cultural Variations Cultural variation sees culture as involving all that entirely surround a person: beliefs, rules for behavior, ideas of right and wrong and material objects; he views culture as the social heritage of a people, those learned patterns for thinking, feeling and acting that are transmitted from one generation to the next, including the quintessence of those patterns in physical objects (Macionis, 2010). By nature, human beings evolve shared meaning that shapes their cultural practices among different ethnic groups around the world. Thus, it is in the context of shared meaning that members of a cultural community come to construct what concepts such as what is normal or abnormal, victimization and victim mean. However, the exact relationships which can be construed as incest will vary from culture to culture. It is crucial to approach this analysis from a standpoint of cultural relativism, acknowledging that different societies have distinct values, beliefs, and moral frameworks. What may be considered taboo or immoral in one culture may be accepted or even encouraged in another. By considering these differences, we can avoid imposing our own cultural biases and better appreciate the complexity surrounding incest practices (Akpoghome & Nwano, 2016). In many Nigerian cultures, incest is considered a taboo. It is understood as sexual intercourse between persons who are too closely related to be married or have any sexual relationship. Thus, drawing from historical experiences there were arguments over what can be termed a universal incest taboo. Tidefors, et al., (2010) citing Parlor (1996) explain that during the era of the Roman occupation of Egypt there was a rise in brother-sister marriages. The reason adduced for this form of incest was to promote what was termed as own and "pure" people and to control the distribution of land for agriculture. This was because their daughters who got married to outsiders also had a share of the family land. In Hausa culture, incest practices among family members are not considered taboo as most people married to their cousins. Although sexual relationships between family relations are only considered taboo if it occurs outside marriage. For example, Ibrahim Garba, a Hausa and lawyer from Kano state got married to his first cousin. He argued that my culture and religion not against it (Punch, 2022). According to Abdullahi and Abdulrahman (2021) in Hausa land, more than 30% of marriages are between first or second cousins. This is considered ideal and are actively practiced among the Hausa people. Conversely, in the Igbo traditional world-view, there are behavior and practices that are conceived to be crime, while some are abominations (Okafor, et al., 2020) most Igbo societies, incest practices are considered taboo. And people belonging to the same village, whether related by blood or conjectural are not permeated to marry themselves. It is an abomination. According to Okafor, et al., 2020) they argued that in some cases, villages that have bloodline linkages are not supposed to marry each other even when they are sparsely dispersed. When incest is committed in Igbo culture, it is believed that blindness, deafness, poverty or death might result as consequences. Similarly, the Gbagi culture like that of the Igbo, incest is also considered abnormal act. According to Danjuma (2022) in Gbagi culture, there are strict rules and taboos regarding marriage and sexual relationships. The Gbagi people practice a form of patrilineal descent, where lineage and inheritance are traced through the male line. As a result, there are restrictions on marrying within certain kinship groups, known as "kindred" or "clans." Marrying within one's kindred is considered incestuous and is generally prohibited. Thus, the practice of incest among the Gbagi people is not widespread or culturally accepted. Incestuous relationships are generally stigmatized and considered taboo in Gbagi society (Danjuma, 2022). --- Determinants of Incestuous Relationship in Nigeria Several factors have contributed to incestuous relationship in Nigeria. Lack of traditional family values, moral decadence, broken homes, emotional imbalance, a shift in family roles due to poverty and ignorance among others. identify broken home as most of the reasons for incestuous relationship in Nigerian society. According to McClendon (1991) cited in Funmilayo and Amenaghawon (2019), the high divorce rate puts children at greater risk for sexual abuse by their step-fathers. She argues that women, in an attempt to get partners, they remarry or cohabit, and by doing so they expose their children to sexual abuse by their partners. Lack of self-control on the part of parents, families and guidance for the extreme increase in the case of incest in the society. On the other hand, the unemployment of the father may be a source of stress for him, rendering him powerless, inadequate, with low self-esteem; as a result, he compensates for his own emotional pain and frustration by abusing the vulnerable dependent child (Prusent, 1992). Other factors noted are social isolation where the family tends to shy away from social relations outside the family and depend on each other, as a result they do not have an easy access to external resources to help them cope with daily life stressors; and also, they cannot form extra-familial sexual attachments due to lack of social interactions with the external world (Funmilayo & Amenaghawon, 2019). Adingu (2021) said infiltration of western influences and negative attitudes also promotes incest in the society. Easy access to pornography through the internet could encouraged siblings, who most of the times are left alone to engage in sexual relationship. Furthermore, many traditional and religious institutions would rather cover incidences of rape up by opting for secrecy. Perhaps, these are some of the reasons why incest has not received adequate attention that could foster its abolishment in Nigeria society. There is a pressing, need therefore for an inclusive, vibrant media and community support system in order to curtail incest and its diverse implications, especially for young females in Nigeria (Haskins 2003). --- Implications of Incestuous Relationship in Nigeria Incest and sexual abuse of minors are social problems that directly affect the moral, social, and physical aspect of the victims as well as marriage and family institution of the society. Evidently, incest has serious implications on the lives of victims which can compromise their peace and well-being (Testoni, et al., 2018). Incest act has adverse effects on the personality and agency of females in peace activity. The development of victims into passive individuals, who are unable to defend themselves is an indicator of individuals who will be unable to set limits or stand up for their basic human rights in the future. This belief undermined the victim's self-esteem and sense of personal dignity and integrity (Funmilayo and Amenaghawon, 2019). According to Muhammad, et al., (2021) psychological scarring resulting from these sexually traumatic events may not present themselves for several years. Instead, they tend to exhibit behaviours related with frigidity, depression, uncontrolled violence and rage, as well as other antisocial behaviours. These are expressions of outrage at the betrayal and insecurity that the child had to endure as a victim of sexual and often physical abuse. He further pointed out several persisting negative effects of incest, and examined these characteristic-disguised presentations by victims, so that clinicians could easily identify these presentations and provide the necessary help for the victims. Furthermore, some of the implications of incest is depression, intense guilt, poor self-esteem, drug and alcoholic abuse, anxiety, somatic complaints and learning difficulties, marital difficulties, increased risk of physical and emotional abuse toward the children of incest victims and an increased intergenerational risk of incest among the children of the victim by her spouse (Aneni, 2019). Theoretical Framework. Social constructionism was utilized and adopted in this paper. The main founder of social construction is Peter L. Berger and Thomas Luckman (1966). They co-authored the influential book "The Social Construction of Reality: A Treatise in the Sociology of Knowledge" in 1966. This work is widely recognized as a foundational text in the field of social constructionism. Social constructionism beliefs that people develop knowledge of the world in a social context and that much of what we perceive as reality depends on shared assumptions. That is, the theory originated as an attempt to come to terms with the nature of reality. The basic assumptions of social constructionism theory are that the phenomenon of incest are defined, understood, and managed through worldviews. To social constructionists, they believe that things that are generally viewed as natural or normal in society, such as gender, class, disability, are socially constructed, and consequently aren't an accurate reflection of reality. The theory also beliefs that incest practices in the society are social constructions: that physical and mental conditions have little or no objective reality but instead are considered taboo only if society defined it as such. Therefore, they depart from the notion that incest is the result of unequal power relations in the patriarchal society, which results in women and children being victims of abuse (Joyce, 1997 in Funmilayo andAmenaghawon, 2019). The theory emphasized the importance of taking into consideration the dynamic interactions amongst the family members as their view indicates that incest results from the dysfunctional family system. That is, Dodds, (1999) cited in Adagbada, (2018) argued that the focus of social construction theory is on the family characteristics that could potentially increase the vulnerability of children to sexual abuse based on dynamic social interactions and meanings people attached to it thereby providing grounds for social ills in the society. That incest is viewed as the symptom or the product of an already dysfunctional family unit. The paper therefore adopts the social constructionism theory because as argued above, incest might be one of many problems in the family, it may be useful to look at other factors influencing incestuous relationships. Social problems such as absence of family values and moral decadence, poverty, unemployment, substance abuse, financial difficulties, and domestic violence may be present as a result of social interaction and meanings people attached to it thereby influencing incest practices. --- Methodology The study was carried out in Karu local government area of Naarawa State, Nigeria. He study was designed to investigate incestuous relationship across culture Karu local government area of Naarawa State, Nigeria. The study therefore, adopted cross-sectional survey research design. The target population for this study consisted of the people Karu local government area of Naarawa State, Nigeria with a population projection of 333, 800. The study considered sample from four (4) communities which included Masaka, Kuchikau Kabusu and Tudunwada. The study employed simple random and cluster sampling techniques were used to select o select respondents. Sample size of 398 respondents was drawn from the population of 81801. The sample size of 398 used in this study was determined using Taro Yamane (1967) method which is given as: n= 398 However, the 398 respondents were drawn using lottery method to pick the sample size. Questionnaire served as the survey instrument for data collection. The questionnaire contained closed ended questions with options (Aliyu, 2004). Thus, data collected was analyzed using descriptive statistical tools such tables, frequencies and simple percentages, using a 5-point Likert scale. n = N 1 + N (e) 2 --- Result The socio-demographic characteristics of the respondents that participated in the study such as sex, marital status, ethnic group, age, education, and occupation of the respondents are presented in this section. Compared to male, women participated more in the study and it was represented by 50.5% (201) while men are represented by 49.5% (197). On the marital status, most of the respondents represented by 40.7% (162) were single, 34.4% (17) were married and 24.9% (99) were widow. The ethnic groups of the respondents show that Gbagi participated more in the study and it is represented by 40.7% (162), 33.9% (135) were Hausa and 25.4% (101) were Igbo. On age distribution, 34.9% (139) were majority of the respondents who are within the age bracket of 18-25 years, 31.6% (126) were between 26-35 years, 22.4% (89) fall within age bracket of 36-45 years and 11.1% (44) are those with the age 46-75. The educational characteristics of the respondents showed that many of the respondents represented by 32.2% (128) had secondary education, 24.9% (99) had tertiary education, 18.3% (73) had no formal education while 4.6% (98) had primary education. This study also reveals that the major occupation of the respondents represented by 31.7% (126) were businessmen and women, farmers are represented by 24.9% (99), civil servants are represented by 20.6% (82) and students were represented by 22.9 (91). The table above reveals that one of the major form of incest practice in karu local government, Nasarawa states is between cousins and it is represented by 31.9% (127), among siblings is represented by 30.9% (123), uncle to niece is represented by 24.9% (99), while step father to daughter is represented by 12.3% (49). Corroborating the above findings, Lisak, (2011) argued that in Nigeria, incest between family members is common. It happened between fathers and daughters is hardly reported because nobody wants such a story to be heard outside the family. Nevertheless, other form of incest that are common are among cousins and this could be as a result of family disorganization and moral decadence in the Nigerian society. The table above reveals that several factors where responsible for incestuous practices in Nigerian society, these include lack of traditional family values represented by 31.6% (126), moral decadence is represented by 24.6% (98), shift in family roles due to poverty is represented by 24.4% (97), psychological factor is represented by 12.3% (49) and spiritual purposes is represented by 7.03% (28). Admittedly, Ime, et al., (2014) argued that the high divorce rate puts children at greater risk for sexual abuse by their step-fathers. She argues that women, in an attempt to get partners, they remarry or cohabit, and by doing so they expose their children to sexual abuse by their partners. And that the prevalence of this phenomenon is as a result of lack of traditional family values and moral decadence in the society. The data in the table above showed that some of the effects of incest practices as stated by respondents include psychological and emotional trauma represented by 34.9% (139), family disorganization 28.3% (113), inbreeding genetic disorder 9.5% (38) and shame, guilt and stigmatization represented by 27.1 (108). Similarly, incest and sexual abuse of minors are social problems that directly affect the moral, social, and physical aspect of the victims as well as marriage and family institution of the society. Evidently, incest has serious implications on the lives of victims which can compromise their peace and well-being (Testoni, et al., 2018). Incest act has adverse effects on the personality and agency of females in peace activity. --- Discussion of Findings The issue of incest practices is prevalence and have become major source of concerns among in Nigerian society toddy. Findings from this study as revealed by the participants shows that lack of traditional family values, moral decadence, psychological factor, shift in family roles due to poverty and spiritual purposes were some of the factors influencing incest practice among some ethnic groups in Karu LGA, Nasarawa state, Nigeria. This is corroborated by Akpoghome & Nwano, (2016) who argued that in some cases, incestuous relationships may be driven by power imbalances within families. This can occur when individuals in positions of authority or influence exploit their familial relationships for personal gain or control. In some cases, individuals may develop psychological disorders or deviations that lead to incestuous desires or behaviors. These disorders can be influenced by a range of factors, including childhood trauma, mental illness, or genetic predispositions (Adagbada, 2018). The implications of incest practice are significant and wide-ranging consequences as reported in this study. The results revealed that psychological and emotional trauma, family disintegration, inbreeding/genetic disorder and shame, guilt and stigmatization. This finding also corroborated Aneni, (2019) who argued that incestuous relationships can cause severe psychological and emotional harm to individuals involved. The power dynamics and exploitation that often accompany incest can lead to feelings of guilt, shame, and trauma. Individuals may struggle with their identity, self-esteem, and ability to form healthy relationships in the future. Incestuous relationships increase the likelihood of genetic disorders and birth defects in offspring. This is because close relatives share a higher proportion of genes, which can lead to an increased risk of inheriting harmful recessive traits. This phenomenon can fracture family dynamics and erode trust within the family unit. When incest is discovered or suspected, it can lead to a breakdown in communication, isolation, and estrangement among family members. This can have long-lasting effects on the well-being and functioning of the entire family (Aruna, 2018). --- Conclusion Cross-cultural analysis highlights the diversity in societal norms and taboos surrounding incestuous relationships. It is crucial to approach this topic with sensitivity, recognizing that cultural relativism plays a significant role in shaping these practices. By understanding the historical, social, and psychological aspects of incest, we can foster informed discussions and promote tolerance while respecting the legal and ethical boundaries established within each society. However, findings from the study show incest practices is taboo among several ethnic groups in Karu LGA, Nasarawa state, Nigeria. incestuous relationships or abuse result from emotional imbalance, ranging from depression, loneliness, deprivation and psychological issues. Recommendation 1. There is the need for implementation of comprehensive education programs that raise awareness about the negative consequences of incestuous relationships. These programs should target both young people and adults, providing information on the psychological, emotional, and genetic risks associated with incest. 2. Establishment of accessible and confidential support services for individuals who have experienced or are at risk of experiencing incestuous relationships. These services should offer counseling, therapy, and resources to help individuals heal from the trauma and navigate healthy relationships. 3. Government should strengthen and enforce laws against incestuous relationships. This includes ensuring that appropriate legal consequences are in place for those found guilty of engaging in incest, such as imprisonment or loss of custody rights. 4. Develop family support programs that aim to address dysfunctional family dynamics and prevent incestuous relationships. These programs can provide counseling, mediation, and resources to families in crisis, helping them address underlying issues and rebuild trust.

LGA Nasarawa states, Nigeria. Incest can be seen as a situation in which person has a sexual relationship with family member. In Nigeria, the phenomenon of incestuous relationship has been on the increase in recent time with adverse effect on marriage and family institution. The objective of the study is to analyze cross cultural practice of incest among the Hausa, Igbo and Gbagi ethnic groups in Karu LGA Nasarawa states, Nigeria in order to identify the forms and determinants of incest relationship among family members. Social constructionism theory was utilized and adopted in this paper. The study employed a cross-sectional research design to gather data, using primary and secondary sources. 398 respondents were selected through the aid of simple random and cluster sampling techniques. Findings show that the determinants of incestuous cases include lack of family values, moral decadence, loneliness, psychological problem and spiritual purpose. Some of the effects include psychological and emotional trauma, family disintegration, inbreeding/genetic disorder and shame, guilt and stigmatization. The study recommends that there should be proper parenting and community therapy. Emphasis should be place on motherhood and fatherhood, stakeholders, religion and traditional leaders should do more to educate and raise awareness in order to disabuse the mind set of those engaged in incestuous relationship. Social services, legal measures, and community engagement should be intensified in order to mitigate arising cases of incest in the society.

Introduction The economic dynamics of the news industry led us to explore some of the characteristics of audiences who consume news through the Internet. Authors such as Fletcher and Nielsen (2017), Fletcher and Park (2017), Junior (2023), Martin and Sharma (2022), Newman et al. (2022), and Yang and Peng (2022) have delved into the evolution of the news market in a digital environment on a global scale. Some of the main topics addressed are the decrease in trust in the news industry and interest in the news (Newman et al., 2022), various levels of political polarization, and audience avoidance of news content (Goyanes, 2020). The macro-and microeconomic environment in which the Mexican sector develops is similar to that of other Latin American countries (Junior, 2023;Newman et al., 2022). The knowledge of digital news consumer audiences has become a relevant issue because of the importance of the media in society's public opinion (Thompson, 1995). Understanding the public from the academic perspective of media management allows news firms to implement effective market strategies that help them clearly define their target markets. News companies can communicate with the different audience segments participating in the digital environment (Arrese, Medina & Sánchez-Tabernero, 2019;Xiau & Su, 2022); above all, video offers attractive and varied content. In Mexico, more research needs to deal explicitly with socioeconomic variables that can classify audiences' interests in digital news content. Industry and academia are concerned about understanding how the audience is classified in terms of their interest in the news of those who consume this content in its digital version, according to the generational segments of the market and socioeconomic level to which they belong. It is necessary to analyze the influence of socioeconomic factors that affect interest in the news according to the various segments of the market audience in this country. The aim of this study is to analyze the interest in digital news and its correlation with audience fragmentation, as measured by socioeconomic factors in Mexican society. This study is divided into four parts. The first part presents academic literacy related mainly to media management studies and those related to the classification of audiences by their interest in news. The second part deals with the general background of Mexico's digital news industry. In the third part, the methodology is presented, and in the fourth part, the results are detailed. Finally, the main conclusions are presented, followed by future research directions and limitations of this study. --- Literature related to media management studies Interest in the news and fragmentation of audiences are topics of academic interest due to the media's role in the democratic lives of countries (Fletcher & Nielsen, 2017;Lee et al., 2020;Putnam, 1995). This research belongs mainly to the academic area of media management, detached from the science to which the media economy belongs (Albarran, Mierzejewska & Jung, 2018). Audiences' knowledge matters in elaborating a competitive market strategy, and news media models should be adapted to the strategy of news media firms to be effective in the digital environment (Chan-Olmsted, 2005;Gutiérrez-Renter<unk>a & López-Hernández, 2021;Ha, 2021;Mierzejewska & Kolo, 2019). Currently, audiences have greater power to influence the news programming of media firms because of the multiple accesses they have to this content on digital platforms and the place and time that interests and suits them (Zheng et al., 2021;Xiau & Su, 2022;Yang & Peng, 2022). At the same time, audience fragmentation has modified the modes of interaction between the supply and demand of news content in the industry, as stated by Doyle (2020) and Tseng and Fogg (1999). One type of fragmentation is given by age groups with different characteristics. Below are some distinctive notes that contribute to understanding the characteristics of the audience (Avenda<unk>o, Chavez & Mu<unk>oz, 2019) by generation: 1. Baby Boomers (1946)(1947)(1948)(1949)(1950)(1951)(1952)(1953)(1954)(1955)(1956)(1957)(1958)(1959)(1960)(1961)(1962)(1963)(1964): They are characterized by having become accustomed to the use of legacy media under an analogous system that functioned independently. Their primary motivation is order and respect for the institutional or company hierarchy. They are loyal to the brands they consume. This generation likes to spend time with their family and home. (1965)(1966)(1967)(1968)(1969)(1970)(1971)(1972)(1973)(1974)(1975)(1976)(1977)(1978)(1979): This group is considered the digital immigrant. This generation had the challenge of learning to use the first computers and email to communicate. Their primary motivation is to set achievements and goals. 3. Generation Y, known as the Millennials (1980Millennials ( -1999)): They are considered digital natives. --- Generation X This generation had to deal with the arrival of mobile phones, electronic screens, and digital mobile devices. This generation prefers digital media such as social networks and instant communication through messages. 4. Generation Z (2000-2014): This group is also considered digital natives and, in some ways, is like the Millennial generation. Regarding media use, this generation is distinguished by the use of fashionable social networks and video consoles as the leading entertainment and media consumption sources. They communicate via mobile devices. They are constantly looking for change. Their primary motivator is their social contribution to improving the planet's health, and they want constant mobility. Otherwise, the topic of interest in the news of audiences may be correlated with socioeconomic factors and personal motivations (Chyi & Lee, 2013;Boczkowski, Mitchelstein & Matassi, 2018;Drok, Hermans & Kats, 2018;Fletcher & Nielsen, 2017;Salaverr<unk>a, Harlow & De Lima, 2022;Schr<unk>der, 2019). These motivators can be linked to social identities (Gil de Z<unk>iga et al., 2010;Markov & Min, 2020) --- Digital news industry in Mexico In the Mexican news industry, legacy media and digital native media are trying to get ahead due to an economic contraction, advertisers' advertising revenue falls, and a different industry dynamic due to electronic commerce and entertainment media products -such as social media and platforms of video streaming-on the Internet (Garc<unk>a, 2022;Inegi, 2022;Sánchez-Nuevo, Guerrero-Mart<unk>nez & Carrasco, 2022). In this Latin American region, leading brands have been harmed by a decline in the levels of trust and interest in the news industry, loss of confidence in various institutions, changes in audience consumption habits, and the amount of false news information distributed through social networks (Gutiérrez-Renter<unk>a et al., 2018;Newman et al., 2022). Undoubtedly, Mexican media is not exempt from the acceleration of a digital economy open to the global market, which should encourage them to be disruptive and innovative in their business models, as suggested by Doyle (2020), Salaverr<unk>a, Harlow andDe Lima (2022), andWirtz (2019). News brands must establish a close relationship with the target audience (Lischka, Siegert & Krebs, 2018). Audience segmentation helps understand how media companies can communicate effectively with their target audience. For instance, Albarran et al. (2018), Arrese, Medina and Sánchez-Tabernero (2019), Chan-Olmsted (2005), Doyle (2020), Ha (2021), and Mierzejewska and Kolo (2019) point out that market segmentation by the age of audiences is crucial for creating an effective market strategy for the media firm participating in the current digital economy environment. On the other hand, there are authors like Seifert, Clement and Otten (2020), Doyle (2020), and Tseng and Fogg (1999) that establish that the fragmentation of audiences is influenced by socioeconomic factors. In this order of ideas, the work carried out by Goyanes (2020), Newman et al. (2022), and Xiao and Su (2022) agree that people's socioeconomic level and age influence their interest in the news. RQ1. Which are the most homogeneous subsets of age groups with a similar average interest in the news, and which are they? RQ2.It is relevant to identify the classification of how interest in news content changes according to education and income levels. For this reason, the second research question is: What are the predictions of average interest in the news with information about the attributes of education level, and what is the classification of average interest in the news with information about the attributes of income level? RQ3. What will be the classification of average interest in the news if the attributes of education level and income level are added to the attributes of age groups? --- Methodology --- Subjects The research is based on a survey of 2,005 people in Mexico by the digital market research company YouGov, commissioned by the Reuters Institute for the Study of Journalism at the University of Oxford (Newman et al., 2022). The surveys were conducted during the last week of January and the first week of February 2022. Of these 2,005 surveys, 384 were discarded because of the lack of data required for this research. The survey was carried out such that the people surveyed stated that they accessed the news online at least three times per week. The population used for statistical analysis corresponds to a random sample of people over 18 years of age who consume digital news in Mexico. Of the people surveyed, 48% were male and 52% were female. The digital audience of the market, measured by age, comprises the following segments: 18-24, 25-34, 35-44, 45-54, 55-64, and 65+ years. The age groups to which these audiences belong would correspond to the following generational segments: Baby Boomers (people between 55-64 and over 65 years old); b) Generation X (people between 45-54 years old); c) Generation Y -known as Millennials-(35 and 44 years old), and d) Generation Z -Centennials-considered digital natives' media (18-24 and 25-34 years old). The question used to measure the dependent variable of interest in the news was: How interested if at all, are you in the news? This question is measured on a Likert scale: 1) extremely interested; 2) very interested; 3) somewhat interested; 4) not very interested; and 5) not at all interested. The annual income level of the people surveyed is measured on a scale from 1 to 19. 18 corresponds to "I do not know" and 19 to "I do not want to say." Three hundred fifty-six survey participants with these two responses about their income levels were discarded. Level 1 corresponds to an annual income of fewer than 5,400 USD. The increments from level 1 to level 12 are 5,400 USD. Level 12 is an income ranging from 59,400 USD to 64,800 USD per year. The increment between levels 12 and 14 was 10,800 USD. The increment from level 14 (86,400 USD) to level 15 is 21,600 USD. Level 16 was incremented by 54,000 USD, equivalent to an income of USD 162,000. Level 17 is an annual income higher than 162,000 USD. Respondents are asked about the highest level of education they have regarding: 1) those who did not complete any formal education; 2) first years of kindergarten; 3) elementary education; 4) secondary; 5) high school; 6) high school with technical studies; 7) technical studies without an academic degree; 8) bachelor's degree; 9) master's degree; and 10) doctoral degree. --- Procedure The method to analyze interest in Mexican audiences' news integrates statistics and computer science in a machine learning (ML) process. Predictive data mining is the most important method for this purpose. One such technique is classification using a decision tree (DT). In the domain of categorical data analysis (as in this research), decision trees (DTs) frequently demonstrate superior performance compared to linear regression because of their adeptness in managing nonlinearity and collinearity. They categorize instances into distinct output values and are well suited for automating decision-making processes, segmenting groups, and recommending pertinent segmentation strategies. One of the notable attributes of decision trees is their high interpretability, which allows for straightforward tracing of the decision-making process. This interpretability is pivotal in applications in which elucidation and transparency are crucial, as it reveals how decisions are derived from categorical features. Decision trees provide a potent and transparent decisionmaking framework, especially for handling categorical data and producing results that can be easily interpreted across various domains of research and analysis. In general, decision trees represent a disjunction of the conjunctions of constraints on the attribute values of the instances. Each path from the tree root to a leaf corresponds to a conjunction of attribute tests, and the tree itself to a disjunction of these conjunctions (Mitchell, 1997, p. 53). Since the research questions ask about interest in the news, interest (average interest) will always be the main attribute at the root of the DT; age group, education, and income level are the independent variables (Cardona, 2004;Berlanga, Rubio & Vilá, 2013). In the next section, the DTs are shown to answer every research question, and the splitting and predictions at the leaf node are explained. Any path of DT always begins at the root, in this case, with interest in news. The trees are organized hierarchically with a collection of "questions." Every node, not a leaf, contains a condition that splits a tree into branches. DT describes data separating sequences until a Boolean outcome at a leaf is achieved, where the value of every leaf contains a prediction. A tree grows if the next split reduces its overall complexity. Otherwise, the growth process was stopped. The complexity parameter (cp) controls and selects the optimal tree size. The default value of cp is 0.01; the higher the value, the smaller the tree. While running a DT, the cp argument helps pre-prune the tree. The DT may discard some values of a given attribute and classify them as "unused," meaning that they are insignificant for decisions. For this research, the DTs were run in R, with the "rpart" and "rpart.plot" instructions, which generate a tree with nodes, their conditions, branches, and final nodes, to facilitate making predictions and taking decisions. The optimal complexity parameter "cp" was calculated, and a graph of the relative error against tree size was run for all DTs. An important fact for the DTs is that the reported percentage in the leaf nodes corresponds to the percentage of people surveyed who showed attributes following the splitting. A percentage of 0% reported in the DT means that although few people have been surveyed (less than 0.5% of the total persons surveyed), the leaf is significant for those attributes and the predictions. In the next section, the DTs are shown to answer every research question, and the splitting and predictions at the leaf node are explained. --- Results To answer the first research question, which is the most homogeneous subset of age groups with similar responses to interest in the news, and which they are, DT builds a model of classification of interest in the news as the dependent attribute based on the independent attribute age group. In Figure 1, it is predicted that the audience is split into two subsets. The right leaf node is represented by an audience no older than or equal to age group 3 (age segments 1 and 2 from 18 to 34 years old), cataloged into class 3 of interest, which characterizes them as somewhat interested in the news. The left leaf node is the audience aged between 35 and 65+ (age groups greater than or equal to 3), compiled to be interested in the news in class 2, representing them as being very interested in the news. The first box, the root of DT, reports the percentage distribution of interest in the digital news of Mexican audiences (1, 2, 3, 4, and 5 of interest). Interest in the news, classes 1, 4, and 5 are unused, which means that only classes 2 and 3 were significant (see 39% and 31% for interest in the news of class 2 and class 3). Figure 1 shows a segmentation of the people surveyed into two main groups: those under 35 years of age, who are somewhat interested in the news content, and the other group belongs to people over 34 years of age, who are very interested in the news. However, the authors consider it essential to make a finer classification, which is why R is run with average interest in news values. Figure 2 displays the DT for the average interest in news and attribute age groups. Running R classification models with "Anova" (that is, with average interest in the news), it was found that the overall average interest in the news is 2.4 (this value will be found in all decision trees). The optimal cp value of 0.0000895 by R resulted in classifying all age groups with their corresponding averages in the interest of news content. The results show that their average interest in the news grows as people get older. Note that interest in the news 2 is "very interested," and 3 is "somewhat interested." Audiences older than 65 years have an average interest in the news of 2.1, and surveyed people between 55 and 64 years old have an average interest in the news of 2.2. Audiences of age groups 4 and 3 (between the ages of 35 and 54) have the same interest in the news of Section 2.3. The age group 2 (between 25 and 34), and age group 1 (between 18 and 24) have an average interest in the news of 2.5 and 2.9, respectively. The second research question concerns predictions at the leaf nodes of the dependent attribute of average interest in the news by the independent attributes of education level and income level. Figure 3 shows the DT for the attribute of average interest in the news by education level. The left-leaf node predicts that an audience with an education level greater than or equal to 7, that is, education levels 7, 8, 9, and 10 (from technical studies without a degree to a doctorate) will have an average interest in the news of 2.2. The middle leaves with an average interest of 2.5 and 2.6 relate to the audience with an education level of 6, 5, 4, and 3, 2 (from high school with technical studies down to kindergarten). An audience with an education level of 1 (with no formal education) will have an average interest of 3.4, that is, between somewhat interested and not very interested in the news. Audiences with no formal education have the lowest average interest in the news however they consult the news at least 3 times a week. As a resume, it could be said that Figure 3 suggests a segmentation of the audiences with respect to interest in the news into three main groups, considering only education level. The first one with an education level higher than 7, the second one is between 2 and 6, and the last one with education level of 1. Audiences with an education level of two to six have almost the same average interest in the news (2.5 and 2.6), while audiences with an education level higher than six have the highest average interest in the news. There is a difference in the average interest in news between education levels 1 and 7 to 10. For the second part of the second research question, a DT was run (TREE4) for the average interest in the news by the attribute income level. First, the annual income level was split into income levels of less than 10 (less than 54,000 USD) and income levels over 54,000 USD. The third leaf node, on the right, predicts an average interest in the news of 2.8 (nearly somewhat interested) for audiences with an income level of not less than 10 (equal to or greater than 10). The left branch splits into income levels greater than or equal to two (2, 3, 4, 5, 6, 7, 8, and 9) and an income level of one. The prediction of an average interest in news of 2.3 corresponds to an inclusive income level between 2 and 9. The audience with the lowest income level (1) is predicted to have an average interest in the news of 2.4. The analysis of DT (TREE4) shows that the difference lies in income levels less than 10 and greater than 10. In fact, only 4% of the surveyed people registered an annual income level higher than 54,000 USD, they have the lowest interest in digital news. This suggests that, if one considers only the income level, 96% of the surveyed people with an annual income level from 1 to 9 have a similar interest in the news (2.3 and 2.4). This means that the annual income levels of these groups (1-9) did not differ from each other. In relation to Research Question 3, what will be the classification of Mexican audiences by average interest in the news if the attributes of education level and income level are added to the attributes of age groups? First, the audience members were split into two groups: age groups 3 to 6 and age groups 1 and 2. Subsequently, audiences of age groups from 3 to 6 (35 to 65+ years) were split into two subsets, with an education level greater than 1 (any formal education) and equal to education level 1 (no formal education), with an average interest in news of 2.2 and 5. This last group is represented by a percentage of the audience of less than 0.5%, but it is significant for DT. Age group 1 was split into three subsets, first by income level less than 8 with an average interest in the news of 2.8 (education level was not significant) and further by an income level greater than 7 with an education level less than 5 with an average of interest in the news of 2 (very interested) and an education level greater than 4 with an average interest in the news of 3.7. Audiences of age group 2 (25 to 34), the third leaf node from the right, are classified with an interest in the news of 2.5. For this subset, the education and income levels were not significant (Figure 5). Running Tree5, including age groups, income level, and education level, the interpretation states that for some groups, income level and/or education level is insignificant. This means, for example, that age group 2 has an average interest in the news of 2.5, and neither income level nor education level is important. For age groups 3 to 6, education, but not income level, is significant, with an average interest of 2.2. At least for age group 1 only income level 1 to 7 is significant and the average interest for this group is 2.8. These findings correspond only to the age groups with more than 10% of the total surveyed people. To clarify the meaning of the predictions and classifications, for example, if we ask a 45 years old person with a master's degree who consumes news digital content at least three times a week, she/he will probably be very interested in the news, while his/her income level is not essential. --- Conclusions This is the first study of digital news audiences in the current environment in Mexico in 2022, conducted by the Reuters Institute for the Study of Journalism, based at the University of Oxford. The survey follows the same criteria and rigor in the 46 countries that participate. In Mexico, research that contributes to the understanding of audiences in the current digital context primarily focuses on the gaze on political science and the behavior of citizen news consumption during the various presidential elections, and other studies related to media management of Mexican audiences focus on social media and video platform consumption on the Internet (<unk>lvarez-Monsivais, 2022;Gutiérrez-Renter<unk>a & López-Hernández, 2021;Avendano, Chavez & Mu<unk>oz, 2019;Benavides & Garc<unk>a-Béjar, 2021;Cornelio-Mar<unk>, 2022;Mac<unk>as & Garc<unk>a, 2019;Meneses, Ortega & Urbina, 2014;Sued, 2022). The research presented here focuses on classifying Mexican digital news consumer audiences according to their interest in the news regarding the attributes of socioeconomic variables such as age, education level, and income level. This concept relates to media market segmentation. This study predicts the interests of a person with specific attributes or characteristics will have. Classifying audiences based on these attributes can identify whether the product offered by the news firm and the way it is presented will be welcomed by the segments of the groups identified in the research. For example, the first ramification (Figure 1) is by age group, and that, in turn, represents the generation to which they belong. The Centennial and Millennial generations are somewhat interested in the news (Category 3), while the other segmentation represents generations Y, X, and Baby Boomers, which are very interested in the news (Category 2). However, the method used leads the authors to delve even deeper into the attributes of the age groups of the Mexican digital audience (Figure 2). It is found that interest in news increases with increasing age. This fact coincides with other research on audience fragmentation (Fletcher & Nielsen, 2017;Park et al., 2020). In this sense, these findings reinforce the idea that the content product should be directed, well-adapted, and attractive in the topics, narrative, and language to engage persons of the generation they belong to, as suggested by Albarran (2017), Chan-Olmsted (2005), and Sylvie (2008). The authors run the classifications shown in Figures 3 and4 in an attempt to explore how the level of education and income level independently influence the interest in the news due to the characteristics of Mexican society. It is found that the higher the education, the greater the interest in the news. However, the finding in the Mexican case that the higher the income, the less interest in the news confirms the words exposed by Fletcher and Nielsen (2017, p. 492): "All communication exists in the context of its audience. This context is changing around the world, in part due to large trends like the rise of digital media that many associate with a more fragmented media environment." The classification in which the attributes of age groups, level of education, and income level are considered simultaneously concerning the interest of audiences in digital news indicates that some of the classifications or predictions made by the DT model indicate that some attributes may not be significant in some subsets, except for age group. For example, the prediction for a person between the ages of 35 and 65 + with any education will be classified in the interest group of 2.2, which means close to very interested. This audience segment does not have ramifications regarding income level. In other words, income is not significant. Another example is the classification of a person between 25 and 34 years old (age group 2), whose interest in the news is 2.5 (between very interested and somewhat interested), regardless of their levels of education and income (see Figure 5 and Table 2). One of the findings is that the Centennial generation requires from news companies to adapt their differentiating offer based on these attributes of income and education since there is a classification regarding the level of education and the level of income in this Mexican segment. The media firm must pay special attention to the segmentation marked by DT. In the Mexican case, it is confirmed that age is the main socioeconomic criterion to segment audiences according to their interest in digital news. Second, the level of education matters, and finally, the income level. On the other hand, the Centennial generation and Millennials have specific characteristics that distinguish them from other age segments and make them particular. For example, in these groups, income level had a greater influence than education level. Therefore, marketing strategies aimed at these segments of the Mexican audience must be analyzed in greater detail, and according to the results of this research, this research also adds to what was established by Doyle (2020), who points out that the fragmentation of audiences and the progressive empowerment of people to express their editorial preferences through digital platforms have modified the modes of interaction between supply and demand in the industry. The consolidation of the competitive advantage of the news media firm also consists of achieving effective market segmentation and emphasizing the target market to which the content is directed according to the specific characteristics of the audience groups mentioned in this research, as affirmed by Albarran (2017Albarran (, 2019)), Sylvie (2008), andDoyle (2020). Finally, this research coincides with the findings on young people's low interest in news and that interest increases as age increases (Casero-Ripollés, 2012;Newman et al., 2022). In this sense, in the Mexican case, the idea is validated that readers cannot be thought of as a single audience, but rather as different groups of audiences that must be understood mainly from the generational segment to which they belong and that participate in the current digital economy environment, as pointed out by Vara-Miguel (2023). This research provides evidence that the main socioeconomic criterion for segmenting audiences concerning their information interest is age, followed by academic level, and finally, the economic income in this country in the Latin American region. --- Future lines of research and limitations This study shows the need to delve into the descriptive characteristics of the digital news consumer profile according to the motivator they have to be interested in the news product according to the target market defined by the company. This study promotes the development of other research that addresses the qualitative characteristics of news and entertainment content consumers in the current digital environment in Mexico. Likewise, this work invites scholars and industry to understand the structure of the competitive market of this national news industry from the point of view of supply, where traditional legacy media and digital natives' news media firms compete to capture the time and economic resources of audiences and advertisers. This research is confined to a sample of Mexicans who consume digital news at least three times a week. This is relevant because the Internet penetration rate in this country was 67% in 2022, the year when the survey was conducted. However, the survey design limits further delving into the qualitative characteristics of the low interest these audiences have in Mexico.

The news industry faces challenges due to the global macro and microeconomic environment. The current digital situation leads to the study of the characteristics of the audience interested in news content products. The central aim of this research is to classify the main attribute interest in digital news content in Mexico of the audience's market by the attributes of age group, education level, and income level. This research is based on a survey of 2,005 digital news consumers in Mexico, directed in 2022 by the Reuters Institute for the Study of Journalism at the University of Oxford for the annual Digital News Report Study. The statistical method used is data mining with decision trees that classify the audience by the attribute of interest in the news as the dependent variable and attributes of age groups, education level, and income level as independent variables. These findings confirm the segmentation of digital news consumers' audiences. The classification in which the attributes of age groups, level of education, and income level are considered simultaneously concerning audiences' interests indicates that some of the predictions made show that some attributes may not be significant in some subsets, except for age group. The lowest average interest in the news is between 18 and 24 years, and the highest average interest in the news, which is nearly very interested, has audiences over 35 years.

INTRODUCTION The overall and age-specific incidence for female breast cancer differs between developing and developed countries [1][2][3][4][5]. In Figure 1 we show age-specific rates for breast cancer using the data from Cancer Incidence in Five Continents IX for Sweden and selected countries from which migrants have moved to Sweden. The incidence differences are small until age 35 years when the low-incidence rates diverge and reach a maximum at around age 50 years. The Swedish rate reaches a maximum at the age of 60 years and the white U.S. rates at age <unk>70 years [5]. Mammography has reshaped the age-incidence curves for Sweden and the United States as for these populations age maxima were higher in the premammography era [6,7]. In the United States, the age-specific rates of breast cancer are almost identical between white and black women until menopause but the white rates are substantially higher toward higher ages [8]. Among the Californian Asian immigrants, postmenopausal breast cancer rates are at a plateau, similar to the Serbian rate in Figure 1 [5]. In South Africa, most white women are postmenopausal at diagnosis compared with women of other races who are premenopausal [9]. In spite of the distinct age-specific incidence rates for breast cancer in low-risk and high-risk regions, the interpretation of these differences has remained controversial [1,3,4,9,10]. One line of interpretation posits that age at presentation depends on tumor biology, which is assumed to differ between low-risk and high-risk ethnic groups or regions because of genetic and environmental risks factors. Another view considers the early maximal age in developing countries to be a cohort effect of rapidly increasing rates in the young population. Yet another view is doubtful about the level of registration of cancers in the old patients. A solution to this problem may advance understanding of breast cancer etiology and prevention. Probably the only means of finding a solution to this problem would be to study age at diagnosis of breast cancer in relatively recent immigrants who are still at a substantially lower risk than women in the host country. We analyzed the age at diagnosis of breast cancer in female immigrants to Sweden by their region of origin and compared the results to the age at diagnosis in women from Sweden matched on birth year and other relevant factors. The study is based on the nationwide Family-Cancer Database with 11.8 million individuals, among whom some 15% are foreign born [11]. Sweden offers excellent opportunities to study cancer experience in immigrants because of a uniform cancer registration and health care system and the origin of immigrants from practically all around the world. --- SUBJECTS AND METHODS The Swedish Family-Cancer Database was first assembled from the national databases in 1996 and since then it has been periodically updated [12]. The database contains data on those born in Sweden since 1932 with their biological parents and additionally data on immigrants are included. This database is the largest in the world on familial cancer and its updated version (2008, VIII), which has been supplied with longitudinal demographic and socioeconomic data from each national census from 1960, 1970, 1980, and 1990, has been used for the present study [11]. Immigrants were defined according to their birth country. First-generation immigrants were defined as those without identified parents in the database. For each female first-generation immigrant, four women from Sweden were selected by matching on birth year, age at first childbirth, parity, and geographical region. To exclude women who immigrated with diagnosed or suspected cancer, cancers in immigrants Figure 1. Age-specific incidence of breast cancer in some countries/regions from which women have emigrated to live in Sweden, illustrating differences between high-and low-risk regions, based on Cancer Incidence in Five Continents (logarithmic scale) [5]. were included when diagnosed at least 4 years after immigration. The follow-up of the controls was started at the same time as that of the immigrants. The follow-up was stopped for all in the case-control sets when the first of them was diagnosed with cancer, emigrated, or died or when last day of the study, December 31, 2006, was reached, whichever occurred first. Confidence intervals for the difference in mean diagnostic age between immigrants and reference population were based on the t statistic. The incidence in immigrants was compared with that in natives of Sweden and standardized incidence ratios (SIRs) were calculated, as done previously [13]. The expected numbers were calculated for 5-year age groups, sex, time periods (10-year bands from 1958 to 2006), age at first childbirth (<unk>20, 20 -24, 25-29, 30<unk>), and parity (0, 1, 2<unk>) in the native Swedish reference population. The immigrant populations were divided into three groups according to the World Bank income classification from year 2009 (http://siteresources. worldbank.org/DATASTATISTICS/Resources/CLASS. XLS). --- RESULTS The Family-Cancer Database included 4.3 million women from Sweden and 0.6 million female immigrants. The relative risk of breast cancer in female immigrants compared with that in women from Sweden is shown in Table 1. Women from Finland were by far the largest immigrant group and their risks were lower than those of women from Sweden, SIR 0.90. Among the European immigrants, women from Greece had the lowest risk, 0.70. Among women from non-European countries, those from Turkey had the lowest risk of 0.45, followed by those from Chile (0.54) and Southeast Asia (0.57). Table 2 shows the number of women by their birth region and the percentage distribution of ages at first childbirth and parity, which were the matching criteria. The reproductive features differed extensively between the immigrant groups. Although only 3.5% of women from the Benelux region had their first child under age 20 years, 32.4% of women from Turkey already had their first child by that age; 41.3% of women from North America had their first child after age 29 years. More than half of the women from the Indian subcontinent were nulliparous and 70.3% of the women from Asian Arab countries were multiparous. The Family-Cancer Database covered years 1958 -2006 from the Swedish Cancer Registry and it included 128,885 cases of breast cancer in the native Swedish population and 11,323 in the first-generation female immigrants. The mean diagnostic age in the immigrant populations and the corresponding Swedish reference populations are shown in Table 3. Women from nine regions showed a younger mean diagnostic age (means and age difference in bold) than their matched Swedish controls, the largest differences being 5.5 years for women from Turkey, 5.1 years for women from both Asian Arab and "Other African" countries, 4.3 years for women from Iran, and 4.0 years for women from Iraq. Among only women from European countries, those from Greece (3.6 years), former Yugoslavia (1.9 years), Russia (2.5 years), and Poland (1.3 years) were diagnosed at a younger age than women from Sweden. No immigrant group had a significantly higher mean age than the women from Sweden. We carried out an additional analysis by classifying parity further, instead of "multipara," as para 2, 3, The immigrant populations were divided into three groups according to the income in their native country (Fig. 2). The age at diagnosis differed significantly between immigrants from middle-income countries and natives of Sweden (p <unk>.0001) and low-income countries and natives of Sweden (p <unk>.0001). Age-specific incidence rates for the three immigrant groups with the lowest diagnostic age were compared with the Swedish rate as shown in Figure 3. The rates for women from Turkey and Other African countries were well below the Swedish rates, whereas women from Asian Arab countries showed an intermediary incidence curve. To find evidence for a cohort effect in breast cancer, age-specific incidence rates of diverse Chinese populations were plotted using Cancer Incidence in Five Continents (Fig. 4). If cohort effects were important in shaping the agespecific curves, one would assume that the Chinese populations at various levels of socioeconomic development would show distinct patterns. This was not the case, and the postmenopausal incidence plateau was reached in all populations at age 45-50 years. Note the two lowest curves for Jiashan, a farming and fishing county, and metropolitan Shanghai, located 80 km apart. --- DISCUSSION In the present paper, covering cancers from the Swedish Cancer Registry through year 2006, we showed that the first-generation female immigrants in Sweden have a lower risk of breast cancer than the women from Sweden. The difference in risk was largest for women from developing countries, women from Turkey showing the lowest SIR of 0.45. Remarkably, the age-specific incidence curve for the Turkish immigrants (Fig. 3) was practically superimposable with the Izmir Turkish data (Fig. 1). The SIR of 0.45 for women from Turkey is in line, to the second decimal, with a previous study that we conducted with cancers followed through 1998, with less than one half of the number of cases in immigrants and even relatively fewer cases in non-European immigrants [13]. The difference in risk between the natives of Sweden and the immigrants from developing countries, such as China and India, was not as large as that cited in Cancer Incidence in Five Continents (about fourfold) [5]. The most important reason is that the non-European immigrants in Sweden are still relatively young [11] and, according to Figure 1, the incidence differences between developing and developed countries are mainly due to postmenopausal breast cancer. Other minor reasons may be that the local incidence rates differ because of geographic and socioeconomic factors and the emigrants are likely to be a selected active group of the population [14]. The duration of residence in Sweden has probably narrowed the difference in rates between the immigrants and the natives of Sweden, as has been observed for women of Italian descent living in Australia [15] and women of Asian descent living in California [16]. In a comparison of the age at diagnosis of breast cancer, a number of design features were introduced to guarantee unbiased results. The populations were matched on birth year, region, period, and reproductive factors. The follow-up was started 4 years after immigration to exclude individuals who might have entered Sweden for cancer treatment. The follow-up was terminated whenever any member of the case-control set ceased to be at risk. The results showed that women from nine regions, five from non-European and four from European countries, showed younger mean age of onset than their matched Swedish controls. The largest differences were 5.5 years for women from Turkey and 5.1 years for women from both Asian Arab and Other African countries. The diagnostic age for these women was around 45 years compared with 50 years for the Swedish matched controls. This difference is equal to comparing women with and without family history of breast cancer [17]. Notably, no immigrant group had a significantly higher mean age than the natives of Sweden. These data should settle the debated issue of whether the different agespecific rates between low-risk and high-risk countries are truly biological or whether they are recording artifacts because of rapidly changing incidence or missed elderly patients. Whether these biological effects are related to known or yet unknown risk factors will be discussed below. --- CONTRIBUTION OF KNOWN RISK FACTORS Among the reproductive variables in Table 2, the countries with low age at breast cancer diagnosis, particularly the Middle East countries, were distinguished by high frequency of multiparity. However, when we divided the parity classes even further, the results remained. Thus, parity is an unlikely explanation to the findings. No data were available on the start of menstruation. According to the literature, however, no large differences have been reported for women from Turkey (12.4 -13.3 years) and India (12.4 -12.9 years) and female adolescents from Sweden (13 years) [18 -20]. A study on London schoolgirls in 1980 -1981 found mean ages at menarche as 13.6 years (of European descent), 13.2 years (of Afro-Caribbean descent), and 13.1 years (of Indo-Pakistani descent) [21]. Of course, we do not know how relevant these data are for women who migrated to Sweden some decades ago. Age at menarche is a relatively weak risk factor of breast cancer and the available data on ethnic variation do not support contribution by this factor. Another uncontrolled factor was the length of lactation, which is weakly protective of premenopausal breast cancer in white populations of women who have ever breastfed compared with those who never breastfed any children [22]. A study on women from China found a protective effect on all breast cancers but the shortest significant breastfeeding duration was 6 -9 years, which is probably uncommon among immigrants to Sweden [23]. For the relevant birth cohorts of the present study, women born between 1930 and 1950, breastfeeding rates were at a historical low in Sweden around 1970 (2 months of breastfeeding, <unk>35% of infants; 6 months, <unk>10%) [24]. In 1950 and 1980 the rates were much higher (about 80% and 40%, respectively). Discounting this short period, the Swedish breastfeeding rates have been high in comparison with those of European countries, which does not help to explain the low age at diagnosis for women from Greece, Russia, Poland, and the former Yugoslavia [25]. Historical data from developing countries are limited but they suggest that lactation periods for many infants were extended to 2 years [26]. This trend appears to remain among immigrants to Sweden: 6-month breastfeeding rates were around 75% and not different from natives of Sweden, but 12-month rates were lower for natives of Sweden (18%) than for, for example, women from African (44%) and Middle Eastern (36%) countries [25]. We had no data on whether tumors were found in the national mammographic screening program. The participation of non-Nordic immigrants in this screening has been lower (about 80%) compared with that of natives of Sweden (90%) [27]. However, the difference is not large and the effect, if any, would be opposite to the present findings because the start of screening (between ages 40 and 50 years, depending on regional programs in Sweden) would probably advance the detection of breast cancers [28]. Finally, early age at diagnosis is a feature of familial and heritable cancers but there is no evidence that familial breast cancer or BRCA1/2 mutation carrier frequencies would be higher in non-European ethnic populations [29,30]; a high familial cluster would not be compatible with the generally low incidence in immigrants. --- CONCLUSIONS The present data provide strong support to the notion that the age-incidence relationships for breast cancer are not registration artifacts between high-risk and low-risk populations. It is also unlikely that the differences were only due to cohort effects because they were uniform between the different Chinese populations (Fig. 4) and in many other populations in low-risk countries at various levels of development [10]. Additionally, according to the Danish and Swedish cancer registries (started in 1943 and 1958, respectively), age-specific incidence data have never resembled those from the developing countries, although cohort effects have been observed over the years [31]. In low-risk immigrant populations premenopausal breast cancer is relatively more common than in natives of Sweden. It is not obvious from the discussion in the above paragraph that the identified biological factors modulating risk would explain the differences. Tumor characteristics can potentially be distinct in immigrants from low-risk areas but our preliminary data on histology and survival in breast cancer show only minor differences to the natives of Sweden. Instead, the Western lifestyle, low physical activity, and being overweight may contribute and these should be targeted in prevention [32,33]. Western lifestyle with changing reproductive patterns and improved access to diagnostics is also contributing to the increasing breast cancer rates in developing countries [34,35]. Moreover, even studies among Swedish immigrants show that many elderly immigrants, particularly from the Middle East, have become physically inactive with ensuing weight gain, which may unfavorably influence their breast cancer risk in the long run [36 -38]. Increasing rates, particularly for postmenopausal breast cancer, have also been noted for women of Asian American/Pacific Islander descent living in the United States and California [8,39]; in Sweden, trend analysis by individual immigrant groups is not yet possible because the residence time of the low-risk immigrants is too short. --- AUTHOR CONTRIBUTIONS Conception/Design: Kari Hemminki, Seyed Mohsen Mousavi Provision of study material or patients: Kari Hemminki, Jan Sundquist Collection and/or assembly of data: Kari Hemminki, Jan Sundquist Data analysis and interpretation: Seyed Mohsen Mousavi, Andreas Brandt Manuscript writing: Kari Hemminki, Seyed Mohsen Mousavi, Jan Sundquist, Andreas Brandt Final approval of manuscript: Kari Hemminki, Seyed Mohsen Mousavi, Jan Sundquist, Andreas Brandt

Background. Age-specific incidence rates for breast cancer in low-risk and high-risk ethnic populations differ by age at which the incidence maximum is reached: around 50 years in low-risk populations and over 60 years in high-risk populations. The interpretation of these differences remains unsettled, one line primarily referring to biological differences, the second one to cohort effects of rapidly increasing rates in young populations, and the third one to incomplete registration of cancer in the elderly. Methods. The nationwide Family-Cancer Database was used to analyze standardized incidence ratios (SIRs) and age at diagnosis of breast cancer in female immigrants to Sweden by their region of origin compared with women native to Sweden matched on birth year and other relevant factors. Results. We showed first that the SIRs for breast cancer were lower in many immigrant groups compared with natives of Sweden; women from Turkey had the lowest SIR of 0.45, followed by those from Chile (0.54) and Southeast Asia (0.57). Women from nine regions showed an earlier mean age at diagnosis than their matched Swedish controls, the largest differences being 5.5 years for women from Turkey, 5.1 years for those from Asian Arab and "Other African" countries, 4.3 years for those from Iran, and 4.0 years for those from Iraq. Conclusions. The results show that in many immigrant groups, the diagnostic age is earlier (<50 years) than in natives of Sweden (>50 years), suggesting that true biological factors underlie the differences. These factors may explain much of the international variation in breast cancer incidence. Identifying these factors should advance understanding of breast cancer etiology and prevention.

Introduction As the world becomes increasingly progressive, changes have occurred in the rights of sexual minorities, and the last decade has seen a series of victories for LGBT+ communities across the globe (Michelson 2019). But despite all the advancements and acceptance for the LGBTI+ community in some countries today, members of this group remain at high risk of becoming victims of violence for their sexual orientation, gender identity, and gender expression. In fact, in many countries, the human rights of LGBTI+ people are not guaranteed. More specifically, in six countries, sexual minorities are punished with the death penalty, and in 57 others, the maximum sentence for belonging to this community is between 8 years and lifetime imprisonment (Mendos and ILGA World 2019). The LGBTI+ community has been at the receiving end of violence for a very long time in different social spheres (Parker 2017). And violence toward LGBTI+ people can affect them for many years after the aggression occurs (Mawira-Gitari and Walters 2018). It has been reported that LGBTI+ people who are victimized are less likely to complete their studies and, therefore, have fewer job opportunities (Logie et al. 2016). Furthermore, many gay, lesbian and bisexual people feel the need to hide their sexual orientation to avoid experiences of discrimination in different social settings (Pereira and Costa 2016). Some groups within the overarching classification of LGBTI+ people are more vulnerable than others. For example, trans people subjected to physical and sexual violence have been found to be more likely to attempt suicide, and experienced greater suicidal ideation and increased risk of drug abuse (Testa et al. 2012). In fact, a study conducted with a sample of university students reported that attitudes toward homosexual or bisexual men/women were more positive than attitudes toward transgender people (Copp and Koehler 2017). Additionally, LGBTI+ people belonging to religious minorities or ethnic minorities may be even more vulnerable to violence and discrimination and experience even worse repercussions (Chin et al. 2016;Cyrus 2017;Peumans 2017). According to reports and studies undertaken in different countries, LGBTI+ students are more likely to be victims of violence and assaults while at university. However, there are no national or autonomous community data that serve to illustrate the current situation of LGBTI+ university students in Spain. These data can be used to establish prevention measures and actions against acts of violence. Therefore, this study is part of the competitive project called Uni4Freedom.Violence due to sexual orientation and gender identity or expression subsidized by Fundació Obra Social la Caixa. It should be noted that this work constitutes the first research project to present data on violence and discrimination in the university environment in Catalonia (Spain). --- Background in educational contexts The challenges faced by the LGBT+ community in educational institutions has been the focus of much attention in recent years. Several studies have revealed evidence of the discrimination and prejudice that sexual minorities face in educational institutions (Costa et al. 2015;McGinley et al. 2016;Rankin 2005;Coulter and Rankin 2020;Hong et al. 2016). In addition to the family environment, the educational setting is one of the social contexts that most influences psychosocial development and the formation of a child's identity. More specifically, adolescents develop their identities through social interactions, especially at school. It has been well established that the cultural context of a child's education is crucial for the development of adolescent identity (Eccles and Roeser 2011). For this reason, educational institutions should be places free of discrimination, aggression, and violence. As previously stated, situations of violence against sexual minorities are present in most societies in the world, and university settings are no exception. Several studies carried out in different parts of the world show that students belonging to sexual minorities due to sexual orientation, gender identity, or gender expression are more likely to be victimized in different ways throughout the university journey (Costa et al. 2015;McGinley et al. 2016;Rankin 2005), and the odds are even higher for trans students (Coulter and Rankin 2017;Hong et al. 2016;Goodrich 2012). Although the forms of violence to which these people are subjected have been changing and taking on more subtle manifestations, they retain the same intention of causing harm to the LGBT+ person and result in the same consequences for the victim. A more in-depth study carried out by Garvey et al. (2015) looked at the campus climate for LGBT+ undergraduate students at community colleges. Their results revealed perceived inequalities and hostile environments on campus and in the classroom for LGBT+ students, and that the teaching staff was viewed as indifferent to these problems. The authors claim that community colleges have failed to adapt to the growing and changing diversity of their student populations, and suggest that faculty positions on such issues are essential to the student experience, whether positive or negative. Furthermore, the research conducted by Seelman et al. (2017) with a sample of LGBT+ university students revealed a high prevalence of blatant victimization and microaggressions. These variables were related to low self-esteem and higher levels of perceived stress and anxiety symptoms. In addition, trans students exhibited a stronger negative association between victimization and self-esteem than cisgender students. In the same vein, a study of 8184 Brazilian university students revealed a moderate prevalence of prejudice towards LGBTI+ students; specifically, 2389 reported extreme, high, and moderate levels (Costa et al. 2015). In the Spanish context, few studies have evaluated the violence, aggression, discrimination, and prejudice experienced by sexual minorities at universities. For this reason, the objective of the present study was to identify students' perceptions of violence in the Catalan university setting because of sexual orientation, gender identity, or gender expression. --- Method --- Participants Since the main objective of our research consisted of studying the perception of violence based on sexual orientation, gender identity, or gender expression in university students, data were collected from university students. The sample comprised 571 university students from six public and private universities in the autonomous community of Catalonia (Spain), specifically from the University of Barcelona, University of Girona, University of Lleida, Ramon Llull University, Rovira i Virgili University, and the University of Vic. The age range of the participants was between 17 and 55 years, with a mean age of 21.27 years (SD = 3.95). The participants self-reported their gender identity: 77.8% female, 20.5% male, 0.3% trans person, 0.7% non-binary person, 0.4% person of fluid gender, and 0.4% preferred not to reveal their gender identity. Regarding sexual orientation, the participants identified themselves as follows: 71.9% heterosexual, 17.8% bisexual, 6.3% homosexual, 1.7% pansexual, 1.1% asexual, and 1.2% preferred not to answer the question. The sample size was estimated according to the method proposed by Daniel and Cross (2013) for finite populations in order to obtain a significant sample of the study population. The statistical parameters considered when determining the estimation were (population size = 120,980, margin of error = 5%, confidence level = 97%) = N adequate (469), N obtained (571). The population size corresponds to the total number of undergraduate, master's, and doctoral students from the six universities under study. Our sample is therefore representative. To obtain a heterogeneous sample based on the fields of study to which the surveyed student sample belonged, the different disciplines were grouped into three main areas: social sciences and humanities, health sciences, and science and engineering. A proportional distribution was calculated based on the total number of students belonging to each group, and by applying the following criteria: 1) Students from more than one field of study had to be surveyed from each university. 2) Each field of study had to contain students from more than one university. --- Measures A dichotomous-answer survey was developed for this study. The instrument was designed based on previous findings reported by studies at universities in different parts of the world. The research team conducted a literature review in the Web of Science and SCOPUS databases to select the questions. In addition, the survey was validated by an international expert committee on gender studies and violence against LGBT+ people and by a social affairs committee on LGBTI+ issues made up of members of different associations. This process ensured that the questions were drafted inclusively, reflect situations that LGBT+ people may face in universities, and relate to the objectives of our research. The questionnaire consisted of four blocks of questions. The first block, A) sample characteristics, was designed to collect demographic information. The second block, B) general identification of violence based on sexual orientation, gender identity, or gender expression, consisted of dichotomous yes/no questions based on 12 situations for which the person surveyed had to answer whether they considered it violence or not. This block also included dichotomous questions focused on the university environment. In this case, the person had to answer whether they had witnessed any violence within the university context. This dimension consisted of different parameters: physical, psychological, and sexual violence; discriminatory comments; hostile environment, persecution, surveillance, and second-order harassment. The third and fourth blocks were C) knowledge of the victim's reaction and D) knowledge of measures to prevent violence due to sexual orientation, gender identity, and gender expression in the university context. --- Procedure This study was conducted following the principles of the Declaration of Helsinki. It was also approved as under the ethical principles of the University of Lleida and the University of Girona (Catalonia-Spain). An online form was used to administer the survey using the Lime Survey software. The data was encrypted and the computer servers of Rovira i Virgili University (Tarragona-Spain) were used to guarantee the confidentiality and safe custody of the data. Before administering the questionnaire, a pilot test was carried out with undergraduate students to detect errors and ambiguities in the questions. The survey included an introduction, which contained an explanation of the response format for the different questions. It also explained that the data would be completely anonymous and would remain confidential and protected. The participants had to accept the study conditions before participating and express their consent to answer the survey. The effectiveness of surveys administered online has been previously demonstrated. More specifically, the responses to questionnaires on attitudes and perceptions are as valid when administered online as on paper (Mangunkusumo et al. 2006). The online application is useful when inquiring about aspects susceptible to bias based on social desirability and when guaranteeing complete anonymity is imperative. At the end of the survey, information was provided on victim support services at both the university and state levels. --- Results Table 1 shows the 12 situations of aggression towards the LGBTI+ community and the percentage of participants who considered them a form of violence. All the situations were identified as aggression by more than 86% of the sample. However, situations seven and eight were considered violence by fewer respondents than the other situations. These two situations refer to the concealment of sexual orientation or gender identity for fear of negative consequences. In contrast, insults and teasing, raised in question one, received the highest percentage with 96.35% of the participants regarding them as violence. The participants were asked if they knew of any violence motivated by the sexual orientation, gender identity, or gender expression of the victim, and 61.2% of the people surveyed stated that they knew at least one case of violence in the university context. The participants were then asked if they themselves had experienced or if they knew anybody who had experienced eight specific situations. Table 2 shows the situations and their corresponding percentages. Having to hide sexual orientation or gender identity obtained the highest percentage of identification (45%), followed by discrimination and humiliating comments (16.83%), and psychological attacks (15.86%). In contrast, the situations with the lowest percentage of identification were leaving university (1.84%) and second order of sexual harassment (1.84%). The third block of the survey was designed to determine whether participants were aware of the victim's reaction after a case of violence or aggression in the university environment. The answers obtained in this block refer to the most serious of the specific cases that the people surveyed knew about. Therefore, the results do not show all the cases or the students' average number of known cases. The results revealed that 76.6% of those surveyed recognized the victim's reaction, while 23.4% stated that they did not know how the victim reacted. Table 3 presents the results and their corresponding percentages. The percentages are not summative because the participants were able to choose different options. Among the respondents, 67.05% who knew of a case of violence in the university context stated that the act was not reported, though it was disclosed to other people. Among the unreported cases, 77.46% maintain that the victim told a friend about the incident. In contrast, 1.16% stated that the victim reported the violence or assault to university staff. --- Discussion The main objective of this study was to identify different types of violence due to sexual orientation, gender identity or gender expression in Catalan universities. Participants were asked to consider 12 situations and state whether each situation constituted violence in the university environment. Our results revealed that all of the situations were identified as aggression by more than 86% of the sample. The situation with the lowest percentage of identification as violence was avoiding expressing sexual orientation and gender identity for fear of negative consequences. In fact, these data coincided with those generated by another question. When participants were asked if they had information about acts of violence against LGBTI+ people, among those who reported being aware an act of violence, 45% reported knowing of a case in which at least one LGBTI+ person hid their sexual orientation or gender identity. This aspect can condition the free expression of one's gender identity and sexual orientation out of fear of negative consequences. Several studies have found that many LGBTI+ students report being afraid of the negative reactions and homophobia that could occur if they declared their sexual orientation or gender identity (Ellis 2009;Evans and Broido 2002;Lapinski and Sexton 2014;Rankin et al. 2013;Rothmann 2016). This is a problem for LGBTI+ students, because hiding sexual orientation has been linked to mental health problems such as depression and stress (Pachankis et al. 2020). We also surveyed participants about their awareness of the different types of violence that occur in the university context. The survey revealed that 61.2% of the respondents knew of at least one case of violence in the university context. These data reflect the hostility that university students belonging to sexual minorities may perceive. These results coincide with those from studies conducted in universities in different parts of the world, which report different types of violence directed against LGBTI+ students (Mart<unk>nez-Guzmán and <unk>iguez-Rueda 2017; Ellis 2009; Okanlawon 2020). Although Catalan and Spanish universities have increased their efforts in recent years to protect sexual minorities from discriminatory acts, violence and aggression, apparently these types of attacks have remained in the form of more subtle expressions of violence. These more subtle acts of aggression may go unnoticed (Hong et al. 2016) and may not have physical repercussions, which can make it difficult to eradicate them in the university setting, resulting in harm to the individual and to the social well-being of LGBTI+ students. Indeed, as mentioned above, our data corroborate others' findings that some students belonging to sexual minorities choose to hide their gender identity and sexual orientation, which can affect their permanence and success at university (Renn 2020), their ability to establish and maintain positive social relationships (Duran and Nicolazzo 2017), and their psychological well-being and mental health (Riggle et al. 2017). Along the same lines, discriminatory and humiliating comments were the second most identified situation of violence, and psychological aggressions were the third most identified by the respondents. This type of violence can cause the normalization of these types of discriminatory expressions and attitudes in the university community, causing them to be perpetuated over time. This affects the objective well-being, that is, the quality of life of LGBTI+ minorities, as well as their subjective well-being, both cognitive and emotional. Previous research has reported that most of these aggressions and discriminatory attitudes towards LGBTI+ students are perpetrated by students who in turn require accomplices, or silent facilitators, and this combination of actors and situations of violence creates an environment that is hostile, discriminatory and intolerant towards sexual minorities (Clarke 2016;Kheswa 2016;Martin-Storey and August 2016;Rankin 2005;Woodford et al. 2013). To a lesser extent, but no less important, 8.49 of the participants reported being aware of at least one case of physical violence within the university community. The emotional and social consequences of being a victim of this type of violence has been widely studied in the LGBTI+ community, and include emotional anguish, humiliation, fear and depression (Mallory et al. 2017;Davis et al. 2020). This impact is not only experienced by LGBTI+ people who are the victims of physical attacks. People who know of or have witnessed physical attacks may sustain the same psychological repercussions (Gollub et al. 2019). This phenomenon is based on social learning theory (Bandura 1977), which states that people learn by observing behaviors, and that people's perceptions can be influenced by other people or the consequences that other people's actions have. Another aspect that we analyzed was the reaction of the victim to a case of violence or aggression in the university environment. Our data revealed that most cases of violence were not reported to either the university authorities or the police. This can generate a feeling of impunity before the educational community and a feeling of helplessness in the victims (Musalo and Bookey 2014;Konstanski 2011;Vasanthi and Melanie 2017). The scarcity of complaints reflects the lack of visibility and awareness of these events in Catalan universities. Studies conducted with victims of sexual assault show that in the university environment there may be a series of obstacles that make reporting impossible, including, for example, the victim's fear of the consequences, questioning whether the aggression, discrimination or violence was sufficiently serious to report, not trusting the law or considering that the aggressor(s) powerful enough to delegitimize the complaint, or fear of being blamed for the aggression they have experienced (Holland 2018;Brubaker et al. 2017). Therefore, there is a clear need to promote mechanisms that allow students to lodge complaints without reducing secondary victimization, accompanied by protective services and support for victims. Furthermore, ease of reporting must be accompanied by services that allow victims to seek help. --- Conclusion The results of the present study reflect different conclusions. First, some situations of violence against LGBTI+ people may go unnoticed or be normalized. For example, avoidance of freely expressing gender identity or sexual orientation for fear of negative consequences were the situations with the lowest percentage of identification of violence. This fact is a problem for the general well-being of LGBTI+ students because having to hide sexual orientation or gender identity can cause discomfort and abandonment of university studies. Future studies should focus on two aspects, 1) design and evaluation of university educational programs that allow the identification of different types of violence, including the most subtle. 2) Analyze and evaluate university policies and good practices on the protection of LGBTI + students. Second, there was a high percentage of violence not reported to the university or the police. This result is worrying because many attacks, discrimination and violence have gone unpunished, this can generate a feeling of helplessness in LGBTI + students, a sense of impunity for the university community, and obvious legal implications. Furthermore, this may be skewing the data on violence, assault and discrimination against LGBTI+ people. Multidisciplinary studies are necessary to analyze these aspects in the university context. Third, this study is the first in Catalonia and Spain to identify violence due to sexual orientation, gender identity and gender expression; the data show expressions of subtle but equally harmful violence. --- Abbreviations LGTBI+: Lesbian, gay, transsexual/transgender, bisexual, intersexual, other minorities due to sexual orientation or gender identity; M: Mean; SD: Standard deviation Authors' contributions J-MD wrote the article and provided the final approval of the version to be published. SR have checked ethical issues and provided the final approval of the version to be published. PM and PSV have participated in the collection of the data. Each author revised the manuscript critically for important intellectual content. All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. --- Availability of data and materials Our data is not available for ethical reasons. This study is part of the "Uni4freedom" project, which has been approved by two ethics committees (the University of Lleida and the University of Girona), the ethics committees recommended that the data should not be public and should be kept by the principal researcher of the project in a specific virtual space. --- Competing interests The authors declare no competing interests. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Social struggles have led to the legal recognition of the rights of LGTBI+ people in some countries. Even so, violence against LGTBI+ people is a social problem throughout the world, and has resulted in the vulnerability and victimization of the members of this group. In Spain, no research has been published to date that analyzes this problem in the university context. Considering the scarcity of studies on the identification of this type of violence in Spain, the main objective of this study was to identify violence against LGBTI+ people in Catalan universities. We administered a battery of questions to a sample of 571 university students from six universities in Catalonia (77.8% women) between 17 and 55 years old (M = 21.0; SD = 3.96). Of the 12 situations of violence presented, psychological violence was identified as the most common type. Within our sample, 61.0% reported either being aware of or having experienced some type of violence related to the university context and motivated by the sexual orientation, gender identity, or gender expression of the victim. The results also show that these types of violence in the university context are rarely reported, especially when they do not include physical violence. This study highlights a previously unreported problem and identifies future research avenues in university contexts.

Malaya, made familiar to a Western audience through the writings of Joseph Conrad, Anthony Burgess and Somerset Maugham, was controlled by the British from 1874 (Pangkor Treaty) to 1957.2 These authors represented Malaya from an expatriate perspective, often focusing on the colony's tropical setting, people, customs and way of life. The reader is given not only a view of local life but also expatriate living in the Malay Peninsula. The British author's writing of Malaya invites responses from postcolonial critics who study the Orientalist implications of literary representations of the East in Victorian England, the Edwardian era, World War I and World War II. These representations offer scope for analysing the colonial perspective brought to bear on the experience of cultural difference encountered in the colonies, an experience that may result in an expatriate or colonist "going native" or deciding there is little point of contact between the peoples of Asia's primitive backwaters and the superior culture of Great Britain. The historical backdrop of nineteenth-century and twentieth-century Malayan life is Great Britain's colonial presence in Southeast Asia, established in the Malay Peninsula through the creation of a Crown Colony (the erstwhile Straits Settlements) and establishment of protectorates. This backdrop focuses on familiar themes: the relationship between colonial authority and colonised subjects; the coming of the Chinese to work in the tin mines; World War II and the Japanese Occupation; the rise of nationalism; and the achievement of Independence. It offers space and material for representing the intertwining of race and politics in Malaysia's development as a postcolonial nation. In this history, the Malaysian of ethnic Chinese descent is a citizen who belongs to a community that traces its origins to the early coming of the Chinese to the Malay Peninsula from China. Remembering the ancestral country is one of the defining features of the diasporic experience. Remembering the past often assumes the form of nostalgia, which can over time decrease in intensity as the diasporic subject develops an accommodative relationship with the foreign land in which he or she has settled. Remembering exists in tandem with forgetting, with leaving behind, and with abjection, affected by time's passing and by the diasporic subject's absorption into the environment of the host country. In Chinese-American literature, an important corpus of the Anglophone Chinese diaspora, China is the overseas Chinese's originary homeland and source of ancestral culture. Central to the writings of canonical Chinese-American authors such as Maxine Hong Kingston and Amy Tan is the diasporic theme of dislocation and assimilation, an experiential tension that is played out between first-generation and second-generation Chinese-American subjects, and between ethnic culture and American culture. For Kingston and Tan, US-born citizens of Chinese descent, gain access to Chinese history and culture through the stories of experience narrated by their parents (mothers in particular) who came to America from China. In this literature, the Pacific Ocean not only stands as a literal expanse that separates East Asia from North America, it also metaphorises the geopolitical and cultural distance that exists between East and West, a distance often viewed through Orientalist lenses. The violent encounter between China, Great Britain and other Western powers in the nineteenth and twentieth centuries draws attention to the Pacific Ocean as the vast body of water that must be crossed to reach Gold Mountain (Gum Shan) and join in the search for riches in America. The transpacific crossing from Asia to America is central to the diasporic experience of sojourning, dislocation and assimilation, one in which "claiming America" for American citizens of Chinese descent constitutes an important motif in the narrative of migration and belonging. Concurrent with the arrival of the Chinese (primarily men) in California in the nineteenth century is the influx of migrant workers from China to work in the tin mines of Malaya, an industry which developed as the result of discovering rich tin deposits in Perak and Selangor. The coming of the early Chinese to Malaya offers an important narrative of the Chinese diaspora in Southeast Asia, one that has not attracted the same degree of critical attention as the literature of Chinese sojourning and settlement in the United States. One reason for this is the presence of a sustained corpus of literary works that has come to be known as Chinese-American Literature, a subset of Asian-American Literature. But Malaysia has its own diasporic perspective, distinctively exemplified, for example, in the work of Malacca-born Chinese-American author Shirley Lim, which is read often enough through the interpretative lenses of the immigrant experience in America. When we consider the writing of the Chinese diasporic experience in Malaysia, we find that Shirley Lim's literary works derive cultural significance not only from the context of the immigrant experience in the New World but also from that of the Chinese diasporic experience in Southeast Asia. These works focus on two countries not usually considered together in writings of the Chinese diasporic experience: Malaysia and the United States. Lim's focus on Malaysia foregrounds the phenomenon of the Chinese diaspora in Nanyang. Translated as "South Seas," Nanyang is an appellative used by China to designate the geographical region to its south (Southeast Asia), favoured by would-be Chinese immigrants seeking to escape the political upheavals of nineteenth-century China. In the history of the Chinese diaspora, most of the Chinese who left China because of war, poverty, overpopulation and political instability ventured to Southeast Asia instead of to the United States or any other country (Writing the South Seas vii-viii). For many Chinese, Malaya promised a better life than China. The overseas Chinese (huáqiáo) who settled in Nanyang were not necessarily illiterate coolies or traders and merchants. They included "intellectuals, students, teachers, journalists, writers, political reformers, and dissidents" (Writing the South Seas ix). The Chinese who came to British Malaya in the latter nineteenth century comprised more labourers than merchants, their aim to work in the tin mines ("Chinese Migration and Entangled Histories" 80-81). The coming of the Chinese brought them into contact with local Malays and with the British colonial presence in Southeast Asia, an encounter portrayed as tension-filled interactions between local and foreign cultures across generations in Suchen Christine Lim's novel A Bit of Earth (2001). In Nanyang, the huáqiáo became part of the society in which they found themselves by working hard and with grit and determination. Venturing into Nanyang involved the experience of alienation and acculturation, of working out the terms of one's identity as an ethnic and cultural Other in a foreign land. Setting up diasporic communities in Southeast Asia is difficult because of racism and discrimination. In 1967, for example, a presidential decree in Indonesia, aimed at forcing "Indonesians of foreign descent" to undergo "a process of assimilation," exerted tremendous pressure on Indonesian Chinese to change their Chinese names for Indonesian ones ("Class, Race and being Indo (Eurasian)" 230). The Chinese in post-Independence Malaysia likewise found themselves living in a country in which national identity cannot be separated from the politics of race. In Malaysia, Malay was chosen to be the national language of the country while the launching of a New Economic Policy (NEP) in 1971 favoured Malays over citizens of other races ("Linguistic Diversity: Asia"). The NEP was a statesponsored system of affirmative action set up to improve the economic condition of the country's bumiputra ("son of the earth"). For the Chinese in Malaysia, policies such as the NEP are prejudicial and transform the country's ethnicminority subjects into second-class citizens. According to Pue Giok Hun, Malaysia's organisation of race into categories enforces "racial identification [that] influences people's life choices and choices at the individual level, via the implementation of various socio-economic policies that advocate affirmative action along racial lines, such as in education, finance and property" ("Our Chinese" 147). Viewing Malaysia's bumiputra policy as discriminatory because it privileges one racial group over others, ethnic minority subjects find themselves pressured into engagement with the cultural politics of identity in the nation-state. The cultural politics of race and national belonging is central to the thematic concerns of Shirley Lim's Among the White Moon Faces (1996). A postcolonial and feminist bildungsroman, Among the White Moon Faces narrates the life of its author from her early beginnings in British Malaya through her university education to her journey to the United States and American naturalisation. Lim contributes to literature of the Anglophone Chinese diaspora by identifying Malaysia (and, by implied extension, Nanyang) as the controlling point of reference for representing the Chinese diasporic experience. As a land that facilitated the development of a major Chinese community in Southeast Asia, Malaya's transition from British rule to Independence allows for interpreting the cultural politics of home and national belonging for the ethnic minority person. Shirley Lim begins Among the White Moon Faces with a portrait of her mother who is identified as a "nonya" (24) and who exemplifies "peranakan female power" (25). The mother is described as "a native goddess [who] presided over an extended family" (25), the centre of its worship and reverence. She remained the family's presiding genius until Lim was eight years old when she abandoned the family. Foregrounding her mother's Peranakan identity directs the reader to the history of the early Chinese in the Malay Archipelago. Referring to peoples of mixed Chinese and Malay/Indonesian heritage, Peranakan signifies the condition of racial and cultural hybridity that developed as the result of interactions between early Chinese labourers and traders and local Malays. The coming of the Nanyang Chinese to Peninsular Malaysia to work as labourers led to contact between Chinese and Malays, resulting in cultural intermingling and miscegenation. Pue Giok Hun explains that "[t]he term 'Peranakan' is a Malay/Indonesian term derived from the root word 'anak' which means child (offspring). When circumfixed with 'per-... -an', Peranakan originally referred to the womb, but eventually evolved into a metaphor that refers to local-born of non-indigenous descent" ("Our Chinese" 149). Lim's experience of Southeast Asian history is the experience of discrimination at all levels of social and cultural life. First there is the condescension of Malaya's British masters for whom the English language is only on loan to the colonial subject. English is Great Britain's linguistic possession and it serves in the colonies to distinguish rulers from ruled. In schools and at university, the English language reminds students of Great Britain's superior culture, proudly showcased in its literature. As Thomas Babington Macaulay (in)famously declared in his Minute on Education (1835): "I have never found one among them [Orientalists] who could deny that a single shelf of a good European library was worth the whole native literature of India and Arabia. The intrinsic superiority of the Western literature is indeed fully admitted by those members of the committee who support the oriental plan of education" (Minute on Education). As an accomplished reader of English literature, Lim found that literary works allowed her an escape to foreign worlds and cultures through the imagination. However, the more she absorbed this literature, the more she thought about its cultural significance for her as a young Chinese woman in Malaysia. Thinking about the relevance of English poets such as Wordsworth, for example, to her own culture-specific positioning, Lim arrived at the conclusion that not only is English literature the prized possession of the British Empire, but it also functions to denigrate the writings of other peoples as inferior (174-80). And, importantly, she realised that English literature could not address the cultural and political concerns of the local and the national. For all its pleasures, English literature could not engage in conversation with her experience as a Chinese subject living in Malaysia. Lim wants to read and write literature on her own culture. For literature to be relevant to a nation, it must come from the experiences of its own people and culture. Born and raised in British Malaya, Lim did not register a desire to visit the United Kingdom in Among the White Moon Faces. In this respect, Lim's memoir departs from the familiar motif of the (post)colonial subject's desire for the political and cultural centre of empire. Lim does not reveal any interest in London, the capital of the British Empire, in the way that another Chinese-Malaysian author Lee Kok Liang does. In Lee Kok Liang's semi-autobiographical novel London Does Not Belong to Me (2003), London attracts the postcolonial and expatriate subject. However, despite its attraction, London seems to lack the energy for which it is historically famous. For expatriate characters like the narrator and others who come to England from places as different as Ireland, Australia and the United States, London represents loneliness and tenuous relationships, offering little material for meaning-making. Unlike Lee Kok Liang's narrator who goes to London only to experience emotional dislocation and alienation in the great city, Lim resists Great Britain's gravitational pull exerted by its imperial history, choosing instead the United States because she believed its academic culture would be more accommodating of her research interests in minority and non-canonical literatures. Choosing the United States amounts to a symbolic rejection of everything that the British Empire stood for. Lim might have interrogated the hegemonic structures of her country's British-based education, but it is mastery of the English language that gave her the advantages of symbolic and cultural capital with which to navigate the challenges of America. When she flew to the United States for her doctoral studies, she brought with her an English language proficiency that first-generation Chinese-American immigrants, portrayed in the writings of canonical Chinese-American authors Maxine Hong Kingston and Amy Tan, did not possess. This linguistic lack made it difficult for early Chinese immigrants to assimilate into American society and culture. Possessing symbolic and cultural capital facilitates ease of transnational mobility, replacing involuntary ejection from one's birth country with the capacity to choose between national homelands. Arriving in America and finding she had to struggle with cultural dislocation and prejudice did not stop Lim from choosing to embrace American naturalisation. One reason given by Lim for the decision to be an American citizen is the importance of bestowing on her American-born son "the privileges of a territorial self" (123), ensuring he does not experience the instabilities of diasporic subjectivity. She wants to shield her son from pressures that can "undermine the infant primacy of an American homeland," pressures entwined with nostalgia, regret and the inescapable "consciousness of another country" (287). Expressing confidence in America's ability to afford political and social stability, Lim identifies her maternal instinct to be close to her son in the land of his birth as an important reason for her decision to become an American citizen. The United States is a country that can give her son the advantages of a stable national homeland whose ideals outweigh its many problems and shortcomings. Despite its imperfections, which include "instances of still invidious discrimination" (339), the United States is a far more accommodating country for the minority subject than Malaysia. Lim embraces the mythos of America as the land of the free and the home of the brave: "The U.S. Constitution, endowing every citizen with equal rights without regard to race, gender, religion, and national origin, protects individual freedoms, of speech, religion, public association, from the tyranny and prejudices of the majority" (339). American political and philosophical ideals are invoked by way of contrast to Malaysia. For Lim, Malaysia has far to go before it can hope to achieve the kind of political freedoms for self-actualisation afforded by America. In Malaysia, "merit was not the main criterion for professional status," and Lim, a young Chinese woman, "would always be of the wrong gender and the wrong race" (197). When she left Malaysia for America, she understood that she would henceforth view her native country through the eyes of a traveller and a visitor. Lim's oeuvre is defined not only by the relationship between one's birth and adopted countries but by engagement with the experiences of expatriatism, exile, transnationalism and globalisation frequently invoked in discussions of the Chinese diaspora. As a concept, diaspora conjures up vast movements of people compelled by the throes of political upheaval. Beyond its classical definition as the forced sowing, scattering and dispersal of a people (the term is found in the Greek translation of the Bible), diaspora deals with political and social negotiations between originary homelands and host nations resulting from the experience of a people forced into foreign lands. Diaspora is a sufficiently broad theoretical concept. Its traditional definition focuses on the experience of forced uprooting and exile that involves the trauma of radical geographical and psychological dislocation. At the theoretical end, postcolonial thought and postmodern paradigms afford space for considering the liberational possibilities of diaspora, supported by the idea of hybridity that comes into play when diasporic peoples interact with host cultures. Being forced to live in a foreign land in response to problems in one's birth country has sometimes been described as exile. Exile can be involuntary, or it can be voluntary. Involuntary exile refers to forced expulsion from one's native country, an experience that covers the possibility and hope of return. On the other hand, voluntary exile accommodates availability of choice in leaving one's home country. Associated with banishment from the ancestral country, the experience of exile and self-exile can be distinguished from the experience of migration, which, as Rajeev Patke tells us, "blurs the distinction between choice and necessity" ("Diaspora as Translation" 118). Shirley Lim emigrated to the United States pressured by social and political circumstance as well as empowered by education. Among the White Moon Faces contributes to Anglophone Chinese diasporic literature by bringing a postcolonial perspective to bear on representing the Southeast-Asian subject's emigration to the United States. The thematic concerns of Lim's writing signify in relation to both the context of late twentieth-century transnational mobility and the experience of diasporic Chinese communities in Southeast Asia. In this writing, we glimpse some of the historical experiences of these communities, experiences that have inspired people to cross the Pacific Ocean in the hope of joining the diasporic Chinese community in America. Like Shirley Lim, Taipei-born Chinese-Malaysian author Tash Aw represents Malaysia as the starting point for transnational crossings. In Five Star Billionaire (2013), Aw considers the implications of transnational crossings between Southeast Asia and East Asia in the lives of five Chinese characters from Malaysia who find themselves drawn to the promises of twenty-first century China. It is possible to pursue one's goals not in the West but in China, the ancestral homeland of the Chinese diaspora. The apparent ease of transnational travel enjoyed by Aw's characters highlights China's contemporary appeal and the open relationship that exists between nations of the Asia-Pacific realm in the globalised twenty-first century. The Malaysian romancing of Shanghai does not take place at the expense of attachment to one's home country. In portraying the huáqiáo's return to the ancestral country, Aw's novel expands the critical terrain for a theoretical consideration of the Anglophone Chinese diaspora, posing questions about the social and political conditions that might encourage thematic emphases such as those found in the novel. Narrating the overseas Chinese subject's return to China allows the diasporic Chinese author not only to reverse the familiar trope of East-West immigrant desire but also to revisit the development of Chinese history from the nineteenth century with China's defeat by the West in the Opium Wars to its current position as the world's second largest economy. Shanghai symbolises twenty-first century Chinese modernity in Five Star Billionaire. As the controlling setting of the novel, Shanghai is a city in which the present is never disengaged from the past. Enjoying a reputation as the "Paris of the East," early twentieth-century Shanghai was a vibrant port and cosmopolitan city, boasting its foreign-built Bund (the waterfront area in central Shanghai), thriving commercial life, capitalist industrialisation and modern infrastructure. Famous people imprinted their presence on the historical canvas of the city, reinforcing its exoticism and mystique. Sir Victor Sassoon, a wealthy businessman and hotelier, made real-estate investments in Shanghai and transformed the cityscape with luxury hotels and apartment buildings. The Jazz poet Langston Hughes, a social activist of the Harlem Renaissance, dined with Madam Sun Yatsen, the young widow of the founder of the Chinese Republic, when he visited Shanghai in 1933. Hughes reported that Shanghai's "free port and its various International Settlements were wide open to all sorts of vices and corruptions," which included the drug trade, sales of children for sexual purposes, prostitution and kidnappings. This account reinforces Shanghai's association with "oriental intrigue, colonial greed... sex, money, power, opium, gangsters, and revolutionaries" (Grand Strategies 241). Shanghai also had the unenviable reputation as a "haven for radical intellectuals and home to the active underground Chinese Communist Party" ("Spies and Spiders" 29). It is no surprise that, in addition to its nickname as the "Paris of the East," the city also became negatively known as the "Whore of the Orient" because of its association with opium, gambling, commercial sex and interracial fraternisation (Shanghai Nightscapes 180-84). The city offers a rich historical setting for novels as diverse as Lisa See's Shanghai Girls (2009) and Kazuo Ishiguro's When We Were Orphans (2000) as well as for films such as Ang Lee's Lust, Caution (2007), based on Eileen Chang's short story. Tash Aw's Shanghai is more than just a semi-colonial and cosmopolitan treaty port defined by Westerners in "concessions" granted by a battered Qing court, wealthy Chinese merchants, and bohemian artists all living in close proximity. Aw's Shanghai is a global city that promises success to men and women who are brave enough to take on the challenges of the new millennium. Responding to Shanghai's allure, characters in Five Star Billionaire make their way to the city not to escape a dysfunctional society or oppressive political system in Malaysia. Given in snapshots in the novel's narrative movement between past and present, Aw's Malaysia is not a country that had recently secured Independence from colonial rule and rocked by race tensions, portrayed in Shirley Lim's Joss and Gold (2001). Malaysia is the site of familial memories, defined by daily activities such as family meals and the dispensing of parental advice to susceptible children. In Five Star Billionaire, a factory girl named Phoebe travelled to China because of the promise of a (non-existent) job. Stranded in an unfamiliar city, she survives by taking on a false identity and by dating rich men. Gary from Kota Bahru has his dreams to be a celebrity star shattered when his involvement in a drunken brawl in a Shanghai bar was recorded and went viral. Another character, Justin Lim, is in China to help expand his family's real-estate business while Yinghui, the leftist-leaning daughter of a Malaysian government minister, is in the city to establish herself as a successful businesswoman. Finally, there is an elusive billionaire, entrepreneur and self-help guru Walter Chao, thrown into the mix. Aw's characters come from different social backgrounds and are shaped by different experiences. There are shameful family secrets, abusive guardians, impoverished childhood and loss of family wealth, facts of life shared with readers so they can assess the transformative change(s) and success(es), if any, brought about by the characters' encounter with Shanghai. These characters are connected by their presence in Shanghai, inspired by the understanding that a person can be whoever or whatever he or she wants to be in China. Malaysia's huáqiáo travel to Shanghai not in search of roots and ancestral culture but to experience the promise of a future that is anticipated to be dominated by China. Venturing into Shanghai involves bringing self-determination to the city of possibilities. However, when characters find the city fast-paced, ruthless and impersonal, they are forced to navigate the many challenges that emerge or risk being crushed. Survival in Shanghai involves the individual capacity for selfinvention, achieved through different pathways including forgery, dishonesty and lies. People are taken advantage of and human relationships involve mind-games and manipulation. People come into contact but in transient ways with not much promise of permanent relationships. If the reader begins with the premise that the struggles of various characters signify the virtues of determination, tenacity and hard work, any sense of the virtues associated with the work ethic is compromised by a lack of positive personal attributes that stand out. An important question posed by the novel is whether the success attained in pursuing one's dreams is influenced more by the values of an individual or by the conditions afforded by the external environment. Five Star Billionaire grapples with the social and cultural implications of China's economic rise by looking at the phenomenon of Shanghai. Its portrayal of Shanghai complements familiar images of the city advertised in billboards, commercial advertisements, airline posters and film. In Sam Mendes's James Bond instalment Skyfall (2012), Shanghai makes its filmic presence felt as the representative megacity of the globalised twenty-first century. In Skyfall, Bond (Daniel Craig) swims in a penthouse rooftop pool set off against the backdrop of nighttime Shanghai. Mostly filmed in London, the scenes of Shanghai capture the wealth and vibrancy of the ultramodern city, which, with its fast-moving expressways and imposing skyscrapers, is nothing short of spectacular. If Shanghai is associated for some audience with the exotic Orient, the film projects images that draw attention to the city's self-conscious display of ostentatious modernity. Aw's novel recognises the importance that images of a cityscape play in showcasing a country's prosperity. Gleaming high-rises, skyscrapers and swanky financial districts all contribute to projecting a city's and, by extension, country's economic success. In Southeast and East Asia, we are familiar with skyscrapers such as the Petronas Towers in Malaysia; Taipei 101 in Taiwan; Shanghai World Financial Centre; and the Shanghai Tower, China's tallest skyscraper in Lujiazui. Cities participate in a country's economic success in their re-creation of the physical and urban environment. What does Shanghai's cityscape tell us about Asian capital and China's economic ascendancy? Viewed from a distance, Shanghai is an impressive city. However, close-up shots reveal an abundance of unsightly grit and grime. Shanghai is a constellation of dark streets, deindividualised inhabitants, dense markets and ceaseless noise (74-75). The view from Gary's apartment confirms the monotony of urban and city life. An apartment dweller can look directly into other people's apartments and observe his or her neighbours' daily routines. Such voyeuristic impulses are reciprocated as one's neighbours could very well return the courtesy by peering into one's own apartment and taking mental notes. The glamour of the city hides the mundane existence of men and women going about their daily chores. Claustrophobia is a commonplace experience in the global city. Shanghai's inexhaustible energy eludes human attempts to harness the possibilities of the global city for profit and self-fulfilment. Phoebe finds that Shanghai "weighed down on her with the weight of ten skyscrapers" (9), a stifling and oppressive sense. While Justin Lin finds the Pudong skyline and skyscrapers of Lujiazui impressive at night, he also notes its contrast with day-time Shanghai "obscured by the perpetual haze of pollution" ( 22). Intertwining images of smog and skyscrapers direct readers' attention to the cost of China's political project of modernisation and economic development. Shanghai is immense, its impersonal character not only inscribed in the buildings and infrastructure that make up the cityscape but exemplified in the lives of foreigners who want to squeeze out as much as they can from the world without the burden of ethical responsibility. Shanghai does not stand still but is always changing. Not appreciating the concept of present time, "[e]veryone is busy preparing for tomorrow" (217). Barely three months in his apartment, Justin notes that Shanghai "seemed to have changed completely, the points of reference in his world rearranged and repositioned in ways he could not recognise" (210). "Nothing," Phoebe finds, "ever stood still in China, nothing was permanent" (17), invoking the Heraclitean motif that all life is flux. For Phoebe, life in Shanghai is experienced as intense loneliness. Even Walter Chao struggles with loneliness, which is why he comes to meet Phoebe through internet dating. Contrary to expectation, Shanghai does not readily support dreams and human aspirations: "People say it is the size of a small country, but it is not, it is bigger, like a whole continent, with a heart as deep and unknown as the forests of the Amazon and as vast and wild as the deserts of Africa. People come here like explorers, but soon they disappear; no one even hears them as they fade away, and no one remembers them" (381). This assessment suggests that China is a country inimical to the pursuit and fulfilment of dreams. Hope easily vanishes in China. Efforts made to embrace the promises of a vibrant Chinese economy are destabilised by Shanghai's impersonality as a city that hurtles into the future without a care for the individuals living in its midst. Inscribing sociocultural and political significance, cities tell the stories of relationships between nations and empires. As major cities in China, Shanghai and Beijing are settings that draw us into important historical events of twentiethcentury East Asia such as the Sino-Japanese War, the Chinese Civil War, the Communist Revolution and the Tiananmen Square Massacre. Beijing has been linked by émigré and exilic writers like Ha Jin and Anchee Min to the oppressiveness of Chinese communist rule while Shanghai has been invoked by Lisa See to portray the Japanese invasion of the city and its devastating aftermath. Beijing and Shanghai bring focus to the Chinese totalitarian state and the disjunction between China's impoverished condition in the early decades of communist rule and its great economic transformation in the twenty-first century. Like other major cities of the world -London, New York, Paris -navigating the physical and existential space of this cosmopolis (from the Greek "kosmos" [world] and "polis" [city]), Shanghai encourages imagination, courage and tenacity. If Shanghai, the novel's synecdoche for China, functions as a gateway to the future, promising good things for those who have the courage to dream, it is also an alienating and "never-ending city" (261) in which "if you stop for one moment, you fall, you disappear" (291). China may stand for the promises of the new millennium, but it is also nihilistic. If, according to conventional wisdom, the twenty-first century will be economically dominated by China, then Five Star Billionaire imagines the possibilities of this new world order replete with all the problems that attend the pursuit of capital and dreams. While courage and tenacity are valorised as attributes necessary for success, they do not always produce the desired result. Five Star Billionaire takes the opportunity to represent the fragmented and alienated nature of individual and social being fashioned by Asian capital. In a book review, David Annand rightly identifies Five Star Billionaire as "a new kind of immigrant novel" that finds its significance in the context of an "increasingly multipolar world" (The Telegraph). He concludes that the novel affirms that China "is not America: there is no constitution to believe in, no sense they are helping to build a shining city on the hill. The country itself is living a lie: nominally socialist, it is nakedly exploitative, with an emblematic city that is cold and unforgiving. Each of [the characters] seems to contain within [him or her] a fearful knowledge: there is no conventional narrative for the immigrant in China" (The Telegraph). Finding China in Five Star Billionaire to be socially and economically exploitative, Annand suggests that Aw views China through lenses not too dissimilar from that of US President Donald Trump, who had responded to China's alleged unfair trade practices by imposing heavy tariffs on Chinese goods and starting a trade war with global economic consequences. While it may be true that Aw's China is exploitative and does not possess a conventional immigrant narrative, it must be said that China does not advertise itself as a country that would-be immigrants dream of coming to and settling down. It is nevertheless conscious of its status as the world's second largest economy and a rising economic and political power. China's significance comes from its positioning in a globalised world defined by increased porousness of national boundaries and interconnectedness between peoples and cultures. Aw's characters do not go to Shanghai as immigrants but as seekers of opportunity, enjoying the advantages of transnational mobility that is not dependent on the possession of symbolic and cultural capital. In their encounter with China, they participate in the conditions of Asian capital with all its contradictions and instabilities. The journey to China is not made at the expense of the Malaysian citizen's attachment to his/her national homeland. The twists and turns of Chinese history that include the communist ascendancy of 1949, Mao Zedong's Great Leap Forward and Cultural Revolution, and the Tiananmen Square Massacre have afforded ethnic Chinese authors material for writing the diasporic experience, often highlighting China's political conditions that necessitate the search for alternative homelands. Five Star Billionaire contributes to writing the Chinese diasporic experience not so much by interrogating China's political system as by representing its promise and allure as well as its problems. Importantly it calls attention to Southeast Asia as a region of the world that must be accounted for in literary representations of the Chinese diasporic experience.

Anglophone Chinese diasporic literature has historically focused on the sociocultural and political implications of the movement of Chinese subjects from the Middle Kingdom to the West, in particular the United States. In this representation of the Chinese diasporic experience, China symbolises political and economic "lack," compelling many Chinese to consider looking overseas for a better life. Malaysia-born author Shirley Lim contributes to the corpus of Anglophone Chinese diasporic literature by highlighting the significance of Southeast Asia in literary representations of the Chinese diasporic experience. In Among the White Moon Faces, Lim emphasises the importance of the postcolonial experience in shaping the Southeast-Asian immigrant's choice of alternative national homelands. Choosing the United States instead of Great Britain as Shirley Lim's adopted homeland carries ideological implications for the postcolonial author. Like Shirley Lim, Taipei-born Chinese-Malaysian author Tash Aw represents Malaysia as the starting point for transnational crossings. Unlike Lim, however, Aw portrays China instead of the West as the land of promise. In Five Star Billionaire, Aw imagines the possibilities of Shanghai as a city representing China's economic prosperity with all the problems that attend the pursuit of capital and dreams. Malaysian subjects of Chinese descent make their way to Shanghai in pursuit of their dreams. While courage and tenacity are valorised as attributes necessary for success, they do not always produce the desired result. Five Star Billionaire represents the fragmented and alienated nature of individual and social being fashioned by Asian capital.

Great Leap Forward and Cultural Revolution, and the Tiananmen Square Massacre have afforded ethnic Chinese authors material for writing the diasporic experience, often highlighting China's political conditions that necessitate the search for alternative homelands. Five Star Billionaire contributes to writing the Chinese diasporic experience not so much by interrogating China's political system as by representing its promise and allure as well as its problems. Importantly it calls attention to Southeast Asia as a region of the world that must be accounted for in literary representations of the Chinese diasporic experience.

Anglophone Chinese diasporic literature has historically focused on the sociocultural and political implications of the movement of Chinese subjects from the Middle Kingdom to the West, in particular the United States. In this representation of the Chinese diasporic experience, China symbolises political and economic "lack," compelling many Chinese to consider looking overseas for a better life. Malaysia-born author Shirley Lim contributes to the corpus of Anglophone Chinese diasporic literature by highlighting the significance of Southeast Asia in literary representations of the Chinese diasporic experience. In Among the White Moon Faces, Lim emphasises the importance of the postcolonial experience in shaping the Southeast-Asian immigrant's choice of alternative national homelands. Choosing the United States instead of Great Britain as Shirley Lim's adopted homeland carries ideological implications for the postcolonial author. Like Shirley Lim, Taipei-born Chinese-Malaysian author Tash Aw represents Malaysia as the starting point for transnational crossings. Unlike Lim, however, Aw portrays China instead of the West as the land of promise. In Five Star Billionaire, Aw imagines the possibilities of Shanghai as a city representing China's economic prosperity with all the problems that attend the pursuit of capital and dreams. Malaysian subjects of Chinese descent make their way to Shanghai in pursuit of their dreams. While courage and tenacity are valorised as attributes necessary for success, they do not always produce the desired result. Five Star Billionaire represents the fragmented and alienated nature of individual and social being fashioned by Asian capital.

SOCIAL SUPPORT AND DISCLOSURE ON FERTILITY STRESS 3 Interactive effects of social support and disclosure on fertility-related stress An infertility diagnosis is attributed to a couple after 12 months of unprotected sexual intercourse (Zegers-Hochschild et al., 2009). Notwithstanding, defining oneself as infertile is a process that begins earlier as the members of a couple realize their successive attempts to conceive have failed (Orshan et al., 2009). This identification process progresses further as couples experience significant changes to their social network and subsequent sociocultural reality (Greil, 1997;Greil, Slauson-Blevins, & McQuillan, 2010). Most societies see parenthood as an essential milestone of adulthood (Bos & Van Rooij, 2007;Purewal & van den Akker, 2007), and young couples are continually exposed to normative pressure towards childbearing (Bernardi, 2003;Bute, 2009). For those struggling with a fertility problem, dealing with such pressure can lead to social isolation (Allison, 2011). Social expectations can produce strain on infertile people not only within the social relations sphere, but also on other important domains such as the marital relationship and personal health and well-being (Greil, 1997). Even though disclosure is important to constructing and maintaining relationships (Greene, Derlega, & Mathews, 2006), couples might feel stigmatized and fear disclosing their fertility status to their social networks. In fact, those experiencing infertility often receive unhelpful social support from well-intended others, which results in additional stress (Mindes, Ingram, Kliewer, & James, 2003;Slade, O'Neill, Simpson, & Lashen, 2007). The present study examined the joint contribution of social support and disclosure of fertility status to fertilityrelated stress in the social, marital, and personal domains. Social support is an essential interpersonal resource in improving and preserving both physical and psychological well-being (Berkman, Glass, Brissette, & Seeman, 2000;Bolger & Amarel, 2007;Kawachi & Berkman, 2001). Perceived social support refers to a stable expectation of having an available confidant to provide help or caring attitudes when needed (Cohen & Wills, 1985;Walen & Lachman, 2000). Having a sense that these sources of support are accessible becomes especially relevant in the event of a life crisis. There is well-documented evidence showing a positive relationship between social support and psychological adjustment in the face of a large number of chronic stressors including HIV-positive status, cancer, vision loss, and myocardial infarction (Kalichman, DiMarco, Austin, Luke, & DiFonzo, 2003;Reinhardt, Boerner, & Horowitz, 2006;Schwarzer & Knoll, 2007). Infertility has been compared to a chronic illness in the sense that it requires adaptation over time and no immediate resolution can be offered (Fleming & Burry, 1988). When it comes to dealing with the stress of infertility, there has been an increasing awareness of the important role interpersonal resources can play (Greil et al., 2010;Schmidt, 2009). In fact, a small but growing body of evidence shows that supportive behaviors from others influence adjustment to infertility. Overall support or support from specific sources such as partners and families has been positively associated with fertility adjustment (Mahajan et al., 2009), and negatively related with fertility stress (Gibson & Myers, 2002;Martins, Peterson, Almeida, & Costa, 2011), depression (Lechner, Bolman, & van Dalen, 2007;Lund, Sejbaek, Christensen, & Schmidt, 2009;Verhaak et al., 2005), and anxiety (Lechner et al., 2007;Verhaak et al., 2005). Given the results of these studies, it would be reasonable to assume that infertile couples that have supportive relationships would always report healthier emotional outcomes than couples who cannot count on others for support. However, since one key purpose of social support is to provide a safe environment where one can talk openly about concerns and feelings (Zakowski, Ramati, Morton, Johnson, & Flanigan, 2004), couples experiencing infertility who do not disclose their struggles to others are likely denied the benefits of such discussions. In other words, if one does not feel comfortable disclosing an issue of central importance in a couple's relationship, adjusting to the emotional roller-coaster of infertility might be more difficult. Pennebaker (1995Pennebaker (, 2000;;Pennebaker & Susman, 1988) has provided substantial evidence to support the idea that occulting personal information can be both psychologically and physically stressful, whereas openness can improve health. Disclosure, defined as an interaction where personal information is voluntarily shared (Chaudoir & Fisher, 2010;Greene et al., 2006), can strengthen intimacy and trust and improve the overall quality of relationships (Derlega, Metts, Petronio, & Margulis, 1993;Reis & Shaver, 1988). However, when it comes to the disclosure of a concealable stigmatized identity, unburdening oneself of a particular worry might not always alleviate the associated stress. In fact, a significant number of individuals can experience negative outcomes such as misinterpretation, discrimination, stigmatization, rejection, or abandonment after disclosure (Alter & Oppenheimer, 2009;Chaudoir & Fisher, 2010;Kalichman et al., 2003;Vyavaharkar et al., 2011). Infertility may differ from other invisible stigmatized identities (Cousineau & Domar, 2007;Greil, 1991;Slade et al., 2007;Whiteford & Gonzalez, 1995) such as HIV-positive status or homosexuality: Because young married or cohabiting couples are often regularly confronted with intrusive questions about childbearing and pregnancy (Bute, 2009), individuals are likely to have to deal with the anxiety of having their infertility unveiled at some point (Ragins, 2008). Among long-term involuntarily childless couples, fertility problems are disclosed in close relationships in about 90% the cases, and in more distant relationships in about half of the cases (van Balen, Trimbos-Kemper, & Verdurmen, 1996). Because of the complex relationship between receiving the positive emotional benefits of social support and disclosure of infertility, there is a need to examine the relational consequences of disclosure in varying social contexts (Greene et al., 2006). Moreover, the disclosure of fertility status is a relatively unexplored topic within the infertility literature, and the few completed studies have produced mixed findings. Van Balen et al. (1996) found that secrecy was related to poorer adjustment, while Schmidt, Holstein, Christensen, and Boivin (2005) found no differences in fertility stress in relation to the degree of secrecy adopted in communication strategies. Slade et al. (2007) reported that disclosure was associated with higher stress in women, and with lower levels of stigma consciousness in men. Finally, a recent qualitative interview study found that the use of silence was used as a strategy to avoid undesirable advice (Allison, 2011). This diversity of results might be explained by recognizing that communication strategies do not always match individual needs (Schmidt et al., 2005) and that the effect of communication may be shaped by the social context and the degree to which needs can or cannot be openly expressed in that context. Social support and disclosure are related but contain distinct constructs that can co-occur at similar or contrasting levels. For example, an individual might feel the need to share a fertility problem with his or her parents even though the individual knows they are not supportive and responsive to his or her needs, and end up feeling greater stress than before the disclosure. Thus, it is plausible to expect that the disclosure of infertility may affect the way social support predicts fertility-related stress. The current study examines the role of disclosure of fertility status in moderating the relation between social support and fertility-related stress. We investigated social support and disclosure within the social contexts of family, family-in-law, friends, and colleagues. Because people usually share their emotions with close others (Rimé, Finkenauer, Luminet, Zech, & Philippot, 1998), these contexts were distinguished by their closeness-distance. Separate analyses were performed for personal, marital, and social stress domains, as previous research has shown that infertility stress is experienced differently across these spheres (Greil, 1997;Schmidt, 1996;Tj<unk>rnh<unk>j-Thomsen, 1999, 2005). Infertility-related social stress is related to perceived changes in one's social networks due to infertility, infertility marital stress refers to relational and sexual changes within the couple's marriage, and infertility personal stress is related to perceived physical and mental health changes. Significant joint effects of social support and disclosure were expected on both the personal stress domain and on the social stress domain. We hypothesized that while each individual's level of social support would be prospectively and negatively associated with his or her levels of fertility-related personal and social stress, the strength of this relationship would weaken as the level of disclosure of the fertility status decreased. Specifically, we expected that for individuals hiding their fertility status, the relationship between personal and social stress and social support would cease to be significant. Because infertility is a couple's shared problem (Peterson, Pirritano, Christensen, & Schmidt, 2008), and disclosure to one's partner is a given within infertility, it was expected that the interaction would not be significant in the marital domain. Because women have been found to report greater infertility-related stress when compared to men (Benyamini, Gozlan, & Kokia, 2009;Greil, 1997;McQuillan, Greil, White, & Jacob, 2003;Peterson, Newton, Rosen, & Skaggs, 2006), particularly within the personal and social stress domains (Boivin & Schmidt, 2005;Peterson et al., 2009;Peterson et al., 2008), gender was included as a control variable in the fertility-related stress domains models. --- Method Participants Participants were derived from The Copenhagen Multi-centre Psychosocial Infertility (COMPI) Research Programme (Schmidt, 2006;Schmidt et al., 2003). This prospective cohort study comprised a consecutive sample of all new couples starting fertility treatment in one of five fertility clinics in Denmark initiated in 2000. In total, 2812 fertility patients received a baseline questionnaire (T1), and 2250 (80.0%) responded. One year later (T2), 2206 participants received the 1-year follow-up questionnaire (44 were lost to follow-up: 38 whose identity was not registered at T1, 4 whose address could not be traced, 1 who had died and 1 who suffered a severe brain injury), and 1934 (87.7%) responded. Because stress levels significantly differ between childlessness and secondary infertility (i.e., the inability to become pregnant after having one or more children) (Benyamini, Gozlan, & Kokia, 2005;McQuillan et al., 2003), participants who were pregnant at T1 or had a child after treatment (n = 1107), and participants who already had a child together with their partners at T1 (n= 29) were excluded. Participants who were not employed at baseline (n = 88) were also excluded to avoid bias associated with not managing social support and disclosure within the same life domains. Finally, we excluded those who left more than 50% unanswered items of a given measure (n = 12). The final sample for this study included 698 subjects, 364 women (52.1%) and 334 men (47.9%). --- Procedure Data were collected through four large public hospital-based fertility clinics and one private clinic. All COMPI data were collected during a period where access to assisted reproductive technology in Denmark was equal and tax-financed in the public health care system. Between January 2000 and August 2001, all new couples entering a clinic for the first time received a sealed, pre-addressed and stamped envelope immediately before their first treatment attempt (T1). T2 questionnaires were sent 12 months after delivery of T1 questionnaires (January 2001-August 2002). Participants who did not wish to participate returned an enclosed non-participating form, and a maximum of two-reminders at 10-day intervals was sent to those if the questionnaires or non-participating forms were not received. The study followed the Declaration of Helsinki principles and was assessed by the Scientific Ethical Committee of Copenhagen and Frederiksberg Municipalities, who had no objections. Approval was given by the Danish Data Protection Agency. --- Measures The COMPI questionnaire booklet contains several questions related to reproductive health, stress, social relations, coping, and well-being (for a detailed description, see Schmidt, 2006). We describe here only the measures relevant to this study. Socio-demographic and biomedical information and perceived social support were assessed at baseline (T1). Disclosure of fertility status and fertility-related stress variables were assessed on the 12 month follow-up questionnaire (T2). Perceived social support was a developed measure based on Due et al.'s (1999) conceptual framework on social relations. Following the question 'If you need support, can you talk with any of the following people?', participants rated their perceived social support for three different sources of support -family, friends, and colleagues. For each of these contexts, the response key was 'have none' and a five-point (1 =always; 5 = never) Likert scale. 'Have none' scores (n = 1-8) were coded as missing values, and items were reverse coded so that higher scores indicated more social support. An alpha internal consistency reliability estimate of.68 was found for this subscale. Disclosure of fertility status was assessed by eight dichotomous items. Following the statement 'I keep our infertility as a secret to...', participants indicated if they had disclosed their infertility or not to 'close family', 'distant family', 'close in-laws', 'distant in-laws', 'close friends', 'distant friends', 'close colleagues', and 'distant colleagues'. Because our disclosure variables were a set of binary indicators, we initially created disclosure groups to enter in the regression analysis. First, we performed an exploratory principal factor analysis (PCA) to extract sets of variables capturing common information. A PCA of the eight disclosure binary variables revealed a two-factor solution that accounted for 63.57% of the total variance. The first factor, accounting for 36.10%, included all distant relationships (KR-20 =.85); and the second factor included all close relationships (KR-20 =.70) and accounted for 27.48% of the total variance. This result indicates that intimate close relationships appear to be distinguished from more distant relationships. Second, we examined our sample disclosure patterns, revealing 59 possible combinations. Almost half of the participants (43%) reported having fully disclosed their infertility to both close and distant relationships, and no participants reported having disclosed infertility to a distant relationship while keeping infertility as a secret to all close relationships. Hence, participants were categorized into the following groups: (i) 'full disclosure', in which the subject had disclosed infertility to all his/her relationships (n = 300, 43%); (ii) 'disclosure to close relationships', in which infertility was disclosed to all close relationships and was kept secret to at least one distant relationship (n = 242, 35%); (iii)'secrecy within close relationships', in which infertility was kept as a secret to at least one close relationship, regardless of disclosure to distant relationships (n = 156, 22%); (iv) 'others' -no participants fell into this category. Fertility-related stress was assessed by The COMPI Fertility Problem Stress Scales, measuring the amount of stress the fertility problem placed on the personal, social, and marital domains. The instrument has 14 items, seven of them taken from The Fertility Problem Stress Inventory (Abbey, Andrews, & Halman, 1991), and seven developed from The Psychosocial Infertility Interview Study (Schmidt, 1996). The items were factor analyzed and stress was confirmed in relation to three different domains (for a detailed description of this measure, see Schmidt et al., 2005). The personal stress subscale assessed the stress infertility had produced on the person's life and on mental and physical health (6 items; e.g. "It is very stressful for me to deal with this fertility problem"; <unk> =.85); the social stress subscale assessed the fertility-related stress on social relations with family, friends, and colleagues (4 items; e.g. "How much stress has the fertility problem placed on your relationship with your family?"; <unk> =.84); and the marital stress subscale assessed the extent to which infertility had produced strain on the marital and sexual relationship (4 items; e.g. "Infertility has caused stress about divorce"; <unk> =.76). The confirmatory factor analysis (CFA) for this sample confirmed the original structure, revealing overall good fit indices [<unk> 2 (67) = 200.76; standardized root mean square residual (SRMR) = 0.05; comparative fit index (CFI) = 0.97; root mean square error of approximation (RMSEA) = 0.05]. The response key for the subscales personal stress, social stress, and two items from marital stress was a four-point Likert scale (1 =not at all; 4 = a great deal), and for the remaining two items concerning marital stress a five-point Likert scale (1 =strongly disagree; 5 = strongly disagree) was used. For each subscale, items were summed up to produce total scores. Higher scores indicated more personal, social, and marital stress. --- Analytical Strategy To examine the role of disclosure of fertility status in the social support-fertility stress relationship, key assumptions for multivariate linear regression analyses were met, and guidelines for testing interaction effects were followed (Aiken & West, 1991;Baron & Kenny, 1986;Frazier, Tix, & Barron, 2004). To allow the exploration of moderation effects, the social support variable was mean-centered (also avoiding multicollinearity problems) and the disclosure of fertility status was coded into two dummy choice conditions ('full disclosure' and'secrecy within close relationships') against a control condition ('disclosure to close relationships') (Aiken & West, 1991). Because we were interested in the influence of social support and disclosure over and above gender differences, all analyses were performed with participants' gender as a covariate. For each dependent variable (personal, marital, and social fertility-related stress), predictor variables were entered in four blocks: (a) gender; (b) social support; (c) disclosure of fertility status; and (d) product terms between social support and disclosure variables. Interaction occurs when the incremental variance explained by the product term is significant above the variance explained by the predictors' main effects, or when the beta value of the product term is significant (Aiken & West, 1991;Baron & Kenny, 1986). When significant interactions were found, we decomposed this conditional effect to better understand the structure of the relation. To further probe the moderation effects, we plotted significant interactions and determined simple slopes of significance according to the procedures outlined by Aiken and West (1991). --- Results --- Demographic and Descriptive Statistics At baseline, participants had a mean age of 34 years (M = 33.55; SD = 4.69). All subjects were married or living together with their partners for <unk>8 years (M = 7.62; SD = 3.75), and were attempting to have a child for an average of 4 years (M = 4.34; SD = 2.41). Sixty-three percent of the participants had already been submitted to fertility treatments prior to inclusion in COMPI. Thirty percent reported a diagnosis of infertility attributed to a female cause, 28% reported a male factor diagnosis, and 10% reported a combined male-female causation. Table 1 presents descriptive statistics for the predictors and outcome utilized in the study. A vast majority of participants reported having disclosed their infertility to close relationships, including friends, family, in-laws and colleagues. Almost three quarters decided to disclose their infertility to distant family and family-in-law members. Sixty-six percent of the participants chose to disclose infertility to distant friends, and almost half told distant colleagues about their infertility. Overall, 300 subjects decided to disclose infertility to all their relationships. Within the 'disclosure to close relationships' group (n = 242), the most reported secrecy was to distant colleagues (35%), followed by all distant relationships (24%), and both distant colleagues and friends (17%). The most reported combinations within the'secrecy within close relationships' group (n = 156) were secrecy to close colleagues (35%), secrecy to close family in-law (14%), full secrecy (10%) and secrecy to both close direct and in-law family (9%). --- Insert Table 1 about here --- Interaction Effects Results As hypothesized, results revealed statistically significant interactions between perceived social support and disclosure of fertility status related to fertility stress social and personal domains, but no significant interactions were found related to the marital domain (data not shown). --- Infertility marital stress. Even though no moderation effects were found, he final regression analysis showed social support as the only significant predictor of marital stress (<unk> = -.260, p. <unk>.001), F(6, 667) = 4.04, p. =.001. --- Insert Table 2 about here Infertility social stress. The final regression model predicted 11% of the variance in social stress scores, F(6, 672) = 13.73, p. <unk>.001 (see table 2). Above and beyond the effects of gender, social support remained negatively associated with social stress (<unk> = -.375, p. <unk>.001). A significant association was also found for the dummy variable contrasting the full disclosure condition to the control condition (disclosure to close relationships) (<unk> = -.088, p. =.036). Importantly, these main effects were qualified by the interaction between social support and full disclosure (<unk> =.160, p. =.003). No significant association was found between the dummy variable contrasting secrecy within close relationships with disclosure to close relationships and infertility social stress. However, this association was conditioned by the interaction social support X secrecy within close relationships (<unk> = -.118, p. =.015). Significant interactions on fertility-related social stress are plotted in figure 1. Specifically, perceived social support negatively predicted fertility social stress in the 'full disclosure' (<unk> = -.124, p. =.031) and 'disclosure to close relationships' groups (<unk> = -.375, p. <unk>.001), whereas social support was not associated with fertility social stress for those who decided to keep infertility as a secret to one or more close relationships, (<unk> = -.137, n.s.). Also, while at high and mean levels of perceived social support those who kept infertility as a secret to their close relationships scored higher levels of social stress (Y = 1.65 and Y = 2.01, respectively), at low social support those who had the highest social stress were the ones that did disclose to all their close relationships (Y = 2.88). Full disclosure was associated with lower levels of infertilityrelated social-stress at low (Y = 1.75) and medium levels (Y = 1.41) of social support. However, the group perceiving high social support and disclosing infertility to close relationships was the one who revealed the lowest infertility-related social stress scores (Y = 0.89). It seems that disclosing to all close relationships while keeping infertility as a secret to distant relationships has opposite effects on fertility social stress at different ends of the social support spectrum. Insert Figure 1 about here Infertility personal stress. The variables in the final model predicted 17% of the variance in personal stress scores, F(6, 673) = 23.50, p. <unk>.001 (see table 2). Similarly to the social stress model, social support (<unk> = -.260, p. <unk>.001) and full disclosure (<unk> = -.105, p. =.009) remained negatively associated with personal stress above and beyond the effects of gender, but not secrecy within close relationships. No significant interaction was found between social support and full disclosure. Nonetheless, the association between restricted disclosure to close relationships and the levels of personal stress was conditioned by an interaction with social support (<unk> =.101, p. =.029). Post-hoc results concerning the interaction between social support and disclosure on infertility-related personal stress are presented in Figure 2. Similarly to the interaction effect on social stress, the beneficial effect of social support on personal stress ceased to be significant when infertility was kept as a secret within close relationships (<unk> = -.056, n.s.), but remained significant when the fertility status was revealed to all close relationships (<unk> = -.260, p. <unk>.001), or when a full disclosure approach was adopted (<unk> = -.112, p. =.044). Full disclosure was related to lower levels of personal stress regardless whether perceived social support levels were low (Y = 5.44), medium (Y = 4.88), or high (Y = 4.33). Whereas at low and mean levels of social support disclosure of infertility to all close relationships was associated with higher levels of personal stress (Y = 7.23, and Y = 5.94, respectively), at high levels of social support the group scoring higher on personal stress was the one keeping infertility as a secret within close relationships (Y = 5.46). --- Insert Figure 2 about here --- Discussion The present study aimed to examine the role of disclosure of fertility status in moderating the relationship between perceived social support and fertility-related personal, marital, and social stress. Disclosure of infertility moderated the association between social support and personal and social stress, but not marital stress. These findings are an important step in targeting interpersonal factors that influence one's ability to adjust to the stress of infertility. In our study, almost a quarter (22%) of the participants reported hiding their fertility problem to at least one close relationship, and 35% to at least one distant relationship. The workplace -were most waking hours are spent-was the context in which more participants were hiding their infertility, both within close and distant social networks. These findings suggest that dealing with the social implications in facing infertility is a challenging situation for many, where managing disclosure and secrecy can originate "disclosure disconnects" (Ragins, 2008), i.e., presenting different identities across various life domains. Disclosure of the fertility status was not associated with fertility-related marital stress and, as expected, did not moderate the relationship between social support and marital stress. Even though partners may disagree on who is worthy of disclosure, the decision to disclose a couple's infertility problem is co-owned (Steuber & Solomon, 2011a). In our study, the disclosure of the fertility problem per se does not seem to affect the marital relationship. However, results revealed a main effect of initial perceived social support in predicting marital stress one year later. Taking into account the fact that outside support from family and community contexts can be a protective factor of the marital system (Patterson, 2002;Peilian et al., 2011), it seems that having high levels of perceived social support from relatives, friends or workmates can also decrease the stress associated to experiencing infertility exerted within the relationship. We hypothesized that the beneficial impact of social support on both the personal and social stress would cease to be significant if infertility was not disclosed. These hypotheses were only partially confirmed. The inverse relationship between social support and personal and social fertility stress ceases to be significant when individuals refrain from disclosing their infertility to at least one of their close relationships, but not when infertility is kept as a secret only from distant relationships. As mentioned before, perceived social support refers to a stable expectation of experiencing caring attitudes from others (Walen & Lachman, 2000). It is only natural that those expectations relate particularly to significant close relationships, much more than to distant social networks. In effect, at high levels of social support, the group presenting the highest levels of both personal and social stress was the one who chose to keep the fertility problem as a secret within close relationships. This evidence comes to reinforce the idea that hiding a personal crisis like infertility from close relationships may represent such a burden to the point of suppressing the potential benefit that those same relationships could provide (Steuber & Solomon, 2011b). With regards to personal stress, there was no interaction between the full disclosure group with any other group, and the ones fully disclosing their fertility problem were those with the least personal stress regardless of how much social support had been perceived. On the other hand, full disclosure had the lowest social stress levels only at low and medium levels of social support. At high levels of social support, the group showing the lowest social stress levels was the one that disclosed their infertility to all close relationships, but kept it as a secret to at least one distant relationship. This may be because individuals who receive high social support from close relationships might not fear social withdrawal or isolation and keep a sense of privacy by not disclosing their fertility problem to less close and trustworthy bonds. Whereas keeping infertility as a secret to distant relationships can make adjustment to infertility easier if one previously perceives high levels of social support, the opposite seems to happen at low levels of social support. It is not surprising that social and personal stress can rise when there is a decision to disclose infertility to intimate sources that were already perceived as not supportive while hiding it from distant sources. In this particular case where low social support from close ones is perceived, distant relationships might be especially helpful as useful sources of support (Emmerick, 2006;Granovetter, 1973), since connecting to a more disparate range of resources might increase the probability of receiving more diverse responses. Still, even when perceiving little support, full disclosure of one's fertility status was the type of disclosure associated with lower social and personal fertility stress. Counselors and other mental health professionals are often confronted with the question of whether or not their clients should disclose their fertility problem. Learning how to endure infertility and its treatments within different social contexts is one of the significant challenges for people facing infertility (Schmidt, 2009), and findings from this study have implications for health professionals working within this field. Couples can decide to hide infertility from their loved ones as a consequence of having received a discriminatory commentary (Daniluk, 2001), but for those who feel that close family, friends or workmates can function as a safe haven, disclosing their infertility status might be valuable in order to benefit from general social support when facing this life stressor. On the other hand, it might be safer to advise patients that feel more unsupported and isolated from their close relationships to find a distant context in which they can confide their fertility problem. These patients, who might feel misunderstood from receiving little to no support, should be particularly targeted to attend counseling, support groups or group psychological interventions. Support groups can bring social support and a sense of belonging to reduce infertility associated stress, and infertility educational group interventions have been showing positive effects in several domains (Boivin, 2003). Cognitive-behavioral and support groups targeting the stress of the infertility experience have been shown to significantly improve participants' psychological well-being when compared with control participants (Domar et al., 2000). Also, because it is difficult for the general public to better understand the psychosocial consequences of infertility and be aware of the downfalls of generalizing a pronatalist discourse (Allison, 2011), educational campaigns aiming to reduce stigma against infertility and childlessness are warranted. The findings from this study should be interpreted within the context of its limitations. First, disclosure of the fertility status was assessed when participating couples had already been trying to achieve a pregnancy for an average of 5 years (1 year after baseline assessment), and it is important to have in mind that infertility disclosure patterns are dynamic and change over time (Bute & Vik, 2010). Besides not considering the difficult treatment decisions many couples have to take and how these might shift disclosure choices, results are also limited to those seeking treatment, and should not be generalized to those that decided not to pursue treatment, those using third-party reproduction, or those seeking adoption. It could be valuable in future studies to examine how disclosure influences infertility stress developmental trajectories. Second, we obtained a generalized measure of how social support was perceived in different contexts but we did not accessed specific supportive behaviors provided, nor frequency of contact or the quality of relationships with these social support networks. Third, while we controlled for gender effects, it might be valuable to include other predictors in the presented model, as it is conceivable that other variables (e.g., coping strategies) could mediate the interaction effects of social support and disclosure on fertility stress. Although gender differences were not the focus of this study, it would also be valuable to test for the possibility of different interaction effects of social support and disclosure in men and women experiencing infertility. Furthermore, because infertility is a shared stressor, it is also important to study the impact of a partner's disclosure and social support resources on fertility stress. In conclusion, both professionals and patients should be aware that appraisal of social support can be a valuable tool when couples are making the joint decision of disclosure. While trying to conceal the fertility problem might impede couples from taking advantage of social support from their closest relationships, turning to other distant relationships might be worth the risk when close relationships are not perceived as available. Future research that examines the content of disclosure, as well as how to deal with invasive unsupportive reactions, is warranted. Interaction of perceived social support and disclosure of fertility status on social fertility stress. --- SOCIAL SUPPORT AND DISCLOSURE ON FERTILITY STRESS

Individuals perceiving high social support tend to perceive better adjustment to infertility. However, it remains unclear whether this benefit is affected by the actual disclosure of the infertility condition. The present study aimed to examine the role of disclosure of fertility status in moderating the relationship between perceived social support and fertility-related stress. The study population (N = 698) was drawn from a longitudinal cohort design of Danish men and women beginning fertility treatment with a 12-month follow-up. Participants were 698 subjects (364 women and 334 men) who completed self-administered questionnaires measuring perceived social support at T1, and fertility status disclosure and fertility stress at T2. Results indicated that when infertility is not disclosed to at least a close relationship, the beneficial effects of social support on both social and personal stress cease to exist. Also, when participants perceived high social support, higher levels of social and personal stress were associated with keeping infertility as a secret within close relationships, but when low social support was perceived, high social and personal stress levels were associated with disclosing infertility to all close relationships. Findings from this study provide evidence that the prospective relationship between social support and fertility-related stress is moderated by the decision of disclosing infertility. Infertility health professionals can help couples in deciding to which contexts they should disclose their infertility by assessing social support.

closest relationships, turning to other distant relationships might be worth the risk when close relationships are not perceived as available. Future research that examines the content of disclosure, as well as how to deal with invasive unsupportive reactions, is warranted. Interaction of perceived social support and disclosure of fertility status on social fertility stress. --- SOCIAL SUPPORT AND DISCLOSURE ON FERTILITY STRESS

Individuals perceiving high social support tend to perceive better adjustment to infertility. However, it remains unclear whether this benefit is affected by the actual disclosure of the infertility condition. The present study aimed to examine the role of disclosure of fertility status in moderating the relationship between perceived social support and fertility-related stress. The study population (N = 698) was drawn from a longitudinal cohort design of Danish men and women beginning fertility treatment with a 12-month follow-up. Participants were 698 subjects (364 women and 334 men) who completed self-administered questionnaires measuring perceived social support at T1, and fertility status disclosure and fertility stress at T2. Results indicated that when infertility is not disclosed to at least a close relationship, the beneficial effects of social support on both social and personal stress cease to exist. Also, when participants perceived high social support, higher levels of social and personal stress were associated with keeping infertility as a secret within close relationships, but when low social support was perceived, high social and personal stress levels were associated with disclosing infertility to all close relationships. Findings from this study provide evidence that the prospective relationship between social support and fertility-related stress is moderated by the decision of disclosing infertility. Infertility health professionals can help couples in deciding to which contexts they should disclose their infertility by assessing social support.

Introduction Terrell Ward Bynum and Simon Rogerson fostered the ETHICOMP conference back in 1995, and, over the years, they managed to cultivate an inspiring and open-minded community. They stepped down from the throne after ETHICOMP 2013, which took place in Kolding at University of Southern Denmark. In his closing remarks to this The author would like to thank the students, who followed lectures in "Learning, epistemology and ICT" (spring 2014), for vivid and inspiring discussions about AI. conference, Terrell Ward Bynum noticed that (freely quoted by memory): "at the first ETHICOMP, back in 1995 there were around thirty delegates. By now, we are hundred humans and one robot". Hereby, he pinpointed the impact of ETHICOMP, namely, the fact that the ETHICOMP community strives to explore and reflect pro-actively in responding to philosophical, social and moral questions raised by technology. In the same sense, it is well-known that art often captures emerging scientific advances or even, to some extent, functions as a source of enlightenment and inspiration to scientific discovery. But probably most of all, the expressive power of art provides us with ways of understanding ourselves and our being in the world. Here, particularly sci-fi movies stand out in their effort to grasp what is puzzling today seen through the lens of the future. Typically, the storylines in sci-fi movies reveal important philosophical questions regarding moral agency and patiency, consciousness, identity, social relations and privacy to mention just a few. In this paper, I shall be outlining an analysis of selected IT-ethical perspectives in sci-fi movies covering the timeline of the ETHICOMP conference series, which was launched in 1995 by the Centre for Computing and Social Responsibility (CCSR), Terrell Ward Bynum and Simon Rogerson. --- Technology as a social actor Traditionally, we have conceived machines as mere tools or extensions of human activity. But the development of relation-based technology, such as different types of artificial companions, implies a change in perspective to account for the role these technologies play as social actors: ACs [artificial companions] are a technological success because they are not the outcome of some unforeseeable breakthrough in strong AI, but the social equivalent of Deep Blue: they can deal well with their interactive tasks, even if they have the intelligence of an alarm clock. And they are philosophically significant precisely because they are neither Asimov's robots nor Hal's children. Out of the realm of thought experiments and unrestrained speculations, they posit concrete, philosophical questions. (Floridi, 2014, p. 153) Sci-fi movies also display philosophical and moral issues and highlight ways in which our formation of identity and self-understanding are influenced by robots, which have developed to become social actors. Likewise, within the field of human-robot interaction studies, several empirical studies illustrate ways in which we enter into relationships with social robots (Turkle, 2011;Dautenhahn, 2007;Schärfe et al., 2011;Carpenter, 2013;Bartneck et al., 2007). For instance, when it comes to the case of inflicting pain on a robot, Bartneck et al.'s experiment, in which research subjects were asked to switch off a robot (which had assisted them during a test session), illustrates that research subjects were emotionally affected by the pleas of the robot and even entered into long dialogues with the robot before turning it off (Bartneck, 2007). Although, we are aware that robots are nothing but machines, the fact that we are highly meaning-seeking and interpretative beings causes us to anthropomorphize robots and intuitively interpret them as fellows, as illustrated by Schärfe et al. (2011), who refer that relations of trust can be observed in studying physical interaction between a person and a geminoid. Through empirical studies, they find evidence of initial trust formation, which springs from a hand placed on the shoulder of the geminoid, likewise eye contact with the geminoid also promotes intimacy. Similarly, at the ETHICOMP 2013 conference, Henrik Schärfe and his alter ego, Geminoid DK, were present as keynotes (www.geminoid.dk), and some among the female audience felt like they were able to make eye contact with the geminoid. Consequently, as summarized in a phrase by Sherry Turkle, robots press our "Darwinian buttons" (Turkle, 2011, p. 8) and we respond with care even toward very simplistic robot design (Benford andMalartre, 2007, p. 165). Moreover, Turkle (2011, p. 49-ff.) warns us that the robotic moment is lurking in the horizon, which refers to the moment at which we prefer risk-free relationships with robots over challenging engagements with humans: As I have said, my story of this moment is not so much about advances in technology, impressive though these have been. Rather, I call attention to our strong response to the relatively little that sociable robots offer -fueled it would seem by our fond hope that they will offer more. With each new robot, there is a ramp-up in our expectations. I find us vulnerable -a vulnerability, I believe, not without risk. (Turkle, 2011, p. 52) On the other side, the World Robot Declaration was issued in 2004 in Japan, implying that maybe the time has come to discuss if there is a need for granting rights to robots? So far, we have dealt with whether we can assign responsibilities to artificial agents or not (Floridi and Sanders, 2004;Verbeek, 2011). But, according to David Gunkel, we have not yet seriously started to consider whether we ought to have moral duties toward machines (Gunkel, 2012, p. 99). Hence, in The Machine Question -Critical Perspectives on AI, Robots, and Ethics (2012) -Gunkel argues that already by now, the term "person" has opened up to also include animals and corporations, and as we have started to grant rights to non-human agents, it might be a matter of time before we include machines into the category of persons (Gunkel, 2012, p. 39-ff.). If we do so, the question arises whether the kind of responsibilities we would have toward robots would be on par with the kind of responsibilities we have toward animals, corporations or other human beings? In a similar vein, sci-fi movies often highlight what is morally at stake in the relation, per se, rather than framing the plot around a distinction between personhood versus machine. The first mentioned perspective is illustrated in Artificial Intelligence, A.I. (Section 4), but, in what follows, we shall be paying attention to the second perspective, i.e. ways in which artificial moral agency constitute a threat to human autonomy. --- Robots as (in)moral agents The exploration of the impact of technology on civilization and especially the theme of loss of human control and autonomy due to robot interference, is a classic theme in sci-fi movies, as spelled out in A Space Odyssey, by Kubrick (1968), in which the intelligent computer H.A.L 9000 sets the mission of the spaceship above the crew. A similar theme is raised in the first Alien movie -here an android researcher risks the crew to preserve the alien for the sake of science. Within the timeline of ETHICOMP, the robot cast in the role as a moral agent with the ability to do (mostly) evil and good represents a strong narrative. This is shown in the movie I, Robot, by Alex Proyas ( 2004), which takes place in 2035 in a world in which social robots interact with humans as polite and caring servants. The overall storyline highlights challenges in the relationship between imperfect humans and perfect moral robots, which (or who?) by deduction from Asimov's laws of robot ethics, turn against humanity in illustrating the paternalistic point that robots find it necessary to protect humans against themselves -with reference to Asimov's zeroth law: "A robot may not harm humanity, or, by inaction, allow humanity to come to harm". Fortunately, this logical inappropriate implication is short-circuited by the detective, Del Spooner. In this way, paternalism evaporates in favor of human autonomy, which includes our capabilities for imperfection and failures, thereby characterizing what makes us moral beings in the first place: There is nothing particularly ethical about adding up utilities or weighing pros and cons, until the decision maker feels the urge not to follow the ethical course of action it arrives at. (McDermott, 2008, p. 6) Next, and bearing the ETHICOMP timeline in mind, we shall be looking at Terminator 3 -the raise of the Machines, By James Cameron (2003). The plot develops around the latest version of a killing robot T-X, which is sent from the future by Skynet, a consciousness AI, whose main purpose is to get rid of humanity. The Terminator's outstanding information processing abilities include infrared sight and context-sensitive action-guiding scripts. Moreover, the Terminator's deliberations are not distracted by emotions but purely guided by rational calculations. These advantages enable it to always have a lead over humans. And, although we can never know what it is like to be a Terminator (Nagel, 1974), we are still allowed a first-person's perspective on its sense impressions. Thus, we get an inside glimpse of the makeup of its perceptual apparatus and its mind. This camera technique gives rise to anxiety because it reveals a dedicated action minded species, which acts in accordance with efficient calculations without emotional distractions -as summarized by one of the leading actors: "It can't be bargained with, it can't be reasoned with, it doesn't feel pity or remorse or fear, and it absolutely will not stop, ever, until you're dead!" Hence, the Terminator travels back to our time to hunt down and kill Sarah Connor to bypass a future in which she gives birth to a son, John, who will grow up to become the future leader of a revolt against the machine rulers. In this particular movie, from 2003, Skynet also enters into cyber warfare and infects US army computer systems, thereby leaving the country open to attacks. As a minor curiosity in relation to the Terminator films, one might note that traces of our ambivalence toward humanoid machines are observable in the 100 heroes and Villains' list of Hollywood films, on which Terminator was ranked the 22nd villain of all time, while the Terminator in Terminator 2: Judgment Day was ranked the 48th hero of all times. It has never happened before that the same character appears on these two opposing lists (Wikipedia: Terminator). Finally, in The Wachowski brothers' Matrix movies, of which only the first, The Matrix (1999), is outstanding, we are introduced to a future-simulated reality named "the Matrix", i.e. a computer-generated world run by machines to control humans and use their bodies as bio-electric raw material as sources for energy consumption. But a small group of hackers discover the virtual reality fraud. The rebellions grow supernatural powers and their knowledge of the true nature of the computer-simulated reality makes them capable of bending the natural laws. Hence, they try to overthrow the Matrix and win back human autonomy. Both films encapsulate an archetypical AI-narrative, which describes intelligence with reference to logic governed behavior: Some, at least, of what makes minds rational is their ability to perform computations on thoughts; when thoughts [...] are assumed to be syntactically structured, and where "computation" means formal operations in the manner of Turing. (Fodor, 1998, p. 205) This narrative carries over to the present motivations for introducing lethal autonomous weapon systems (LARS) in warfare. Here, a main argument for assigning moral agency to LARS mainly rests upon the assumption that eventually, with the right kind of implementation of a formal moral framework, such robots shall be able to outperform human beings and lead to more moral warfare (Arkin, 2007;Lin et al., 2008). Hence, moral robots are assumed to be better at moral decision-making and subsequently acting in accordance with rules of engagement under stressful conditions. Moreover, future combat robots presumably also hold promises of progressively more bloodless and less harmful warfare (Arkin, 2007, p. 6;Lin et al., 2008, p. 50-ff.), which implies that war might turn into a risk-free business -"When a robot dies, you don't have to send a letter to its mother" (Singer, 2009, p. 31). But, this route down the future warfare lane seems to be paradoxically paved, as in line with Just War Theory (Walzer, 1977), war ought to be the last resort and not something that we turn to too easily, otherwise the global conflict level might increase dramatically. So far, our present discussion has concerned whether it is plausible to assign moral agency and responsibility to an AI agent, a discussion which is increasingly raised in philosophy (Floridi and Sanders, 2004;Sparrow, 2004Sparrow,, 2007;;Verbeek, 2011) in tandem with the discussion of whether this implies that we ought to be responsible toward a robot, i.e. consider a robot as a proper receiver of moral considerations (Gunkel, 2012;Floridi, 2014;Benso, 2000). Consequently, in what follows, we shall be addressing issues of moral patiency in human-robot interactions. --- Robots as moral patient Should their [artificial companions] non-biological nature make us discriminate against them? The question casts an interesting light on our understanding of what kind of persons we would like to be. (Floridi, 2014, p. 154) Artificial Intelligence, AI., by Steven Spielberg (2001), tells the story of the first robot child, David, programmed to love and brought into an ordinary family, in which he functions as a substitute for a beloved son, who is in coma: Programmed to give and elicit love and affection, David is soon calling Monica "Mommy" and, bereft of her only natural child, she accepts and warms the artificial boy. (Clocksin, 2003(Clocksin,, p. 1738) ) Later on, the son recovers and the robot is abandoned. David then sets out on a journey during which he undergoes a process of development. Throughout the film, David wishes to be real to be able to evoke his mother's love, and the movie reflects upon issues of authenticity but at the same time also addresses what we become from entering into relationships with robots, which (whom) we choose to treat as inferior or slaves. This line of argument is reflected in Gunkel's (2012) book The Machine Question, in which he establishes a framework for a thorough philosophical investigation of questions of whether machines are going to be held responsible to us for their actions and whether we are going to be responsible toward the machines' rights. Gunkel emphasizes that a demand for robot rights may arise from their social interactivity (Gunkel, 2012). Consequently, while we may argue about the status of intelligence, people have already started to form relationships with artificial companions. The fact that they look like us, combined with their growing ability to behave as social actors, will cause new forms of friending and bonding in connection with human-robot interaction. If we treat these artifacts as mere machines without questioning whether robots ought to be worthy or deserving of ethical considerations, we risk facilitating a master-slave society. On this background, Gunkel advices us to (re)consider what kind of questions we ought to pay attention to in analyzing human-robot interaction. "When god-like Odysseus", Leopold (1966, p. 237) recalls, "returned from the wars in Troy, he hanged all on one rope a dozen of slave-girls of his household whom he suspected of misbehavior during his absence. This hanging involved no question of propriety. The girls were property. The disposal of property was then, as now, a matter of expediency, not of right and wrong". As long as others -whether human, animal, machine or otherwise -are defined as mere instruments or the property of a ruling group, they can justifiably be used, exploited and dispensed with in a way that is purely expedient and beyond any moral considerations whatsoever (Gunkel, 2012, p. 108). A contradicting viewpoint is reflected in revisiting Turkle's earlier mentioned concept of the robotic moment (Turkle, 2011, p. 49-ff.), which reflects her worry that when we turn to robots we might gradually lose sight of that trust -as opposed to the kind of supposedly risk-free relationships we may enter into with robots -is essential for the formation of flourishing human relationships. Consequently, Turkle (2011, p. 6) argues for human superiority in claiming the existence of fundamental obstacles for forming trustful relationships with robots. According to Turkle, our interactions with robots are biased by our tendencies to anthropomorphize technology, which lacks any kind of authenticity and represents nothing more than a clever collection of "as if" performances. In this sense, it does not make sense to ascribe moral agency or patiency to robots: At the robotic moment, we have to be concerned that the simplification and reduction of relationship is no longer something we complain about. It may become what we expect, even desire. In this book I have referred to our vulnerabilities rather than our needs. Needs imply that we must have something. The idea of being vulnerable leaves a lot of room for choice. There is always room to be less vulnerable, more evolved. We are not stuck. To move forward together -as generations together -we are called upon to embrace the complexity of our situation. We have invented inspiring and enhancing technologies, and yet we have allowed them to diminish us. The prospect of loving, or being loved by, a machine changes what love can be. We know that the young are tempted. They have been brought up to be. Those who have known lifetimes of love can surely offer them more. When we are at our best, thinking about technology brings us back to questions about what really matters. (Turkle, 2011, p. 295) To elaborate on Turkle's observations, it might be valuable to discuss the concept of trustful relations as contrary to "risk-free" relations. Hence, it is generally acknowledged that trust is vital for the flourishing of human life and a precondition of any cultural ordering (L<unk>gstrup, 1997;Rawls, 1999, p. 433);Fukuyama, 2003, p. 126). According to the moral philosophy of L<unk>gstrup (1997), our fundamental human condition is rooted in the fact that life is interpersonal; we are mutually dependent on each other. Consequently, openness, in the sense of trusting, i.e. daring to risk ourselves in coming forward to meet the other, is a definitive feature of human co-existence and inherent in all communication. When we place trust in others, it involves genuine risk-taking, as we surrender ourselves to the other. Thus, the mutual dependence, from which the ethical in human life springs, can only be comprehended in understanding what is at stake in a given context between two given persons. The structure of all human encounters, or any kind of approaching, presupposes a fundamental trust that the other will meet your request and carries within it a risk that you will be met with rejection or carelessness. Hence, we are obliged to act out of consideration to the best of the other. L<unk>gstrup is not addressing the kind of universality we find in Kant's (1785, p. A54) categorical imperative, rather L<unk>gstrup points to that we find ourselves situated in a given context with an particular person in a specific situation -what is ethically important is, so to speak, consideration for the other in an abstract, which allows us to put our moral dispositions to test (Fink, 2005, p. 99). But, in entering into relationships with robots, we are not faced with having to surrender ourselves to the social robot. Even though the robot acts in a human-like way and displays emotions, there is nothing at stake besides "as-if" behavior caused by programmed internal states and executed so as to ensure adequate adaption to the surroundings. We know that this is the case about our relationshipthe robot simulates, and we invest without cost. By now, we have two strong lines of arguments regarding what interacting with social robots might mean and do to us. On the one side, Turkle worries that we will lose something important to our humanity and discover it too late -as the title of her book indicates: "Alone together -why we expect more from technology and less from each other" (Turkle, 2011). On the other side, Gunkel emphasizes that we ought to start to think about rights beyond living things, i.e. give moral standing to robots to frame possible ways in which we perceive of and respond to robots. Hence, it does not matter whether Paro, the seal, is "authentic", what matters is the fact that we will be affected by its social interactivity; grandfather will get emotionally attached to Paro and it will become an important part of his life. From this perspective, it seems inhumane to treat Paro with cruelty and, for instance, tear out its batteries in front of grandfather. A demand for moral rights may arise precisely from such social relationships. In summarizing, Artificial Intelligence, A.I. encapsulates both perspectives; on the one hand, the robot boy, David, is obviously non-authentic, without emotions and even to some extend not able to imitate appropriate responses toward the surroundings (in one scene, he laughs loudly without sense of situational awareness). In this manner, the film expresses that there might be something morally disturbing about the whole idea of the kind of non-authentic substitute relationship the robot boy offers. On this background, we should go with Turkle and her concerns for "as if" relationships. But despite this, we feel sorry for David and find him worthy or deserving of ethical considerations when kids are bullying David and when his mother leaves him behind in a forest -once her real son has recovered and the conflict level between him and David is building up. Both Gunkel and Turkle address what kind of persons we would like to be, but they stay in separate camps: in conclusion, one could say that Turkle emphasizes that personhood is what links moral agency to responsibility and moral patiency to a claim for rights. Gunkel uses the social relationships we enter into with robots as a springboard for asking what happens when robots grow into our lives and if our attachment to social robots implies that we ought to assign moral standing to machines? Artificial Intelligence, A.I., manages to show us both perspectives. --- Altruistic robots As a research field, AI, was coined at the Dartmouth Conference in 1956 and Turing wrote his famous article Computing Machinery and Intelligence six years earlier (Turing, 1950), since the fifties, the classical mind-body problem has been reframed to account for the possibility or unfeasibility of robot and machine consciousness (Wisdom et al., 1952;Scriven, 1953;Mackay, 1956;Ziff, 1959;Lacey, 1960;Culbertson, 1963;Putnam, 1964). More recently, implementation of bottom-up learning is reflected in Rodney Brooks's (1991, p. 139) ideas about the emergence of intelligence as cognition without representation -"with strict reliance on interfacing to the real world through perception and action, reliance on representation disappears". By an incremental approach toward AI, Brooks seeks to avoid the frame problem (McCarty and Hayes, 1969;Dennett, 1988;Ford, 1996) and sets out to create artificial low-level perceptual and sense-motoric routines, which, put together, might eventually evolve into a significant level of intelligence. It sounds rather optimistic that conceptual complex mental activities, like daydreams, planning or deliberative judgment can be broken down into modules of such reflex mechanisms. But, according to a physicalist perspective toward AI, it could be argued that some kind of robot evolution is realizable and will bring about robots with minds of their own. Presumably, based on some initial framework serving as a parent adviser, such robots shall be capable of self-learning and adaption to new environments. This gives rise to ideas about implementing a virtue ethical framework for growing artificial moral maturity: In robotics, so-called "friendliness theory" attempts to deal with this conundrum: rather than using any finite set of top-down rules or laws, intelligent machines should be programmed to be basically altruistic, and then use machine learning in various settings to create a kind of "best judgment" in how to carry out properly altruistic actions. This approach sidesteps the fundamental calculation and programming problem of how to account for a vast number of unforeseeable eventualities. (Lin et al., 2008, p. 39) To phrase moral maturity in the MacIntyrian way, as persons, we acquire virtues in our developmental path from dependent to independent reasoners. As such, we become independent practical reasoners through life experience and through the learning (including rule following behaviour) we get from care persons during our childhood. Consequently, we grow to become moral mature persons capable of expressing and enacting our values in a social context (MacIntyre, 1999, pp. 158-159). If we should ever happen to succeed in creating virtuous machines, we will have to deal with a consciousness robot with free will, intentions, goals, self-interest, that is, a moral agent with a justified claim for rights. If robots have this status, we are committed to treat them as moral beings in their own right even though they might turn out to develop a moral sense beyond our understanding. From a family-friendly angle, an altruistic robot is presented in Wall-E, by Stanton ( 2008). Together with a cockroach, the garbage collecting robot Wall-E is left behind on a polluted earth, from which humans have escaped in big space shuttles. While waiting for everything to get better on the earth, which humans seem to assume will happen all by itself (almost like nowadays attitude toward issues of global warming), they spend their days engaging in superficial activities, quiet similar to a satirical version of American cruise tourists. Hence, they eat (too much), they sit (too much), i.e. they are driven around in flying "arm chairs" with futuristic Ipad-like devices placed right in front of their heads allowing them to take in (too much and too silly) information, which also suggests that interpersonal encounters are spare. Furthermore, due to severe obesity and physical inactivity, they are only able to crawl. Moreover, we can easily imagine that this life style is not doing anything good for the power of sexual reproduction and that this might endanger the survival of the human species. The seamless integration of humans and technological artifacts has turned out not to be of any benefit to humanity, rather humans have become like grown-up helpless babies. Here, Wall-E tells the story of a future world in which love between two robots, Wall-E and Eva (a scout robot, which is sent back to earth from the space shuttle to explore, whether it is possible for humans to return to the earth), becomes a unique catalyst for reestablishing a once lost flourishing human world. The message is that altruistic robots may succeed in saving us from ourselves, in the feelgood sense of the term, i.e. not by trying to take over and deprive us of our autonomy, like expressed above in I, Robot. --- Surveillance So far, the article has dealt with AI agents in the shape of social robots, but other sci-fi themes are of course also worth mentioning, such as the surveillance theme reflected in the movie Nineteen Eighty-Four, by Michael Radford (1984), which is based on the dystopian novel by George Orwell, and describes a totalitarian society with no room for freedom and no ability for building trustful relationships. Stressing our context of the ETHICOMP conference series' timeline, we shall be looking closer into a more recent version of the surveillance theme. Hence, in Minority report, by Steven Spielberg (2002), crime is eliminated from Washington due to the use of advanced knowledge-discovery technology in the shape of three pre-cogs, which operate by means of a kind of distributed cognition allowing them to look into the future and come up with precise crime predictions. Hence, in 2054, law enforcement agencies have the capabilities to respond to criminal activities even before they actually take place, and Minority report highlights what is at stake in cases in which knowledge-discovery technologies may infringe upon individuals and groups control of how information relating to them, their actions and their relations are represented. As an example of a knowledge-discovering technology, the currently ongoing EU project ePOOLICE (www.epoolice.eu) aims at developing an efficient and effective environmental scanning system as part of the early warning system for the detection of emerging organized crime threats and changes in modus operandi. The purpose is to be able to meet the future challenges of fighting organized crime by ensuring that law enforcement are capable of engaging in proactive planning at the strategic level. For the moment being, the current situation and priorities in fighting organized crime can be summarized as follows: The SOCTA, 2013 [EU Serious and Organized Crime Threat Assessment] identifies a number of key priorities, which, in Europol's view, require the greatest concerted action by EU Member States and other actors to ensure the most effective impact on the general threat. Facilitated illegal immigration, trafficking in human beings, synthetic drugs and poly-drug trafficking, Missing Trader Intra-Community (MTIC) fraud, the production and distribution of counterfeited goods, cybercrime and money laundering are the particular crime areas listed in this category. (SOCTA, 2013, foreword by Director of Europol, Rob Wainwright) But it is also important to be able to pay attention to possible future crime scenarios, which may be lurking in the horizon. Hence, in the ePOOLICE system, environmental scanning is carried out on data streams from a variety of online public sources, focusing on modus operandi and crime trends, not on individuals. Different kinds of public online data streams feed into the system's knowledge repository that provides a rich taxonomy of domain knowledge. Moreover, data processing is facilitated by means of information fusion techniques, enabling the extraction of descriptive and predicative meanings used for inferring hidden states, i.e. weak signals or indicators of organized crime activities. In general, such environmental scanning systems for early warning operate at the strategic level of open source intelligence and do not aim at identifying individuals. Nevertheless, ethical and technical issues related to potential privacy infringements in public online contexts still have to be addressed to establish a privacy preserving framework, which ascribes privacy protection into the given system design (Gerdes et al., 2013;Gerdes, 2014). In relation to the development of environmental scanning systems for early warning, it is crucial to balance security at a societal level with citizens' right to privacy -in short, to balance data privacy and data utility, which is by no means a trivial task. Still, and in line with the ETHICOMP spirit, it can be done by engaging in "engineering activism" (a term coined by Nissenbaum, 2001), which implies that to deal with the ethical impact of systems in context, one must take a pro-active stance toward the challenge of bringing ethics to design: Humanists and social scientists can no longer bracket technical details -leaving them to someone elseas they focus on the social effects of technology. Fastidious attention to the before-and-after picture, however richly painted, is not enough. Sometimes a fine-grained understanding of systems -even down to gritty details of architecture, algorithm, code, and possibly the underlying physical characteristicsplays an essential part in describing and explaining the social, ethical, and political dimensions of new information technologies. (Nissenbaum, 2001) --- Concluding remarks Sci-fi movies are not about predicting the future, rather they reflect the issues worth asking in our present time. On this background, this article casts light upon the broad spectrum of moral questions that may arise from human technology interactions, particularly focusing on themes addressed in sci-fi movies within the ETHICOMP conference series' timeline. Hence, sci-fi movies conceptualize philosophical questions in illustrating what assigning agency or patiency to artificial agents means for our being in the world. In conclusion, sci-fi movies encapsulate how we are shaped through the kind of relationships we enter into with robots. Moreover, AI agents can also be embedded in intelligent systems, as illustrated in Minority Report, which gives rise to address issues of intelligent surveillance technologies. Here, concerns related to the increasingly pressure upon privacy, due to the introduction of advanced knowledge-discovery technologies, are illustrated and the article argues that, as IT-ethicists, we should not only take an applied approach to ethics, i.e. engage in after-the-fact critical analyses. Rather, whenever possible we ought to act proactively and "do ethics" by getting involved in the developmental phases of designing technology.

Purpose -This paper aims to explore human technology relations through the lens of sci-fi movies within the life cycle of the ETHICOMP conference series. Here, different perspectives on artificial intelligent agents, primarily in the shape of robots, but also including other kinds of intelligent systems, are explored. Hence, IT-ethical issues related to humans interactions with social robots and artificial intelligent agents are illustrated with reference to: Alex Proyas' I, Robot; James Cameron's Terminator; and the Wachowski brothers' Matrix. All three movies present robots cast in the roles of moral agents capable of doing good or evil. Steven Spielberg's Artificial Intelligence, A.I. gives rise to a discussion of the robot seen as a moral patient and furthermore reflects on possibilities for care and trust relations between robots and humans. Andrew Stanton's Wall-E shapes a discussion of robots as altruistic machines in the role as facilitators of a flourishing society. Steven Spielberg's Minority Report allows for a discussion of knowledgediscovering technology and the possibility for balancing data utility and data privacy. Design/methodology/approach -Observations of themes in sci-fi movies within the life span of the ETHICOMP conference series are discussed with the purpose of illustrating ways in which science fiction reflects (science) faction. In that sense, science fiction does not express our worries for a distant future, but rather casts light over questions, which is of concern in the present time. Findings -Human technology interactions are addressed and it is shown how sci-fi films highlight philosophical questions that puzzle us today, such as which kind of relationships can and ought to be formed with robots, and whether the roles they play as social actors demand that one ought to assign moral standing to them. The paper does not present firm answers but instead pays attention to the selection and framing of questions that deserve attention. Originality/value -To relate sci-fi movies to topics raised during the past 20 years of the ETHICOMP conference series, seemed to be an appropriate way of celebrating the 20-year anniversary of the ETHICOMP conference series.

Introduction A central equity objective of national healthcare systems in Europe and across the world is to ensure that all citizens receive the health care they need, irrespective of their income or social position. 1,2 Sophisticated analytical methods have been developed for measuring socioeconomic inequality in healthcare utilisation, allowing for socioeconomic differences in healthcare need, to help decision makers draw inferences about how far their health system is inequitable or unfair. 3 Cross-country comparisons using household survey data have provided prima facie evidence of pro-rich inequity in specialist medical visits and preventive care in most European countries, 4,5 and are now routinely reported by the Organisation for Economic Co-operation and Development (OECD). 6 The practical utility of these healthcare equity performance benchmarks is, however, hampered by data limitations. Policy makers, managers and clinicians need to know not just how well their country's healthcare system is performing in general, but how well it is performing in relation to specific health services in their own specific area of responsibility. Household surveys typically only sample a few thousand people in any given year, making up a small fraction of national populations containing several million people. Hence, surveys can only provide information about equity in the use of general health services used regularly by a large proportion of the population-such as specialist medical visits and dental services and breast and cervical cancer screening tests. The next frontier of research in this area, therefore, is the use of comprehensive administrative datasets covering the entire national population, which can paint more fine-grained pictures of equity and help hold decision makers to account for the equity performance of more specific health services. 7,8 This study is the first cross-country comparison of equity in health care between European nations to use comprehensive administrative data on a particular publicly funded hospital service-in this case, hip replacement. A pioneering data infrastructure project, the ECHO Project, has assembled comparable hospital data on five European countries (England, Denmark, Portugal, Slovenia and Spain). The ECHO data warehouse, described elsewhere in this special issue, is used here to provide insight into health system performance relating to equity objectives. One of the countries-Slovenia-was excluded from this equity analysis because it has too few sub-national areas for reliable statistical analysis. A limitation, however, is that ECHO has no individual level measures of socioeconomic status or ill-health. Hence, instead we take an ecological approach and examine socioeconomic inequality between administrative areas with differing average income or deprivation. Our approach asks the simple question: are people living in relatively prosperous administrative areas more likely to receive a publicly funded hip replacement than people living in less well-off areas? And is this inequality changing over time? These questions are of policy interest to local healthcare decision makers seeking to make the case for national investment in their own administrative area, but are also of broader interest to national policy makers in relation to decisions about geographical resource allocation, infrastructure investments in medical staff and facilities and wider healthcare regulations and programmes with differential impacts in different parts of the country. We cannot draw conclusions about 'within-area' inequalities between rich and poor individuals. Furthermore, we cannot disentangle how far 'between-area' inequalities are attributable to individual level factors-in particular, the socioeconomic composition of the individuals living in the area-as opposed to area level factors, such as the local supply of medical staff and facilities, or characteristics of the natural, social or economic environment that influence the care seeking behaviour of all individuals living in the area. This study can therefore be seen as a demonstration project. Despite having to rely on area level rather than individual level data about socioeconomic status and need, we explore whether or not cross-country comparisons of healthcare inequality using detailed administrative data on healthcare utilisation provide useful new information. --- Methods --- Study population The to 2009, this country was excluded from the equity analysis for two reasons. First, it has too few areas to yield stable confidence intervals-only 2 or 3 per quintile group. Second, the quintile groups are too similar in terms of average income-the richest group only has 19% higher average income than the poorest-see table 1. For these two reasons, differences between Slovenian administrative areas cannot provide meaningful indicators of socioeconomic inequity. --- Outcome measure: hip replacement Our data includes all publicly funded hospital activity covered by the national health insurance scheme (either social insurance or national health service). This excludes privately funded activity, which is considered to make up around 10% of total hip replacement activity in most European countries but may be higher in Portugal, as discussed later. We included adults aged 35 years and older with any procedure code for primary prosthetic replacement of the hip joint or head of femur excluding diagnostic codes for fractures and accidents. We exclude fractures and accidents to focus on non-emergency surgery as an indicator of quality of care for people with osteoarthritis and rheumatoid arthritis, in which'more is better'. Including fractures and accidents would confound this indicator, as (i) they provide an indicator of quality of care in which'more is worse', (ii) they reflect behavioural risk factors which are socially patterned with poorer communities tending to have more accidents and (iii) hip fractures relate more closely to osteoporosis, which causes fragile bones, rather than osteoarthritis and 3.12 3.12 3.12 3.12 3.12 3.12 3.12 3.12 The ratio rich vs. poor (Q5/Q1) is the ratio of average income in the richest divided by the poorest quintile group, and helps to indicate the scale of income differences between the groups. In England, as we use deprivation score rather than income, this is computed as a Q1/Q5 ratio of average deprivation score in the poorest divided by the richest quintile group. As we standardise area level rates to national populations, these national crude rates are comparable to the corresponding nationally standardised area level rates. rheumatoid arthritis. We excluded adults under 35 because rates of hip replacement among younger adults are low. Details of the coding schemes used in each country are provided in Table B in the Supplementary materials. Spain and Portugal use the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) system for coding both procedures and diagnoses, whereas England, Denmark and Slovenia use countryspecific procedure codes in conjunction with ICD-10 diagnostic codes. Therefore, we developed 'cross-walks' between the different systems, in consultation with experts in each coding system, to ensure the coding is as comparable as possible between countries. These are described elsewhere in this special issue. --- Socioeconomic status Within each country we split administrative areas into five socioeconomic quintile groups using estimates of the average income of each area (or income deprivation in the case of England). As the areas vary in population size, we use populationbased quintile groups to ensure that approximately one-fifth of the country's population resides within each group. --- Healthcare need We allow for demographic differences in need for hip replacement between area populations by indirectly standardising the hip replacement rates in each area in each year to the prevailing national agesex specific rates in that year. National standardisation is appropriate insofar as our focus is on within-country rather than betweencountry inequality in health care. We assume that, other than differences in age and sex, the level of ill-health and consequent need for hip replacement is equally distributed across high-and lowincome areas within each country. Insofar as low-income areas have worse health and higher need for health care than highincome areas, therefore, our approach may be conservative in the sense that it may under-estimate need in poor areas. If so, our approach may tend to under-estimate pro-rich inequality and over-estimate pro-poor inequality. --- Inequality We used simple quintile group-based graphs to visualise the socioeconomic gradient and change therein over time. We measured inequality using a battery of simple two-group inequality indices: the absolute inequality gap and relative inequality ratio between richest and poorest group (Q5 and Q1), between richest and middle group (Q5 and Q3) and between middle and poorest group (Q3 and Q1). These indices cover both absolute and relative concepts of inequality, and look at different parts of the distribution, to facilitate a balanced assessment and guard against bias due to arbitrary selection of one particular inequality measure. We decided against using more complicated summary measures, such as the concentration index and associated concentration curve, for three reasons. First, our area-level measures of average income and deprivation have limited ability to make fine-grained distinctions within quintile groups. Second, concentration curves are inconvenient for visualising year-by-year change over time. Third, the magnitude of a concentration index is harder for decision makers to interpret than simple two-group gaps and ratios. --- Statistical analysis As we have data on the entire national population, rather than a sample, there is a case for interpreting our inequality measures as actual observed population levels of inequality, rather than estimates for which confidence intervals are required. However, there remains uncertainty about how many hip replacements might have happened in a particular area in a particular year, generated by both demandside stochastic processes relating to individual health needs and healthcare seeking behaviour, as well as supply side stochastic processes relating to the availability of healthcare services and the behaviour of medical practitioners. To reflect this uncertainty, we used area-level Poisson regression to estimate confidence intervals around all quintile group rates and two-group inequality indices. We used age-sex-adjusted area count as the outcome variable, population as the exposure and quintile group as the main independent variable. We also used Huber-White standard errors, on the conservative assumption that over-dispersion is due to the stochastic effects of unobserved heterogeneity at individual and/or area levels (an alternative econometric approach yielding virtually identical results would be negative binomial regression, which explicitly estimates an over-dispersion parameter). However, some overdispersion may be due to the deterministic effects of unobserved heterogeneity-for example, a poor area may inevitably have a higher-than-expected hip replacement rate because it is unusually well supplied with orthopaedic surgeons. If so, the Huber-White approach may slightly over-adjust confidence intervals by treating a partly deterministic process as if it were entirely stochastic. As a simple statistical test for change in healthcare inequality between 2002 and 2009, we pooled these two end years, with 2002 as the reference year, and included a year dummy and a year by income interaction as the key variable of interest. In the absence of specific hypotheses about patterns of change over time and how these might vary between countries, we did not conduct formal statistical tests of patterns of year-on-year change during the middle years. --- Sensitivity analysis We ran various sensitivity analyses to check the robustness of our findings, including use of area level income (deprivation) as a continuous variable to provide a simple summary indicator of relative inequality across the whole social gradient; 'frozen' quintile groups fixed to first period population and income values; nonpopulation-weighted quintile groups (with approximately one-fifth of the areas in each, rather than one-fifth of the population). We also used alternative statistical methods for computing confidence intervals: (i) area-age-sex group multilevel Poisson regression, (ii) regression without Huber-White standard errors (which ignores overdispersion and provides a lower bound on the confidence interval) and (iii) formula-based estimation on the assumption that area-level rates follow a t-distribution (which focuses exclusively on betweenarea variation within quintile groups). --- Results Figure 1 shows the socioeconomic gradient in hip replacement in 2009. England, Denmark and Spain exhibit a pro-rich social gradient rising from the poorest group Q1 to the second richest group Q4 but then declining in the very richest group Q5. Portugal exhibits a'reverse' social gradient with precisely the opposite pattern. Hip replacement rates are lower in all socioeconomic groups in Portugal and Spain than England and Denmark. Looking at the confidence intervals, both England and Spain have age-sex adjusted rates of hip replacement that are clearly higher in the richest group than the poorest group, with Q5/Q1 ratios of 1.35 (CI 1.25-1.45) and 1.43 (CI 1.17-1.70), respectively. In other words, people in the richest fifth of the areas of England are 35% more likely to receive a hip replacement than people living in the poorest fifth in England, and 43% more likely in Spain. In absolute terms, people in the richest fifth of the areas in England receive 5.68 (CI 5.18-6.18) more hip replacements per 10 000 people than people in the poorest fifth, and 2.4 (CI 2.11-2.73) more in Spain. Although the relative inequality gap is larger in Spain, the absolute gap is smaller because the average number of hip replacements per 10 000 population is smaller. In Denmark, however, the decline in the richest group Q5 means that we cannot be confident the Q5/Q1 is greater than one, though --- Socioeconomic inequality in hip replacement we can be confident the Q4/Q1 ratio is greater than one. In sensitivity analysis using income as a continuous variable, however, the overall gradient in Denmark is not significant. Finally, in Portugal, the adjusted hip replacement rate is higher in the poorest than the richest group, with a Q5/Q1 ratio of 0.67 (CI 0.50-0.83). Figure 2 shows trends in socioeconomic inequality in hip replacement over time. The top line of graphs shows trends by socioeconomic group, the middle line shows trends in absolute inequality differences (e.g. Q5-Q1) and the bottom line shows trends in relative inequality differences (e.g. Q5/Q1). The basic cross-sectional patterns did not change over time, but there are signs of increasing pro-rich inequality in both England and Spain. Table 2 shows tests of change in the Q5/Q1 relative inequality ratios. England shows a relative inequality ratio increase of 12 percentage points, from 1.23 to 1.35, and Spain an even larger increase of 26 percentage points from 1.17 to 1.43. However, neither of these increases is statistically significant at the 5% level. None of the sensitivity analyses altered this basic pattern of findings. --- Discussion Our cross-sectional findings suggest pro-rich-area inequality in hip replacement England and Spain, though not in Denmark. This mirrors findings from previous studies in England using both individual level survey data and small area level administrative data on socioeconomic status and need. 7,9,10 This convergence of findings is reassuring from a methodological perspective, as is the robustness of our findings to alternative ways of defining socioeconomic quintile groups and estimating confidence intervals. The lack of significant pro-rich-area inequality in hip replacement in Denmark may partly reflect the lower degree of socioeconomic segregation between areas in Denmark, compared to England and Spain. In Denmark, the Q5/Q1 income ratio between the richest and poorest fifth of the areas was only 1.46 in 2009, compared with 3.12 in Spain and 3.21 in England (see table 1). The'reverse gradient' in Portugal is more puzzling, however. It implies-somewhat implausibly-that poor areas have better access to publicly funded hip replacement services in Portugal than rich areas. Although socioeconomic segregation between areas is lower in Portugal than in England and Spain-for example, Portugal has a Q5/Q1 income ratio of 1.81 in 2009 (table 1)-this cannot explain the existence of a significant reverse gradient. One explanation may lie in the relatively high share of privately funded healthcare activity in Portugal, compared with the other countries. According to OECD 2011, only 65% of general health expenditure was publicly funded in Portugal in 2009, compared with 84% in Denmark and the UK, 74% in Spain and 73% in Slovenia; specific figures for private hip replacement expenditure are not available. Insofar as individuals living in rich areas may be more likely to pay privately for hip replacements, private utilisation of hip replacement will be disproportionately higher in richer areas. This activity will not show up in our figures, as privately funded activity is not included in our ECHO data. Missing privately funded activity may also help to explain why the observed pro-rich gradient in Denmark, England and Spain tails off in the richest group Q5. Furthermore, although privately provided activity that is publicly funded is generally included in our data, there may have been gaps in the provision of such data in Portugal in relation to a waiting time reduction programme in Portugal. 11,12 Insofar as private providers are more likely to be located in richer areas, we may therefore disproportionately under-estimate publicly funded utilisation in richer areas of Portugal. Figure 1 Socioeconomic gradients in 2009-age-sex standardised rate of hip replacement per 10 000 adults over 35, by quintile group, with 95% confidence interval. Q1 is the poorest (most deprived) and Q5 the richest (least deprived) administrative area. Each panel shows that country's gradient in black with 95% confidence interval, together with the other country gradients in grey Figure 2 Trends in socioeconomic inequality 2002-09-age-sex standardised rate of hip replacement per 10 000 adults over 35 by quintile group, together with absolute and relative differences between extreme and middle groups. Q1 is the poorest, Q3 the middle and Q5 the richest administrative area. 95% confidence intervals are shown for the Q5-Q1 gap only, for ease of viewing. The Supplementary materials contain larger-scale versions of the graphs in this figure, which are easier to read --- Socioeconomic inequality in hip replacement Another part of the explanation for the'reverse gradient' may lie in climate differences between Portuguese areas. Some studies have suggested that exposure to sunlight may have a protective effect against developing rheumatoid arthritis. 13 Rheumatoid arthritis is an autoimmune disease in which fluid accumulates around the joints, potentially leading to need for hip replacement. It is possible that need for hip replacement due to rheumatoid arthritis may be slightly higher in colder northern areas of Portugal, which tend to be relatively poor, compared with sunnier southern areas. However, the most common cause of need for hip replacement is osteoarthritis, a degenerative joint disease in which cartilage wears down and causes bones to rub against each other. Although many patients with osteoarthritis of the hip report improved symptoms in sunny weather, there is no clear evidence that sunny weather has a clinically significant protective effect against osteoarthritis. 14 The between-country differences in average hip replacement rates are larger than the within-country differences between socioeconomic groups. In 2009, Denmark had the highest crude rate of 27.8 per 10 000, followed by England with a rate of 20.2, and Portugal and Spain with rates of 8.6 and 7.4, respectively. This between-country range of 7.4-27.8 dwarfs the within-country range of variation between quintile groups, as can be clearly seen from figure 1. For example, the poorest quintile group in England has a considerably higher hip replacement rate than the richest quintile group in Spain-in fact nearly twice as high (16 per 10 000 compared with 9 per 10 000). These large differentials cannot plausibly be explained by differences in age and sex structure between countries, though they may be exaggerated insofar as Spain and Portugal have relatively high shares of privately funded hip replacement. Furthermore, large betweencountry differentials in hip replacement are not unique to our five study countries-there is a strong linear association between hip replacement rate and gross national income across all OECD countries, as shown in Figure D5 in the Supplementary materials. This raises an interesting question about how to interpret betweencountry differentials from an equity perspective-how far are they 'unfair'? There is considerable room for disagreement on this question, which raises thorny issues about need-for example, how far does hip arthritis vary between countries due to national variations in climate, physical activity and other factors-and about national sovereignty-for example, how far are between-country differences in healthcare delivery due to legitimate national policy variations reflecting differences in national character and preferences? There is also considerable room for disagreement about whether hip replacement rates in Spain and Portugal are 'too low' or whether hip replacement rates in the other countries are 'too high', with some studies suggesting that some patients have little or no functional impairment or pain prior to treatment. [15][16][17][18][19] If hip replacement rates in England and Denmark are considered 'too high', this raises an interesting question about fairness. Arguably, fairness in healthcare delivery is primarily a matter of ensuring that everyone receives the health care they need. If people in richer countries or areas receive more hip replacements than they need, this may not be unfair. On the other hand, it may be unfair to spend public money on unnecessary hip replacement operations in richer areas if this means there is not enough money to deliver needed health services in poorer areas. Furthermore, insofar as unnecessary hip replacement operations may also be potentially harmful, this may be unfair on people in richer areas. In conclusion, area-level analysis of data on publicly funded hospital activity does seem capable of providing interesting and useful cross-country comparisons and longitudinal monitoring of socioeconomic inequality in the delivery of specific health services. This kind of analysis can help local and national decision makers break free from parochial self-referential inertia by providing a broader international perspective on both the level of provision of a particular health service and its socioeconomic distribution within different societies. Findings must, however, be interpreted cautiously with due regard to the limitations of this approach. In particular, findings are less reliable when (i) numbers of areas are small (as in Slovenia), (ii) between-area differences in income are small compared with within-area differences (as in Slovenia, and to a lesser extent Denmark and Portugal), (iii) the share of privately funded services is high (as in Portugal) and (iv) there may be missing data on publicly funded operations performed in private facilities (as in Portugal). Although this kind of analysis cannot provide definitive answers, it can raise important new questions for policy makers. For example, two important questions arising from this study are: (i) why is there pro-rich-area inequality in hip replacement in both England and Spain and (ii) was the substantial but non-significant rise in pro-rich-area inequality in hip replacement in England and Spain just a statistical 'blip', or will it continue to increase in future years? --- Supplementary data Supplementary data are available at EURPUB online. Conflicts of interest: None declared. --- Key points International studies using survey data have found pro-rich inequality in specialist medical visits and other general health services used regularly by a large proportion of the population. This is the first international study to use hospital data to monitor inequality in a specific health service-hip replacement. Our approach includes all publicly funded hospital activity but only examines inequality between administrative areas, rather than individuals.

Background: Cross-country comparisons of socioeconomic equity in health care typically use sample survey data on general services such as physician visits. This study uses comprehensive administrative data on a specific service: hip replacement. Methods: We analyse 651 652 publicly funded hip replacements, excluding fractures and accidents, in adults over 35 in Denmark, England, Portugal and Spain from 2002 to 2009. Sub-national administrative areas are split into socioeconomic quintile groups comprising approximately one-fifth of the national population. Arealevel Poisson regression with Huber-White standard errors is used to calculate age-sex standardised hip replacement rates by quintile group, together with gaps and ratios between richest and poorest groups (Q5 and Q1) and the middle group (Q3). Results: We find pro-rich-area inequality in England (2009 Q5/Q1 ratio 1.35 [CI 1.25-1.45]) and Spain (2009 Q5/Q1 ratio 1.43 [CI 1.17-1.70]), pro-poor-area inequality in Portugal (2009 Q5/Q1 ratio 0.67 [CI 0.50-0.83]) and no significant inequality in Denmark. Pro-rich-area inequality increased over time in England and Spain but not significantly. Within-country differences between socioeconomic quintile groups are smaller than between-country differences in general population averages: hip replacement rates are substantially lower in Portugal and Spain (8.6 and 7.4 per 10 000 in 2009) than England and Denmark (20.2 and 27.8 per 10 000 in 2009). Conclusion: Despite limitations regarding individual-level inequality and area heterogeneity, analysis of area-level data on publicly funded hospital activity can provide useful cross-country comparisons and longitudinal monitoring of socioeconomic inequality in specific health services. Although this kind of analysis cannot provide definitive answers, it can raise important questions for decision makers.

INTRODUCTION The population of American adults >65 years of age increased from 12.4% to 15.2% from 2000 to 2016 [1]. In the elderly, social and family support are associated with the preservation of functional ability. 'Social isolation' is an objective measure of a lack of social interactions/engagement and contact with family or friends and is well documented in older adults. Studies have demonstrated a positive effect of social engagement in the elderly, with men particularly affected [2]. Mechanisms by which social engagement improve well-being include dissemination of health-related information, provision of illness coping strategies and promoting healthy attitudes, behavior and self-worth. A lack of social contact is associated with cardiovascular disease, cerebrovascular disease and dementia [3], problems that are also highly prevalent in chronic kidney disease (CKD). In addition, social isolation is temporally associated with mortality in the elderly, as shown in a meta-analysis of 70 studies (3 407 134 participants) with a mean follow-up of 7 years, where social isolation was associated with a 29% increased relative risk for death [3]. Social isolation has been reported in patients undergoing dialysis [4] and in transplant recipients [5], but in pre-dialysis CKD, the prevalence of social isolation and its risk factors has not been quantified. Between 21 and 25% of older adults have CKD Stages 3-5 [6]. CKD is often called premature aging, with a high risk of hospitalizations, decreased functional ability and overt disability. In the elderly without CKD, a risk factor for social isolation is mobility limitation. In 1321 participants in the National Survey of American Life, older age, male gender, those requiring less selfcare and higher mobility impairment were associated with social isolation from friends [7]. Another study showed that the Short Physical Performance Battery, a validated test for physical function in the elderly, strongly correlates with social isolation (r 1<unk>4 0.42, P <unk> 0.01). In CKD, multiple studies have shown poor mobility [8]. In the Health Aging and Body Composition Study, older adults with CKD were more likely to develop difficulty walking or climbing stairs compared with those without CKD, after adjustment for demographics [9]. Similarly, in the Framingham Offspring Cohort, those with CKD had 91% increased age-and gender-adjusted odds of developing mobility-disability over time compared with those without CKD [10]. The etiology of musculoskeletal disease and mobility impairment in CKD is multifactorial [11]. However, the contribution of mobility limitation to social isolation is unknown in CKD. We hypothesized that mobility limitation is a key driver of social isolation in males and females with CKD. To test this hypothesis, we determined whether mobility limitation explains differences in social isolation between those with and without CKD, when accounting for gender, using data from the Health and Retirement Study (HRS). --- MATERIALS AND METHODS --- Dataset The HRS is a longitudinal study, supported by the National Institute on Aging and the Social Security Administration, of a representative sample of community-dwelling, noninstitutionalized adults in the USA [12,13]. Data collection started in 1992 and a new cohort of individuals 51-56 years of age was added every 6 years, with a total of 13 waves of data collected on 43 478 individuals. At each time point, core surveys were collected about retirement, disability, occupation, industry, work environment, income, demographics, health conditions and healthcare utilization, cognition, physical functioning, family characteristics and insurance. For this analysis, we used data from the HRS 2016 core survey [14] as well as two datasets collected in 2016, the Venous Blood Study (VBS) with home blood collections [15] and the Psychosocial and Lifestyle Questionnaire (PLQ). In 2016, all HRS respondents were asked whether they would consent to a venous blood draw. The VBS cohort comprises respondents with valid data who consented to a blood draw and met with phlebotomists to provide a blood sample. The PLQ cohort is a 'half-sample' of the 2016 HRS respondents. The PLQ cohort comprises respondents who completed the PLQ and who provided venous blood samples in 2016. Therefore all participants in the PLQ cohort were part of the VBS cohort. The entire HRS is under current institutional review board approval by the relevant committees at the University of Michigan and the National Institute on Aging, the primary sponsor of the HRS. This analysis is approved by the institutional review board at the Indiana University School of Medicine. --- Predictors Kidney function was determined based on estimated glomerular filtration rate (eGFR). Serum creatinine was measured by the enzymatic method (Roche Diagnostics, Indianapolis, IN, USA) with calibration semi-annually to isotope dilution mass spectrometry standards [16]. eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation [17] and CKD Stages 3b-5 was defined as an eGFR 45/mL/min/1.73 m 2 and non-CKD Stages 3b-5 as an eGFR >45/mL/min/1.73 m 2. A measure of albuminuria was not available, so CKD cannot be excluded in those with an eGFR >60 mL/min/1.73 m 2. Also, given the single creatinine measure, the absence of data on albuminuria and the potential for 'normal' age reduction in eGFR [18], we chose a lower eGFR threshold (45 mL/min/1.73 m 2 for comparisons). --- Outcomes Our outcomes of interest were self-reported mobility limitation and standardized social interaction-related outcomes called'social contact' and 'participation in social activities'. Mobility limitation was measured by self-report of the difficulty in completing four different tasks: walking several blocks, walking one block, climbing several flights of stairs and climbing one flight of stairs. A mobility limitation index was created by summing all four tasks (0 1<unk>4 no difficulty, 4 1<unk>4 difficulty with all tasks). Social contact was quantified by a self-administered questionnaire, the Participant Lifestyle Questionnaire (PLQ), collected from a random half-sample of the population every 4 years. Questions included participation in general activities, relationships with others and views on life. Based on this survey, the outcome'social contact' is a measure of nonspouse contact with friends and family. Respondents were asked to indicate how often they met in person with their adult children, extended family and friends. The response categories ranged from 1 (less than once a year/never) to 6 (three or more times per week). A total 'frequency of contact' measure was calculated by averaging the three types of social contact. Higher values represented more social contact, whereas lower values represented more social isolation from friends and family. 'Social participation' was assessed by quantifying how often the subject participated in six social activities: taking care of grandchildren, volunteering for youth organizations, charity work, educational activities, social clubs and civic organizations. Responses ranged from 0 (never/not relevant) to 6 (daily). A global social participation measure was created by summing all six categories. --- Covariates Sociodemographic covariates included age, gender, race/ethnicity, formal education in years and marital status. Comorbidities were obtained by self-report: yes/no for hypertension, diabetes, heart condition, stroke and trouble with pain. Body mass index (BMI) was calculated from self-reported height and weight and 'obese' was defined as a BMI >30 kg/m 2. --- Statistical analysis Sociodemographic characteristics, self-reported mobility limitation and self-reported health conditions (comorbidities) were compared across CKD Stages 3b-5 versus non-CKD Stages 3b-5 using t-tests for continuous variables and chi-squared tests for categorical measures. Logistic regression with self-reported mobility limitation as the dependent variable and CKD Stages 3b-5 as the independent variable was performed. Two models were created for the relationship of components of mobility and the mobility index with CKD Stages 3b-5. Model 1 was adjusted for sociodemographic characteristics (age, gender, race/ethnicity, formal education in years and marital status) and Model 2 for sociodemographic characteristics and comorbidities (yes/no for hypertension, diabetes, heart condition, stroke and trouble with pain). For the mobility limitation index as the outcome, proportional odds ratios (ORs) were created due to the ordinal nature of the variable and cumulative probabilities were calculated. Interactions for gender differences in the effect of CKD Stages 3b-5 on selfreported mobility limitation were tested formally with differences in social contact in aging [19,20]. An interaction variable was created (i.e. female <unk> difficulty walking several blocks) and predicted probabilities were calculated and graphed. Model fit was assessed by likelihood ratios (LRs). For'social contact' and'social participation', ordinary least squares were used to test each of their relationships with CKD Stages 3b-5. Two models were built to test this association. Model 1 studied the relationship of CKD Stages 3b-5 and gender on social contact and participation adjusted for sociodemographic factors and comorbidities. In Model 2, self-reported mobility limitation was entered into Model 1 to evaluate whether mobility limitation explained any association between CKD Stages 3b-5 and social contact/participation. Model fit was assessed by R 2. A third set of models was created to test whether the effect of CKD Stages 3b-5 on social isolation varied by gender. In Model 3, an interaction term (i.e. female <unk> CKD Stages 3b-5) was added to fully adjusted models. A sensitivity analysis was performed for the relationship of CKD Stages 3b-5 with demographics, mobility limitation and social isolation using a more traditional cut-off for CKD Stages 3b-5 with eGFR > and <unk>60 mL/min/1.73 m 2. All analyses were weighted with the 2016 VBS scaled sample weights. Analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC, USA). --- RESULTS Subject characteristics for the analysed population are shown in Table 1, with the first section for the VBS respondents (N 1<unk>4 8806) and the lower rows showing variables from the PLQ subset (N 1<unk>4 3421). The mean age of the VBS sample was 69 6 8.9 years, with 13.2 6 2.9 years of education and 59% of the sample was married. On average, respondents reported having difficulty with one mobility limitation task, most commonly climbing stairs. Thirty-one percent of the sample reported difficulty walking several blocks. The mean eGFR was 75.5 6 22.3 mL/min/1.73 m 2. Ten percent of the study population met our definition of CKD Stages 3b-5 (eGFR 45 mL/min/ 1.73 m 2 ), whereas 29% had an eGFR <unk>60 mL/min/1.73 m 2. The most common self-reported comorbidity was hypertension, and 40% of the population reported pain. BMI was available on 8683 respondents and 33% of them were obese (BMI >30 kg/m 2 ). The sample size of the PLQ half-sample was 3421, and this is a subset of the VBS respondents. The average frequency of social contact score was 3.68, which corresponded to meeting up about once or twice a month. The average social participation score was 6.41 out of an observed range of 0-31 and thus respondents participated in social activities infrequently. The most common activity was taking care of grandchildren. Comparison of the VBS with the PLQ cohorts showed that there were differences in race and ethnicity, but no other measures (see Supplementary data, Table S1). Tables 2 and3 show results from the VBS respondents. Table 2 shows differences between those with and without CKD Stages 3b-5. Subjects with CKD Stages 3b-5 were significantly older, more likely to be male, reported significantly more mobility limitation for each indicator and had a higher overall mobility index compared with those with higher eGFR (all P <unk> 0.001). Those with CKD Stages 3b-5 also had a significantly higher prevalence of comorbidities and health conditions compared with the non-CKD Stages 3b-5 group, with the notable exception of pain. BMI as well as the percentage of obese subjects were not significantly different between those with or without CKD Stages 3b-5. In each model (with the exception of the fully adjusted one for difficulty climbing several flights of stairs), CKD Stages 3b-5 was significantly associated with increased odds of mobility limitation. Women had greater odds of mobility limitation across all measures in both models. We therefore examined an interaction between difficulty walking several blocks and gender. Women with CKD Stages 3b-5 had higher predicted probabilities of reporting difficulty walking several blocks compared with men (Figure 1). Figure 2 shows the predicted probability of reporting difficulty walking several blocks for women and men using a continuous, nonlinear measure (i.e. quadratic) of eGFR. An eGFR of 45 mL/ min/1.73 m 2 is associated with a visual decline in the predicted probability of difficulty walking several blocks in males and females. --- PLQ respondents Table 4 presents social contact and social participation scores for those with and without CKD Stages 3b-5 and were part of the PLQ cohort. Compared with those without CKD Stages 3b-5, those with CKD Stages 3b-5 participated significantly less in all activities (all P <unk> 0.01), with the exception of civic organizations, whereas those with CKD Stages 3b-5 and non-CKD Stages 3b-5 participated equally infrequently. Table 5 shows the models of estimates for both social contact and social participation (PLQ cohort). Model 1 is adjusted for sociodemographic characteristics and self-reported health conditions. Model 2 includes difficulty walking several blocks as an indicator of mobility limitation. CKD Stages 3b-5 was independently associated with a lower frequency of social contact (0.23 decrease on a scale of 1-6) and lower social participation (0.62 decrease on a scale of 0-6). When evaluating standardized betas of social contact (Model 2), CKD Stages 3b-5 had the second largest effect size (b 1<unk>4 <unk>0.07) next to female gender (b 1<unk>4 0.10). The introduction of difficulty walking several blocks in Model 2 did not explain the association between CKD Stages 3b-5 and our social isolation measures. For example, the estimated coefficient for CKD Stages 3b-5 in the social contact models was identical in Models 1 and 2 (see Table 5). The effect of CKD Stages 3b-5 on social contact and participation was not explained by mobility limitation; both measures were independently associated with social isolation, net of all other covariates. Women had higher social contact scores, but there was no difference in gender with social participation (Table 5). Gender did not moderate the effect of CKD Stages 3b-5 and mobility limitation on social contact/participation. The interaction term was not significant in either the social contact or participation models. In sensitivity analyses, we altered the definition of CKD to include all respondents with an eGFR 60 mL/min/1.73 m 2 compared with those with an eGFR >60 mL/min/1.73 m 2 for descriptive statistics (Supplementary data, Table S2). We also compared those with an eGFR divided at 60, as well as between CKD Stages 3b-5 (N 1<unk>4 998, 13% female), CKD Stage 3a (n 1<unk>4 1512, 15% female) and non-CKD (n 1<unk>4 6176, 70% female) for mobility limitation and social isolation (data not shown). The magnitude of differences in mobility limitation and social isolation between CKD Stages 3b-5, 3a and non-CKD did not attain statistical significance in some cases. The size of the comparison groups, as well as gender distributions within these smaller groups, may influence the levels of significance. --- DISCUSSION In the present analysis from the HRS, we examined mobility and social interaction assessed by social contact and social participation. Our results demonstrated that the coexistence of CKD Stages 3b-5 in this older adult cohort is associated with a reduction in all three parameters, but the data do not suggest that the mobility impairment is primarily responsible for the reduced social interaction in CKD Stages 3b-5 group. CKD Stages 3b-5 is associated with 1.44 times increased odds of difficulty walking several blocks compared with those without CKD Stages 3b-5, a 0.23 reduction in the frequency of contact (scale 1-6) and a 0.67 reduction in participation in social activities (scale 0-6). Mobility limitation (measured by difficulty walking several blocks) did not significantly change the relationship between CKD Stages 3b-5 and the frequency of social contact or participation. CKD Stages 3b-5 continued to be associated with a 0.23 reduction in the frequency of contact and a 0.62 reduction in participation in social activities, even with the addition of mobility limitation. There was also no significant improvement in the model R 2 with the addition of mobility limitation to CKD Stages 3b-5 in the models predicting social contact or participation. This is in contrast with much of the aging literature, where mobility impairment reduces social interaction [21,22]. In the National Survey of American Life population, lower mobility Social isolation in CKD | 607 (measured by ability to move in the home, stand for 30 min and walk a distance) was associated with a 21% increased risk of social isolation from friends [7]. In fact, a thematic analysis in the elderly showed that they participated in an intervention to increase physical activity because it improved their social interaction [23]. A possible explanation is that rather than mobility driving a lack of social interaction, other factors resulting from the CKD, such as fatigue, perceived disease stigma or increased medical visits, reduce social interaction in patients with CKD and poor mobility. Research in adult male rodents showed that social isolation results in a significant reduction in physical activity and decreases in activity-related sympathetic nerve system output, which leads to a decrease in aggressive behavior [24]. It could be that decreased physical activity in humans with CKD is an effect of social isolation and not a cause. Our data demonstrate that CKD Stages 3b-5 is associated with lower social contact (increased isolation) compared with those with a higher eGFR. To the best of our knowledge, this has not been previously documented in nondialysis-dependent CKD. However, social contact among patients undergoing dialysis has been described. A systematic analysis of seven studies from five countries in 123 young adults receiving dialysis described social isolation from others as a result of their kidney disease due to difficulties with their appearance or feeling'sick' [5]. These same reasons may exist in nondialysis-dependent CKD, and dietary and fluid restriction may further augment the social isolation. The consequences of social isolation in the elderly general population include frailty, falls, disability and mortality [24][25][26], outcomes increased in CKD patients [8,27,28]. In the CKD Stages 3b-5 group, it is interesting that the highest frequency of contact was with friends and not with family. In the elderly, social contact with friends, as opposed to family, was associated with increased physical activity [29], and yet CKD Stages 3b-5 respondents had lower mobility in the present study. We also found decreased social participation in older adults with predialysis CKD. This is consistent with the finding in the above study in young adults on dialysis where participants reported that barriers to engage in sports and education prevented them from feeling 'normal' [5]. Among the different avenues for participation in social activities in these adults >57 years of age, those with CKD Stages 3b-5 most often cared for grandchildren, although the frequency of caring for grandchildren was lower in those with CKD Stages 3b-5 compared with those without, presumably due to the poorer functional capacity of those with CKD. In the general population, studies have shown that caring for grandchildren helps prevent cognitive decline [30], although it is unclear if the same would be observed in the presence of CKD. Notably, social isolation has also been associated with an inflammatory state in communitydwelling individuals [31,32]. Studies have also shown that social factors affect the human transcriptome with both upregulation of immune function in inflammatory-related diseases such as heart disease, neurodegenerative diseases and some cancers, and down-regulation of immune response to infections [33]. Thus it is plausible that social isolation, whether social contact or social participation, may worsen the proinflammatory state of CKD. We found women with CKD Stages 3b-5 were 20% more likely than men to have mobility impairment. This is consistent with other studies in the aging population, where mobility measured subjectively or objectively is poorer in women [33]. Reasons ascribed for decreased mobility in women include a higher prevalence of disabling osteoarthritis-related pain, depression [34], a higher lifetime risk of stroke [35] and differential reporting of poor mobility [36]. A study of 512 women and 967 men with eGFR <unk>20 mL/min/1.73 m 2 showed that women were more likely to report joint pain compared with men [37]. In contrast, we did not identify any gender differences in social contact or social participation in our study. This is in contrast to the general population, where older men tend to be more socially isolated [2,38] and men's health is more negatively impacted from social isolation [2]. Factors leading to social isolation in CKD are likely different compared with healthy older adults and the effect of the disease process may not vary by gender. The strengths of our study include the sample size, the systematic recording of data elements, small amounts of missing data and collection of this novel measure of social isolation. Limitations include a lack of albuminuria (therefore the inability to exclude CKD in those with eGFR >60 mL/min/1.73 m 2 ) or repeated measures of creatinine to confirm progressive CKD. However, the use of a lower GFR (Stage 3b or 45 mL/min/m 2 ) implies the presence of clinically meaningful CKD. Furthermore, the prevalence of CKD Stages 3b-5 is consistent with studies in the general population for this age group, including the National Health and Nutrition Examination Survey [6]. Another limitation is that this is a cross-sectional analysis. The VBS was started in 2016 and follow-up data for our variables of interest are currently being collected, precluding longitudinal analysis. Finally, only half-samples were asked to answer the PLQ, therefore our sample size for the social isolation parameters is smaller than for mobility, possibly limiting our ability to assess the relationship. --- CONCLUSION 'Social isolation', an objective measure of the lack of social contact and participation in activities, is well documented in older adults and is associated with poor outcomes, including increased burden of falls, frailty and mortality in the elderly [25,26]. Poor mobility is considered one of the published etiologies for social isolation in the elderly. In this cross-sectional analysis of a large population-based study, we show that CKD Stages 3b-5 is also associated with lower social contact and participation in social activities, but mobility appears to be coexisting rather than causative, suggesting other causes of social isolation in CKD. These observations are important in the design of interventions at the community and individual level to improve mobility limitation and social isolation in CKD. --- SUPPLEMENTARY DATA Supplementary data are available at ckj online. --- AUTHORS' CONTRIBUTIONS R.N.M. and K.M.L. were involved in the conception and design of the study, in data analysis and interpretation and in drafting the manuscript. --- CONFLICT OF INTEREST STATEMENT The authors have no conflicts of interest to declare. The results presented in this article have not been published previously in whole or part.

Background. Chronic kidney disease (CKD) is associated with multiple comorbidities, hospitalizations and mortality. In older adults, social isolation and poor mobility contribute to these outcomes. We tested the hypothesis that a glomerular filtration rate (GFR) <45 mL/min/1.73 m 2 (CKD Stages 3b-5) is associated with social isolation and that mobility limitation is a key driver of social isolation in patients with CKD. Methods. Data from 9119 participants, ages 57-107 years, from the 2016 wave of the Health and Retirement Study's Venous Blood Study were used for this cross-sectional analysis. Kidney function measured by estimated GFR (eGFR) was the predictor and patients were classified as CKD Stages 3b-5 or non-CKD Stages 3b-5 (eGFR 45 or >45 mL/min/1.73 m 2 ). The outcomes tested were mobility limitation assessed by self-report and social contact and participation measures assessed by the Psychosocial Life Questionnaire. The associations among kidney function, mobility and social isolation were examined with logistic and ordinary least squares regression, adjusted for covariates and testing for interaction with gender. Results. Participants with CKD Stages 3b-5 (N ¼ 999) compared with non-CKD Stages 3b-5 were older (74.9 versus 68.2 years, P < 0.001) and fewer were female (15% versus 58%, P < 0.001). CKD Stages 3b-5 were associated with higher odds of difficulty walking several blocks [odds ratio 1.44 (95% confidence interval 1.16-1.78)]. Participants with CKD Stages 3b-5 had reduced social contact and social participation (B ¼ À0.23, P < 0.05; B ¼ À0.62, P < 0.05, respectively). Women with CKD Stages 3b-5 were 2.7 times more likely to report difficulty walking several blocks than men with CKD Stages 3b-5, but social isolation in CKD Stages 3b-5 did not vary by gender. In CKD Stages 3b-5 patients, mobility limitation was a risk factor for reduced social contact and participation but did not explain the poor social contact and participation. Conclusion. CKD Stages 3b-5 was associated with both mobility limitation and social isolation in a population-based study of older adults. In contrast to older adults without CKD Stages 3b-5, mobility limitation did not explain the lack of social contact and poor social participation, suggesting other factors are more important.

INTRODUCTION Researchers in sports psychology are interested in the topic of talent development and seek to identify high-performing athletes' key psychological characteristics. Such research has revealed that high-performers tend to employ various cognitive strategies to help them succeed (Weinberg and Gould, 2007). Other researchers have highlighted the importance of roles and the influence of social support networks on these athletes' development, especially when they are young (Wylleman and Lavallee, 2004). Wylleman and Lavallee (2004) developed a developmental model that frames athletes' sports career progression in terms of developmental perspectives, based on Bloom's (1985) three stages of talent development. Wylleman and Lavallee's model presents four different levels of an athlete's development through their athletic careers: athletic, psychological, psychosocial, and academic and vocational levels. The athletic level refers to the different stag-es of athletic development experienced during their careers (i.e., from initiation of sport to retirement from sport). The psychological level explains an individual' score psychological development based on Erikson's (1950) model (childhood to adulthood). The psychosocial level presents and the importance of the development of social support networks throughout the athletic career, and the academic and vocational level indicates athletes' developmental process in educational and professional areas. This model highlights the importance of support networks in athletic development. The authors suggest that there are different social support networks during different stages of an individual's development. For example, the model shows that, for teenage athletes, parents and coaches are the main support network during the adolescent's growth. Several studies have examined the influence of family members on athletes, such as the parents' impact on sport participation (Wuerth et al., 2004), parental pressure on adolescent athletes (Lee and MacLean, 1997), and family members' role in talent development (Côté, 1999). However, most of these studies have focused on identifying the influence of family members on an athlete's development, not on examining how athletes actually perceive these influences. According to Rosenfeld and Richman (1997), if support providers and receivers do not have appropriate exchanges, social support will not be as effective as it could be, because the receivers will not be satisfied with the type of support that was given to them. Therefore, it is necessary to examine athletes' perspectives on the different types of support provided by their parents, because understanding recipients' perceptions of support might aid in clarifying the types of support that are most effective to those athletes in various circumstances. This is especially important for teenage athletes, as previous findings have indicated that parental influences are particularly strong in these individuals. For example, some athletes experience burnout from sport because of pushy parents (Coakley, 1992). Based on the developmental model (Wylleman and Lavallee, 2004), parents maybe the most influential group for teenage athletes. Thus, it is important to identify the impact of parents' social support on young athletes, and examine the gap between the providers' (parents) and the receivers' (children) perspectives. The purpose of this study was to examine the experiences of parents of elite tennis players, the social support they provide their children, and the athletes' perceptions of their parents' influence and support. By examining the perspective of both teenage athletes and their parents, this study will help elucidate the gap between young athletes' perceptions and their parents' intentions of support. --- MATERIALS AND METHODS --- Participants Participants for the current study were young athletes and their parents. Twenty Korean junior tennis players age 11-14 yr (mean age: 12.6; 12 boys and 8 girls) were invited to take part in the study with the permission of their guardians. Their parents were also invited to participate in the study; 15 (4 fathers and 11 mothers) agreed to take part. The players were between 3 and 6 yr into their athletic careers (mean: 4.4 yr), and they trained for 24-40 h per week (mean: 30 h). The parents visited the tennis court 0-7 times a week (mean: 4 times) to see their children's training and competition. --- Procedure The present study employed a focus group method to collect data from both athletes and their parents, allowing the researchers to gain rich information from key informants (Stewart et al., 2007). A focus group was used for the current study for several reasons, which included the following: 1) a focus group is beneficial for examining little-known phenomena, 2) focus group allows researchers to divide participants into different subgroups so that they can be more easily categorized, and 3) through the focus group, researchers can observe group dynamics and interpersonal interactions. Semi-structured focus group topics were developed based on existing literature and theories (Rosenfeld and Richman, 1997;Wylleman and Lavallee, 2004). The focus group topics included 1) the influence of parents on athletic development; 2) behavioral, cognitive, and emotional experiences; and 3) positive and negative aspects of being athletes or athletes' parents. The current study employed purposeful sampling to select participants for four different groups. To examine both athletes' perceptions of their parents' influences and parents' perspectives of their role and influence on their children's athletic development, four focus groups were conducted: two athlete groups and two parent groups. The Korean Tennis Association provided contact information for potential participants, and the focus groups were held in two different locations (Munkyung: athletes, parents; Andoing: athletes, parents) between July and October 2013, at the participants' convenience. Before the focus group interview began, all participants signed consent forms while researchers provided information related to the study, such as the aims of the study and the potential risks and benefits. --- Analysis Each focus group lasted between 61 and 118 min (average: 84 min); the focus groups were recorded on both audio and video devices. The recorded files were transcribed verbatim, resulting in 48,998 total words in Korean. The data were analyzed by thematic analysis, in accordance with Patton's (2002) method. The analysis process contained four different steps: 1) reading and re-reading the original transcripts while watching and listening to the recorded file, 2) breaking down raw data into meaningful units, 3) categorizing meaningful units into first-order and higher-order themes, and 4) developing an outcome matrix that helped to explain relationships between the higher-order themes and directions of parental influence. To enhance trustworthiness of the current study, theory and analysis triangulations were employed (Patton, 2002). Theory triangulation (i.e., applying different models and theories from the existing literature) was derived from the development of the focus group topics and the analysis process. For analysis triangulation, two of the authors of the current study who were involved in the data analysis conducted a cross-reference check for each other's outcomes. In addition, a behavioral sciences expert conducted an audit-trial (Patton, 2002) that attempted to 1) examine the process of the overall research protocol, and 2) ensure that the results were developed from the original data. --- RESULTS The analysis identified 192 meaning units, 19 patterns, 13 first-order themes, and 9 higher-order themes related to experiences of being elite tennis players' parents, the social support they provided to their children, and the athletes' perceptions of the influences of their parents' support (Table 1). The findings of the current study are presented in two sub-sections: general findings and social support. General findings refer to information relating to the participants' experiences. Social support details the type of support provided to the athletes from both the parents' and children's perspectives, as well as how the athletes perceived the provided support (e.g., whether each type of support had positive or negative influences on their psychological well-being) (Table 1). --- General findings Four out of nine higher-order themes related to the experiences of the athletes and their parents, including initiation of their sporting career, expectations, satisfaction, and parental concerns. Both athletes and parents thought that parents influenced the initiation of the athletes' sporting careers. One father said, "I started to play tennis first and brought my son to free tennis class one day, and he continue to play..." However, athletes also discussed personal factors such as fun, and coaches' suggestions that led them to get involved in tennis at an early age. Both parties also discussed their expectations for one another. Athletes tended to seek pleasurable communication with their parents, wanted their parents to trust them, and expected their parents and coaches to provide the same information when discussing their tennis skills. One girl said, "I hope that my parents understood me and had some nice conversation [with them]." In addition, one of the girls hoped to avoid punishment from her father. Conversely, the parents wanted their children to enjoy their sport and have a balance between sporting and non-sporting lives. The parents also discussed the need for education programs for athletes' parents and coaches to address their lack of experience and the limited information available regarding effective ways to support young athletes. Athletes reported satisfaction regarding the support they received from their parents, such as caring for them and cheering them on in their daily lives. From the parents' perspective, they tended to enjoy watching their children's positive development in both physical and psychological areas. One mother said, "I think my daughter become much healthier and better in many ways after she plays tennis." Parents were happy to be a part of the team supporting their children's athletic success, and they enjoyed connecting with other athletes' parents at social events. On the other hand, parents reported concerns and worries about their children's future because not all young athletes become successful adult athletes. They also discussed their sacrifices to support their children's sporting dreams. One father said, "...only few people become world class athletes. Not sure whether my son can do it or not... but as a father, I believe my son and support him even he can't make it..." --- Social support Views on social support fit into the five different categories suggested by Murphy (2009): tangible, esteem, information, emotion, and network support (Table 2). Table 2 presents a matrix that was developed to explain how athletes perceived the support provided by their parents. This table helps to demonstrate that social support is not always positive for recipients, particularly if the support provided was not congruent with the receiver's needs. Tangible support involves parents' attendance at their children's training sessions and matches. Both parties mentioned this behavior, and some of the players said that they enjoyed their parents' presence during training and competitions. However, others stated that it made them feel pressure. One player said, "Sometimes I want to be myself. But my dad is always there. It is good if it happens once in a while but for every day? It makes me feel pressure." Other aspects of tangible support included supplying food and providing equipment for their sport. Athletes tended to be happy with this type of instrumental support. Esteem support also had both positive and negative influences on athletes' perceived psychological well-being. This type of support was considered positive when parents helped athletes to build their self-confidence, especially when they did not have a good match day. In contrast, athletes perceived that social comparison, especially when their parents compared their sons and daughters to other athletes, could hurt their feelings. One boy said, "My dad asks me to play like other players in my age. Even I am better player than them...I don't want to do that...sometimes I just want to quit [tennis] and leave my home." In terms of information, parents discussed how they enjoyed giving feedback to their children, especially when it was related to tennis. Athletes also reported that some information support from their parents was useful in developing their athletic career, both for physical skills and game strategies. Those athletes expressed gratitude for their parents' feedback. One boy said, "I like my mom to tell me how to play..." However, others stated that inconsistent information from parents and coaches confused them, and that it did not help them to concentrate on their sport. For this reason, some of the athletes wanted clearer and more consistent directions from their supporters, such as parents and coaches. One girl said, "My dad says something different from my coach... then I got confused, don't' know what to do..." Emotional support was one of the most commonly reported support types in both the parent and athlete groups. Parents reported that they intentionally attempted to provide positive feedback to their children in any circumstance, including training ses- sions and before, during, and after matches. Athletes also discussed that receiving positive feedback while training and competing had a positive influence on their emotional state. One boy said, "When I had a bad day...my mom comfort me...than [it] makes me feel much better." However, even if their parents provided positive verbal feedback, some athletes said that their parents' non-verbal signals would indicate negative reactions, which usually had a detrimental effect on them. They also mentioned that when parents put too much pressure on winning or suggested they stop playing tennis, it caused them to feel negative emotions. One girl said, "when I lost [my match] and talk to parents... it makes me feel guilty...it feels like shit...I really hate that..." Because parents and coaches are teenage athletes' main support groups, both parties discussed how network support was centered on communication among themselves and with coaches. Parents and athletes both expressed some satisfaction in their communications with each other, but they also reported that there were some difficulties in communicating with the other party. Athletes seemed to perceive communication as satisfactory when parents listened to what they said and put in the effort to understand their children's needs. One father said, "I try to monitor what my kid need...when I know it, all goes well." However, when parents tended to talk too much about tennis or tried to give too much information at once, athletes tried to avoid the situation by not responding. Regarding communication with coaches, parents tended to report a positive opinion. In contrast, athletes were not very happy when their parents and coaches communicated with one another, as their parents would often misunderstand the coaches' feedback, which could lead to arguments. --- DISCUSSION The purpose of this study was to examine the relationships between elite tennis players and their parents, both the social support the parents provide their children and the athletes' perceptions of the influences of their parents' support. The results revealed both positive and negative aspects of parenting an elite athlete, and that parental support could be grouped into five categories based on Murphy's (2009) model. Athletes perceived that all five types of support had both positive and negative influences on their psychological well-being. Similar to previous findings (Wuerth et al., 2004), athletes in the current study were influenced by their parents as to when they first started with their sport. However, the current study also revealed that school coaches played an important role in these young athletes choosing to stay in tennis. In addition, internally motivating factors, such as fun, were an important part of sport participation. The current findings showed that athletes' parents provided various types of support for their children, and athletes were also aware of receiving those different types of support from their parents. Among the five types of support, athletes perceived emotional support as the most effective because it helped them to feel better. Previous findings (Park et al., 2013) suggested that different kinds of support might be effective for different kinds of problems. According to Cohen and Wills (1985), social support could function as the "main effect" to help improve individuals' emotional, psychological, and behavioral status. On the other hand, support can be useless unless receivers are in a stressful situation for which the support is needed, a scenario called "stress buffering." Athletes in the current study might perceive their parents' emotional support as both a main effect and a type of stress buffering, as they mentioned the importance of being understood (main effect), as well as positive feedback after a bad match (stress buffering). In contrast, esteem support was less effective or less satisfactory to athletes because of the social comparisons made by their parents in an attempt to motivate them. This result highlighted that even in parents who expend significant effort to find ways to support their children, there might be a gap between the parents' and athletes' perspectives. For example, all athletes expressed unpleasant feelings when their parents attempted to motivate them by comparing them to other players. This finding supports Rosenfeld and Richman's (1997) argument that providers and receivers may have different perspectives regarding support, and that support could be useless or even have negative effects if it was not tailored to the receivers' actual needs. The current findings indicate that parents make a substantial effort to support their children; however, their support was not effective if it was not congruent with the athletes' needs. Therefore, evaluating the athletes' current status and needs might help in the development of more appropriate ways to assist and support young athletes. In addition, as shown in the results section, parenting an elite athlete might involve unique experiences; for this reason, organized educational programs could be beneficial to assist those parents who are trying to support their children. The current study was conducted with a homogeneous sample of Korean elite tennis players and their parents. Although we were able to collect rich information on the research topic, the results can only be applied to people who are in a situation similar to that of these participants. In addition, responses to questions about sup-Park S, et al. • Athletes' perceptions of parents support port may differ between individuals of different ages, types of sport, and sport contexts. Therefore, future research is needed to examine this issue in other groups of athletes and parents. Parents are one of the most influential contributors to young elite athletes' development, not only in their athletic careers but also in terms of their subjective well-being. The current study contributed to this area of study by revealing the importance of both providers' and receivers' perspectives in the effectiveness of social support. --- CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported.

The purpose of this study was to examine experiences of being elite tennis players' parents, social support they provided to their children, and athletes' perceptions of influences of their parents' support. Four focus groups (2 athletes and 2 parents groups) were conducted to collect data from both athletes and parents. The data were analyzed by thematic analysis and resulted in nine higher order themes including initiation of sporting career, expectations, satisfaction, parents' concerns, tangible, esteem, information, emotion, and network support. Later five themes which indicate kinds of support for athletes received from their parents were used to develop a matrix which can explain athletes' perceptions for each support they received from their parents. The findings revealed that there were some gaps between providers' and receivers' perspectives in effectiveness of provided support because some kinds of support were not effective when the support was provided without considering athletes needs. Therefore, the findings highlighted that support could be much effective if support providers for athletes consider athletes needs before they provide certain support to those athletes.

Background Antenatal care (ANC) is the care a pregnant woman receives during her pregnancy through a series of consultations with trained health care workers such as midwives, nurses, and sometimes a doctor who specializes in pregnancy and birth [1][2][3]. An analytical review of the recent World Health Statistics showed that ANC coverage, between 2006 and 2013, was indirectly correlated with maternal mortality ratio (MMR) worldwide. This indicates that countries with low ANC coverage are the countries with very high MMR [2,[4][5][6][7]. For instance, ANC coverage in United Arab Emirates was 100% with MMR of 8 per 100,000 and Ukraine had 99% ANC coverage and MMR of 23. By comparison, in sub-Saharan Africa, Ghana had ANC coverage of 96% and MMR of 380/100000, Chad had 43% ANC coverage and a MMR of 980/100,000, and Nigeria had ANC coverage of 61% and MMR of over 560. Nigeria's MMR is clearly above the African and global average of 500 and 210 respectively [8]. The poor maternal health outcome in Nigeria could be a result of poor ANC utilization [6,9] although ANC coverage may not provide information on the quality of care provided [10]. The importance of ANC services in the outcomes for pregnant women has been well documented [2,5,11,12]. ANC enhances early identification and management of conditions that could be threatening to the mother and her unborn child. ANC by trained skilled providers screens for infections, treats malaria, reduces the incidence of perinatal illness and death, provides birth preparedness, identifies signs of danger in pregnancy and plans to handle possible delivery complications through timely treatment and referrals [2,5]. It also reduces medical problems in pregnancy such as anaemia, hypertension, ectopic pregnancy, obstructed labour, eclampsia, excessive bleeding and premature labour and delivery [5,10,11,13,14]. In particular, a clinical audit of antenatal services in Nigeria found better maternal outcomes among women who had completed ANC than those who had not [5] though it may not directly reduce the risk of death [15]. Two nationally representative surveys were conducted recently in Nigeria: Nigeria Demographic and Health Survey (NDHS) in 2013 and National AIDS and Reproductive household survey (NARHS) in 2012 [1,3]. The two surveys showed that the proportion of pregnant women who had not attended any ANC services in Nigeria was 33.9% and 34.9% respectively. According to the 2013 NDHS, only 60.9% among women of child bearing age (15-49 years) who had a live birth in the five years preceding the survey received ANC from a trained skilled ANC provider (i.e., a doctor, nurse or midwife, or auxiliary nurse or midwife). Only half (51.0%) reported making four or more ANC visits during the pregnancy. About one third (36%) of births were delivered in a health facility while 38% of all deliveries within the five years were assisted by a skilled birth assistant (SBA) [1,3]. The attendance of ANC and delivery in a facility by a trained birth assistant are far lower than most other Africa countries [8,16]. In sub-Saharan Africa, overall 75% had at least one ANC attendance, 48% had 4 or more ANC visits and 48% of deliveries were supported by skilled birth attendants [8,17]. In comparison with ANC coverage in Nigeria, a neighboring developing country, Mali, had 57% of pregnant women having at least one prenatal contact with a skilled ANC provider within five years preceding the DHS in 2001 [18,19]. In another developing country, Indonesia, about 95% of pregnant women attended at least one ANC visit and 66% of women had four ANC visits within five years before the 2007 DHS [20]. This implies that Nigeria has not attained maternal health care success achieved over a decade ago in Mali and over 5 years ago in Indonesia. The questions are why are pregnant women not attending ANC in Nigeria? What are the limiting factors? What are the barriers? Studies have documented the socio-demographic and other factors affecting ANC use. Lincentto et al. identified inability to pay for ANC services or prescribed treatment as an important barrier to utilization of ANC [2], a finding supported by two other studies [20,21]. In situations where ANC uptake requires travel and long waiting hours, pregnant women and their families experience huge opportunity costs, such as the loss of income in order to attend services [2,22]. Long distances to health facilities as well as insufficient number of ANC providers at various ANC clinics negatively affect ANC utilization [23]. Several studies have identified rural-urban differentials in use of ANC in Nigeria and elsewhere [2,6,9,21,[23][24][25]. The higher ANC coverage in urban areas than in rural areas worldwide has been ascribed to inequities in the number of accessible health facilities [12,26]. In Nigeria, urban bias in public health expenditure, inadequate financing coupled with difficulties in attracting health workers to and retaining them in rural areas have limited government's ability to create an accessible communitybased health care system [26] which could reduce inequities in rural-urban health facilities. This scenario also occurs in other developing countries [25]. Family members of pregnant women as well as the community, have roles to play in ANC attendance. Their involvement in ANC utilization or otherwise affects use of ANC services. Families and communities often consider pregnancy as a natural process of life and therefore, underestimate the importance of ANC [2]. Misunderstandings, conflict or poor communication among formal and informal health care providers and with health service seekers may cause low utilization of ANC services in certain communities [2]. Unprofessional practices, attitudes and behaviours of ANC providers may further increase the nonutilization of ANC. Unprofessional conduct may include failure to respect the privacy, confidentiality, and traditional beliefs of the health seekers, [9,23]. There is a need to understand the reasons and in particular the limiting factors for the low rates of ANC uptake and by extension birth deliveries by a skilled provider in Nigeria. While several studies have identified determinants and factors affecting ANC utilization, very few have focused on documenting the barriers to ANC utilization from the perspectives of the non-users. This is probably due to the difficulties in collecting meaningful data from a reasonably large number of nonusers. The current study used data from over 2000 ANC non-users. Analysis is designed to identify and prioritize reasons given by respondents for not utilizing ANC facilities in Nigeria. --- Methods --- Data source We used the data from the 2012 National HIV/AIDS and Reproductive Health Survey (NARHS Plus II), [1] a cross-sectional study covering sampled men and women of reproductive age. Respondents were selected from rural and urban areas in all 36 states and the Federal Capital Territory (FCT) in Nigeria, as contained in the updated sample frame developed and maintained by the National Population Commission (NPC). Four-stage cluster sampling was used to select eligible persons. Selection of rural and urban localities from each state and the FCT at stage 1; at stage 2, Enumeration Areas (EA) within the selected rural and urban localities were selected; households were listed at stage 3 while stage 4 involved selection of individual respondents for interview. Thirty two individuals were sampled from each of the 30 sampled EA (clusters) from each state. Overall, 35,520 individual respondents were selected for final interview of which 31,235 individuals (88%) were successfully interviewed [1]. Other details of sampling methodology have been reported [1].The Institutional Review Board (IRB) of the National Institute of Medical Research, Nigeria granted ethical clearance to the survey instruments and materials prior to the commencement of the survey. Details of the ethical approvals have been reported earlier [1]. Of the 15567 women interviewed in the 2012 NARHS, only 6299 reported to have had at least one child within five years preceding the survey. About one third (34.9%), 2199, of the 6299 mothers declared not have visited any ANC providing facilities before. All analyses in this paper were based on the responses of these 2199 respondents. --- Variables The outcomes of interest in this study were the proportions of women who gave various reasons for not attending ANC during their last pregnancy. They were to answer "Yes" or "No" to reasons the possible reasons why they did not attend ANC. A "Yes" response implied "A big problem" while a "No" response implied "Not a problem". The assessed reasons were economic, social, cultural, individual, family and ANC service provider related. They include "Obtaining permission from Spouse", "Obtaining permission from Guardian/Parent", "Obtaining permission from Others", "Getting money to go", "Far distance from health facility", "Availability of transport", "Need an accompany/Can't go alone", "Provider is not of the same sex", "No skilled health worker in the hospital/ clinic", "Poor attitude of the health provider", "Can't guarantee confidentiality of information" and "Poor availability of good drugs at the facility". We then compared the reasons given among the sociodemographic characteristics which included: "wealth status -poorest, poorer, Average, wealthier and wealthiest", "educational attainment -no formal education, primary, secondary and higher (tertiary)", "marital statuscurrently married, formerly married and never married", "location of residenceurban and rural", "geo-political zones -North Central, North East, North West, South East, South South and South West", "age of respondent at birth was recoded into <unk>20 years, 20-24 years, 25-34 years and 35-49 years", "tribe -Hausa/Fulani, Igbo and Yoruba", "religion -Islam, Christianity and Others", "employment status -Employed and Unemployed". For all the variables, 5 responses given as "Don't Know" were excluded from further analysis. --- Statistical analyses Due to the multistage cluster sampling technique used in the random selection of the sampling units, we weighted the data by introducing a weighting variable. This was aimed at ensuring that the sample reflected population differences across the states and also avert over sampling of hard to reach areas and under sampling of large populations. The intra-cluster correlation was minimized through the use of effective sample size. We used descriptive statistics to describe the distribution of the socio-demographic and behavioral characteristics of the respondents not using ANC. Bivariate analyses of relationships between the characteristics and reasons given for not taking ANC services were conducted using Pearson Chi-square (X 2 ) test of association. Multiple response data analysis techniques were used to identify and prioritize the multiple reasons given by respondents for not attending ANC clinics. Multiple responses arise when more than one response may be given by the respondents to one question. Details on methodologies for handling the problem of multiple responses have been documented [27]. All statistical tests were performed at 5% significance level. We used STATA 13 and SPSS IBM 20 to analyze the data. --- Results The mean age of the respondents who did not use the ANC service was 29.1 <unk> 8.2 years and was not significantly different from age of respondents (29.4 <unk> 6.7 years) who utilized ANC (p > 0.05, not shown in the tables). In Table 1, rural dwellers were the majority (82.5%) of the mothers who did not use ANC during the period covered, 57.3% of them had no education and nearly all the non-users (93.0%) were either currently married or living with sexual partners. North East was the geographical zone in Nigeria with highest number of non-users as they had 42.1% compared with 3.6% in the South East. Nearly all, 96.5% of them, were employed while 50.6% were of Hausa/Fulani tribe. Also 43.3% of mothers in As shown in Table 2 and Figure 1, the problem of getting permission from the respondents' spouses to attend ANC were cited by 22.0% of the respondents, 14.3% had a problem getting permission from parents/guardian and 14.6% had a problem in getting permission from other family members, cultural or religious leaders. Over half (56.4%) of the non-users reported having a problem with getting money to go for the ANC services while 44.1% claimed that they did not go because transport facilities to the service providers were not available. The reasons given were significantly associated with most sociodemographic characteristics of the respondents except employment status. However, the problem of getting money to go for ANC services was not significantly associated with mothers' age or current marital status. In Table 3 and Figure 1, nearly half (48.8%) of the non-users did not go for ANC services because the providers were far from them. This varied significantly with their locations, 33.7% in urban and 52.0% in rural areas. This problem was significantly associated with lower educational attainment, poorer wealth status, Northern zones, ethnicity and employment status of the respondents. About one fifth (21.4%) did not go for ANC because "the service providers were of the opposite sex". This problem varied significantly with the socialdemographic characteristics of the nonusers (except employment status). Of the facility related factors, 25.5% did not attend ANC clinic because the clinics did not have skilled health workers, 24.1% because of poor attitudes of the workers, 20.0% because the non-users could not trust the workers with their personal information, and 22.6% because the facilities did not have good drugs for the attendees. The analysis of multiple responses presented in Table 4 showed that of the 2199 non-users, 55.7% claimed they had problems getting money to go to ANC facility, 48.2% reported having problem with the distance to the health facilities while 43.6% did not go for ANC because there wasn't any means of transportation to the facilities. Among all the reasons given for not attending ANC services, "Getting money to go" ranked single most important reason, been highest with 16.8% of all the problems, followed by "Distance from health facility" 14.4% and "Availability of transport to the facilities" 13.1%. These three reasons jointly constituted nearly half (44.3%) of all the reasons why the respondents did not use the ANC facilities. Health facility related factors comprising of unavailability of good drugs and skilled health workers, poor attitude and unprofessional conduct of the health workers made up 27.5% of the reasons why the pregnant women did not attend ANC services. The remaining 28.1% of the reasons for not attending ANC services were individual differences, family and societal reasons as shown in Figure 2. Elimination of the three most important problems would increase ANC coverage by about 15% while overcoming health facility loopholes could further boost ANC coverage by almost 9%. --- Discussions We determined and prioritized the reasons why nonusers of ANC chose not to access services in Nigeria. The highest non-users of ANC were found among the poor, rural, currently married, and less educated respondents from the Northern part of Nigeria, especially in the North East zone. Significant associations were found between the stated reasons for non-utilization of ANC among the respondents and socio-demographic characteristics. The reasons varied significantly with regards to respondents' economic status, educational attainment, residence, geographical locations, age and marital status. Our analysis revealed that some respondents with higher educational attainment, and also in the wealthiest quintiles, did not use ANC services during their last pregnancy. This indicated that ANC utilization was not only influenced by poverty and lack of information but also by other factors, such as seeking permissions from spouses and partners, beliefs, dispositions and views on quality and attitudes towards the ANC providers, and distances to health facilities. We found that three reasons were central to non-utilization of ANC services in Nigeria: "Problems with getting money to go health facilities", "Farness of ANC service providers" and "Unavailability of transport to reach the ANC providers". These three problems concern finance and logistics, and they collectively constituted nearly half of all the reasons why pregnant women did not use the ANC services. Therefore, the ANC coverage of 65.1% in Nigeria according to NARHS 2012 [1] might increase by 15.4% to over 80% if more ANC facilities were established and ANC services were made totally free across Nigeria. Of all the identified barriers to ANC utilization, inability to pay for the services was the most common problem preventing pregnant women from accessing the ANC in Nigeria. This finding is consistent with previous findings [2,9,[20][21][22]24,28]. United Nations reported that poverty is a major barrier to ANC utilization across developing countries [29]. A recent Zambia study [30] also found a strong connection between distance to a health facility, the ANC usage and the quality of ANC received. Previous studies have recommended that for the ANC coverage in developing countries to match the coverage in most developed countries, the ANC services should be made free and available especially in rural settings [2,21,23,29], with at least one ANC facility within every 15 km radius [30,31] and staffed with various healthcare professionals [2,30,32,33]. Factors related to health facilities included lack of good medications and skilled health workers. Poor attitude and unprofessional conduct of health workers made up over a quarter of the reasons why pregnant women did not utilize the ANC services. Other studies ascribed such findings to the fact that the previous personal experiences with ANC facility staff, or experiences narrated by women's friends or family members, may affect the care-seeking behavior [12,23,30,34]. Additional ANC coverage of 9.6% could be achieved if all existing health facilities were supplied with adequate drugs and manned by skilled health workers who exhibited professional attitudes and behaviours. We also identified that personal, family, societal and cultural factors affect utilization of ANC, this is in agreement with outcomes of a meta-analysis of qualitative studies reporting the views and experiences of a total of 1,230 women in 15 low and middle income countries who received inadequate ANC [28]. Authors of the latter concluded that any ANC programming at odds with both local theoretical and contextual beliefs and experiences may suffer under-utilization. Obtaining permission from spouses, family members, in-laws, society leaders to visit ANC facilities remains a problem in Nigeria [6]. Our findings were corroborated with the report entitled "Antenatal Care: Opportunities for Africa's Newborns" [2] which highlighted the need to establish meaningful contact between communities and facilities in order to increase utilization of ANC. In North Nigeria, especially the Eastern part, Islam is the main religion and most husbands practicing Islam forbid their wife going out without outright permission [6,7]. Factors related to family and society have been estimated to result in a nearly 10% loss in ANC coverage in Nigeria. There is need for partners and other family members to embrace the ANC and encourage it among pregnant women as their support can help women follow recommendations offered by the ANC providers, promote joint decision making among partners, and improve the health of mothers and newborns. --- Study limitations We used a secondary data which relied solely on ability of respondents to correctly recall and report past events without any means of further verification by the interviewers. The data might have suffered recall bias and other non-sampling errors. Data on some variables that could have been of interest to the researchers were not collected. --- Conclusions Affordability, availability, and accessibility of ANC providers are the most common problems facing utilization of ANC in Nigeria. Poor, rural women with limited education in particular face challenges in these. Joint efforts should be deployed to making ANC services attractive to and reachable by pregnant women and nursing mothers. These efforts should address financial and cultural barriers to ANC use, quality improvement to increase ANC services utilization and satisfaction, and maximal contacts between the woman, the service providers and the health services. Implementation of a free ANC policy, the establishment of more ANC public health facilities within a 15 km radius of every woman across Nigeria, and an emphasized focus on the WHO public health guidelines on ANC are the surest ways to overturn the low ANC coverage in Nigeria. The health facilities should be supplied with adequate drugs, manned by skilled health workers and the workers re-orientated to be professionals so as to win confidence and patronage of women and their partners. Priority must be given to recruitment and to efforts in retaining skilled health workers, and to their adequate supervision, training, knowledge and skills acquisition, and motivation in addition to establishment of health facilities, availability of drugs, equipment and other consumables. --- Competing interests The authors declare that they have no competing interests Authors' contributions AFF conceived the study, wrote the introduction, analyzed and wrote the results and the discussion. ESI facilitated the publication. Both authors proofread and approved the final version of the manuscript.

Background: In Nigeria, over one third of pregnant women do not attend Antenatal Care (ANC) service during pregnancy. This study evaluated barriers to the use of ANC services in Nigeria from the perspective of non-users. Methods: Records of the 2199 (34.9%) respondents who did not use ANC among the 6299 women of childbearing age who had at least one child within five years preceding the 2012 National HIV/AIDS and Reproductive Health Survey (NARHS Plus II), were used for this analysis. The barriers reported for not visiting any ANC provider were assessed vis-à-vis respondents' social demographic characteristics, using multiple response data analysis techniques and Pearson chi-square test at 5% significance level. Results: Of the mothers who did not use ANC during five years preceding the survey, rural dwellers were the majority (82.5%) and 57.3% had no formal education. Most non-users (96.5%) were employed while 93.0% were currently married. North East with 51.5% was the geographical zone with highest number of non-users compared with 14.3% from the South East. Some respondents with higher education (2.0%) and also in the wealthiest quintiles (4.2%) did not use ANC. The reasons for non-use of ANC varied significantly with respondents' wealth status, educational attainment, residence, geographical locations, age and marital status. Over half (56.4%) of the non-users reported having a problem with getting money to use ANC services while 44.1% claimed they did not attend ANC due to unavailability of transport facilities. The three leading problems: "getting money to go", "Farness of ANC service providers" and "unavailability of transport" constituted 44.3% of all barriers. Elimination of these three problems could increase ANC coverage in Nigeria by over 15%. Conclusion: Non-use of ANC was commonest among the poor, rural, currently married, less educated respondents from Northern Nigeria especially the North East zone. Affordability, availability and accessibility of ANC providers are the hurdles to ANC utilization in Nigeria. Addressing financial and other barriers to ANC use, quality improvement of ANC services to increase women's satisfaction and utilization and ensuring maximal contacts among women, society, and ANC providers are surest ways to increasing ANC coverage in Nigeria.

Introduction Case Notification Rate (CNR) per 100,000 population in Indonesia from 2015-2018 shows an increase from year to year. Over the past four years, 130 cases (2015) have increased to 139 (2016), 161 (2017), and 193 cases (2018) (1). This high CNR is one of the indicators of program success because of many cases of TB that can be identified and treated immediately. Unfortunately, the Treatment Success Rate (TSR) decreased during that period: From 85.8% in 2015 to 85.0% in 2016, 85.1% in 2017, and 80.12% in 2018 (1). This situation can impact the accumulation of people with TB, both who are still in the treatment process and those who have not started treatment. This means the general community's risk of exposure to mycobacterium tuberculosis increases even if they are disciplined and use masks. Central Java is one of the provinces with an increase in CNR from 118 in 2016 to 115.4 per 100,000 population in 2018 (2), whereas, at the same time, the TSR decreased from 86.0% (2016) to 83.7% (2018), far from the target of achieving a treatment success rate of 90%. Among 37 public health centers in Semarang City, the five with the lowest treatment success rate were Kedungmundu, Bangetayu, Pegandan, Ngemplak Simongan, and Purwoyoso (3). In addition to the high rates of treatment dropout due to inadequate knowledge of drug side effects, this decrease in TSR shows the inability and unwillingness of patients and suspects regarding TB due to the high stigma in the surrounding community (4). Low social support emerges from stigma associated with low literacy (5). "Women in the Urban Village" (PKK) is a voluntary organization active in the empowerment and welfare of families (PKK). As one of the leading programs of the PKK, they have an essential role in the field of health (6). In TB prevention, they should have good TB literacy to provide social support for the community in the region, especially for TB patients. Health literacy is a person's ability to access, understand, assess and apply information (7). Literacy is one factor that influences the occurrence of stigma in society. Common public domains are social distance, traditional prejudice, exclusionary sentiments, negative affect, treatment carryover, disclosure carryover, perceptions of dangerousness (8). Some of these terms need an explanation: Social distance describes that someone tries to avoid a person with TB (PWTB). It is a traditional stereotype and prejudice believing all people with TB are less valuable. Exclusionary sentiments tend to separate PWTB from everyone else or deny them their rights. Negative affects refer to emotional reactions such as disgust or hatred toward PWTB. Treatment carryover means being afraid of people knowing they were treated for TB in the past. The perceived need for secrecy may linger after a person recovers. Disclosure carryover is when people are afraid of their reactions if known to have TB. Perceptions of dangerousness are the idea that PWTB somehow represents a risk to society (8). --- Materials and Methods A total of 391 respondents filled out valid and reliable online questionnaires (see Annex) containing questions about demographic variables, TB literacy (20 questions), and stigma (20 questions). Respondents were the total number of women active in PKK in 5 public health centers. These primary data are bivariate and analyzed by the Rank Spearman Test (95% CI). The cross-sectional design of the study was conducted with the permission of the ethics commission No: 417/KEPK-FKM/UNIMUS/2020. --- Results Respondents of this study are divided as 24% of Bangetayu, 6.1% of Ngemplak Simongan, 23.5% of Kedungmundu, 9.2% of Purwoy-oso, and 36.8% of Pegandan. Most of the respondents were elderly (>=45 years old, 61.6%) and with high school graduation (70.6%). A majority (80.1%) were health activists and didn't have a family with a health background (71.1%). Only a small percentage of the respondents were teachers (11.0%), the majority housewives (71.1%), for details, see Table 1. Based on the Spearman rank test there is an association between TB literacy and stigma (p.0.001; r.0,165). Age is also positively correlated with stigma. (p.0,03; r.-0,110). --- Discussion Stigma against tuberculosis is a social determinant of health ( 9). Stigma has a potential impact on the health-seeking behavior of persons with TB, reducing the level of mask use, reducing the cure rate or increasing treatment dropouts, and rising patient stress so that the recovery rate also decreases (8). The number of elderly respondents who stigmatize a person with TB can be due to elderly's characteristics. In old age, they often experience mental problems such as patterns and attitudes to life, feeling lonely, worthless, and increasing emotions in the elderly (10). They also have more leisure time because they usually no longer work at this age. So they tend to spend time with their neighbors to talk about various issues, including a person with TB around them. A cadre is a community member who voluntarily assists in implementing health programs in the community. Cadres are more active in health programs than other members of the community. According to the Indonesian health department, cadres are local citizens selected and reviewed by the community and work voluntarily (6). In fact, they have a significant role in creating a supportive atmosphere for people with TB. However, this study shows that some cadre/health activists still stigmatize persons with TB. The cadre/ health activist can discover TB suspects, be drug swallow supervisors, even act as educators improving literacy and public knowledge about tuberculosis. For example, some previous studies increased knowledge significantly in homemakers with high school education (11). Stigma against TB in some areas still shows a reasonably high score, even up to 32 and more. Factors significantly associated with stigma are age and married status (12). Our research shows thatrespondents had difficulties finding and using information about TB. Similar to the previous study (12), where most workers in Semarang city found it more challenging to find information than to understand and to apply (13). Today's society lives in the era of technology where everyone has a device. Various information, including health information, becomes effortless to find through websites, social media, chat rooms, etc. Unfortunately, this flood of information makes it difficult for the public to judge whether specific data is fact or a hoax (14). Thus, health literacy is necessary to make judgments and decide in daily life regarding health care, disease prevention, and health promotion to maintain or improve the quality of life (15). The stigma by the environment ofpersons with TB, especially by their families, can affect the healing process. Patients need motivation, social support, and low stigma to complete treatment (4,16). Public Health Centers are advised to improve the TB literacy of female activists in socialgroups like PKK so that community stigma can be controlled. If activists have adequate literacy, they will jointly influence the general public to remove the stigma against persons with TB. Moreover, counseling can accompanypersons with TB during treatment to stabilize their psychological condition (17).Meanwhile, community leaders and religious leaders need to provide direction so that the community can have a positive atmosphere, provide a supportive social environment for persons with TB and decrease Multi-Drug Resistance. --- Conclusions The stigma shown towards persons with-Tuberculosis (TB) needs to be reduced and even eliminated to support TB patient treatment. Women activists in a social group called "Women in the Urban Village" (PKK) with adequate literacy will influence the wider community not to stigmatize persons with TB. Also, counseling TB patients themselves is needed to overcome psychological pressure due to stigma in society. With the intervention from these two sides, the success of TB treatment will be faster and easier to achieve.

The Case Detection Rate of Tuberculosis (TB) in Semarang city increased from 2014 to 2018, while the Treatment Success Rate declined. Low literacy can trigger stigma in society, especially among women, resulting in low awareness of suspect TB for treatment.The aims are to analyze the correlation between TB literacy and stigma expressed among female health and social activists. Methods: Cross-sectional research was conducted in five public health centers with the lowest Treatment Success Rate (TSR). A valid and reliable self-administered online questionnaire collected data that involved 391 respondents predominantly in the urban areas. Rank Spearman test was used to analyze the data with a confidence interval of 95%.The respondents were mostly elderly (>45 years; 61.6%), health activists with high school graduation, didn't have a family with a health background and did not work. Most of them showed low TB literacy (Me:60; SD±6.62) and high stigma (Me: 76; SD±10.36). They were also difficult to access, understand, assess, and apply information about TB. Age (p.0.03; r.-0.110), being health activist (p.0.081; r.-0.088), and TB literacy (p.0.001; r.0.165) correlated significantly with stigma. Conclusions: Public Health Center's officers require inserting literacy education materials related to stigma to form a comfortable support system for persons with TB.

Background On January 10, 2020, World Health Organization announced the identification of a new strain of coronavirus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing a mild to severe respiratory illness -which may progress to pneumonia and respiratory failure -named coronavirus disease 2019 (COVID-19) [1]. The first positive case of COVID-19 in Canada was reported on January 25, 2020 and a state of health emergency was declared across the country between March 13 and March 22, 2020, depending on the province [2,3]. Mid-August 2021, there were just over 1.4 million cases in Canada and more than 26,700 deaths [2]. Public health measures to control transmission have brought vast sectors of economic activity to a halt, leading to massive unemployment and reductions in income, while reducing people's daily movements and opportunities for in-person social interactions [4]. This has affected people's opportunities and access to resources that sustain mental health and well-being. The COVID-19 conditions reinforce the role of various social and environmental health determinants, with differential impacts on the mental health and well-being of populations, depending on age [5], gender [6], housing conditions [7], education [8], job type [9], income [10], or ethnic background [11][12][13] and, more generally, social and environmental contexts [14,15]. COVID-19 conditions including lockdown, curfew and physical distancing measures reduce social contacts, increase social isolation and feelings of loneliness, and decrease levels of social support; these dimensions directly influence well-being and mental health [16,17]. Canadian data shows pandemic-related increases in social isolation, domestic violence and anxiety [18], with certain groups such as teens, older adults, women and racialized communities particularly at-risk [19]. Daily mobility and related physical activity are reduced through confinement measures and reduced activity spaces have been linked to depressive symptoms [20,21] and sleep troubles [22]. Walkable environments and access to green space are key environmental conditions linked to positive health outcomes including physical activity and well-being [23]. With shrinking activity spaces and policy constraints curbing daily mobility, the role of residential living conditions is further amplified. Marginalized populations often bear the burden of poor social and environmental living conditions and have been shown to be disproportionately affected by the socio-economic impacts COVID-19 [24,25]. Overcrowding or living in inadequate dwellings are important determinants of mental health and well-being; moreover, prolonged exposure to home environments during lockdown conditions further exacerbate these impacts [26,27]. Economic hardship, which is linked to income reduction and job instability, has heavily contributed to the mental health burden of Canadians, and is also related to housing instability and food insecurity [28,29]. In turn, detrimental health behavior such as alcohol or other substance use are increasing and are linked to poorer mental health outcomes [30]. In total, there is an urgent need to better understand, in particular, how the unintended long-term consequences of COVID-19 pandemic and mitigation measures, contextual conditions (e.g., housing conditions, neighborhood characteristics), and behavior (e.g., mobility, social interaction, sleep) are linked to mental health and wellbeing trajectories. Furthermore, impacts are likely to vary between population groups (for instance, according to gender, age, racialized communities, or deprivation level). We developed the pan-Canadian COVID-19: HEalth and Social Inequities across Neighbourhoods (COHE-SION) Study to better understand how the COVID-19 pandemic affects health, key determinants of health, and health inequities, with a focus on mental health and well-being. This study will provide longitudinal evidence of how these change over time and across different provinces in Canada. COHESION adopts a built environment and health framework (Fig. 1) recently published by its team members [31]. This framework positions mental health at the intersection of individual level attributes, health behaviours, and contextual factors. Contextual, or neighbourhood factors include physical (e.g. accessibility to green space, transportation infrastructure, and other healthpromoting resources), and social characteristics (e.g. social deprivation, social cohesion). These factors directly influence mental health, but their primary impact is indirect, mediated through behavioural pathways. Figure 1 highlights the critical disruption points triggered by the COVID-19 pandemic. In the context of the COVID-19 pandemic, the COHE-SION Study aims: • evaluating the direct impact of physical and social neighborhood characteristics on mental health and well-being trajectories, while controlling for individual-level health behaviors and socio-demographics; • evaluating if and how physical and social neighborhood characteristics may modify the associations between individual-level predictors and mental health and well-being trajectories. The current paper has two main objectives: (i) to present the design and methods used in the two phases of the COHESION study, and (ii) to present descriptive statistics from the longitudinal follow-up of the study's first phase, as a basis to discuss cohort characteristics and methodological issues. --- Methods --- Study design and recruitment The two-phase COHESION Study is a pan-Canadian prospective cohort study. COHESION Phase 1 was conducted between May 2020 and September 2021. COHE-SION Phase 2 will be launched in May 2022. All Phase 1 participants will be invited to participate in Phase 2, and additional recruitments (n = 10,000) will be done. After consenting to participate to the study, participants are invited to fill a short eligibility questionnaire. Inclusion criteria are being aged 15 years or above, currently residing in Canada, and reading or speaking English or French. Eligible participants are then invited to complete a baseline questionnaire. The recruitment for COHESION Phase 1 was launched on May 11 2020. We used a combination of methods that have proven successful from previous experience in recruiting population-based research project samples [33], including media communication (e.g., newspaper articles, radio interviews), social media promotion (e.g., Facebook, Twitter, Instagram, and LinkedIn), and outreach through partners' local networks (e.g., local health authorities that relayed the study on their website or through their newsletters). For COHESION Phase 2, we will further use quota sampling at the health region level, based on 2016's Census data (i.e., age composition, gender, income, educational attainment, and ethnic background). We engaged Potloc Inc., a tech-enabled consumer research company that conducts survey sampling through social networks (Facebook, Twitter, Instagram, LinkedIn), for [32] geo-targeting of respondents based on the sampling quotas. Potloc Inc.'s algorithm will push sociodemographic and geographically targeted online ads to our study until local quotas are attained (targets are monitored daily) and that 10,000 participants have thereby been enrolled. Furthermore, a geographical oversampling (n = 1,000) will be conducted in Nord-de-l'Île-de-Montréal (NIM) territory (Quebec), in partnership with the NIM's integrated health and social services center (CIUSSS-NIM). Enrollment and participation in the two-phase COHE-SION Study are voluntary, and a raffle of three prizes ($100 gift cards) is drawn every month for active participants for the duration of the study. --- Data collection In the subsequent paragraphs, we will explicitly indicate whether the information discussed pertains to Phase 1, Phase 2, or both phases to provide clarity for the reader. --- Involvement options For both study's phases, two levels of involvement are proposed. Participants can opt for: (i) participating in the online self-administered questionnaires only (baseline + invitation to follow up questionnaires); or (ii) participating in the questionnaires and downloading a mobile phone application to provide additional active and passive data (cf. 3.2.5). --- Baseline questionnaires Through the COHESION Study Phase 1 baseline questionnaire (35-45 min), participants report on: their sociodemographic characteristics (e.g., gender, ethnic or cultural background, education level, employment status, income, relationship status, and household composition); housing condition (e.g., house tenure, dwelling type and size, outdoor space) and satisfaction; physical (e.g., chronic disease diagnosis) and mental health conditions (e.g., anxiety and depression), and substance use (alcohol, tobacco, vape, and cannabis); COVID-19 infection status, vulnerability towards COVID-19, perception ofand compliance with COVID-19 mitigation measures, and pre-pandemic employment, income, substances use, loneliness, resilience, and social interactions. Additionally, a map-based questionnaire collects data on activity locations and social contacts (cf. Fig. 2). For parents, a supplementary module on mental health and perceptions of COVID-19 mitigation measures concerning adolescents and children who live in the household is administered (participants answer on behalf of children in their household). The COHESION Study Phase 2 baseline questionnaire will consist in one core (10 min) and two optional complementary Sect. (15 min each). The core baseline questionnaire includes: sociodemographic characteristics and key housing conditions; COVID-19 vaccination status, perceptions of COVID-19 pandemic and related mitigation measures; standardized modules assessing general health (first item of the 12-item Short-Form Health Survey) [34], well-being (5-item World Health Organization Well-Being Index, WHO-5 Index) [35], sleep credit (Pittsburgh Sleep Quality Index, PSQI, 4 items only) [36], and psychological distress (Psychological Distress Scale, Kessler-6) [37]; and an outdoor mobility and social interactions module. Optional complementary baseline sections include the map-based questionnaire on activity locations and social contacts (cf. 3.2.4) and additional in-depth questions on relevant themes: additional items retrieved from the Phase 1 baseline questionnaire (it means all items not already included in the Phase 2 core baseline questionnaire); standardized modules on loneliness (University of California Los Angeles, UCLA, 3-item loneliness score) [38], anxiety symptoms (7-item Generalized Anxiety Disorder, GAD-7) [39], depression symptoms (9-item Patient Health Questionnaire, PHQ-9) [40], resilience (6-item Brief Resilience Scale) [41], sense of belonging (Canada Community Health Survey, CCHS) [42], and physical activity (Godin Leisure-Time Exercise) [43]; items for assessing conspiracy beliefs. Slightly shorten versions of the Phase 2 baseline questionnaires (i.e., excluding questions about birth, cultural background, etc.) have been provided for participants coming from Phase 1 and wishing going on Phase 2. --- Follow-up questionnaires Follow-up questionnaires of the COHESION Study are short questionnaires (15 min). For Phase 1, they were first offered biweekly until August 2020, then monthly. COVID-19-related topics cover infection and/or vaccination status, perceived vulnerability, perception of and compliance with mitigation measures, position regarding vaccination, and conspiracy beliefs. Health-related questions focus on general health (SF-12, first item) [34], well-being (WHO-5 Index) [35], sleep credit (PSQI, 4 items only) [36], loneliness (UCLA 3-item loneliness score) [38], anxiety symptoms (GAD-7) [39], depression symptoms (PHQ-9) [40], psychological distress (Kessler-6) [37], and sense of belonging (CCHS) [42] (Table 1). Employment status, household income, and substance use are also documented. Additionally, participants are asked at each follow-up about any changes concerning their place of residence and housing conditions. Supplementary module on mental health and perception of COVID-19 mitigation measures concerning children or adolescents living at home is administered when applicable. At the question- naire administra- tion point X X X X X X X X X X X X X X X X X --- COVID-19-pandemic-related perceptions the past month X X X X X X X X X --- Substance use a Frequency questionnaire During the past 2 weeks X X X X X X X X X X a Four items: alcohol, cigarettes, vape, and cannabis. Follow-up questionnaire waves are named according to their week and year of release (for instance, "20/26" for the follow-up questionnaire proposed to participants in the 26 th week of 2020). For Phase 2, follow-up questionnaires will be split in a core ('light') and an optional complementary ('complete') sections, and will be offered every two months. It will include the same questions as for Phase 1, adding a standardized module for assessing physical activity (Godin Leisure-Time Exercise Questionnaire) [43]. Questions can vary between follow-ups, depending on the situation and priorities raised by the research team and our public health partners. Thus, these additional themes can focus on health insecurity (i.e., access to health care, prescriptions and medicine) [44], sleep troubles (PSQI) [36], food insecurity (10-item Health Canada Household Food Security Module) [45], and children's difficulties (if any) [45]. For Phase 1, follow-up questionnaire waves are named according to their week and year of release (for instance, "20/26" for the follow-up questionnaire proposed to participants in the 26th week of 2020). --- Use of VERITAS-Social to collect daily mobility and social interaction data One of the specificities of COHESION is that it integrates, in baseline and follow-up questionnaires of the two phases, the Visualization and Evaluation of Route Itineraries, Travel destinations, Activity spaces and Social interactions (VERITAS-Social) questionnaire. For COHESION, it was adapted to locate a possible list of up to 20 activities carried out during the past seven Fig. 2 Collecting data on living and activity places with VERITAS-Social. Screenshot from the VERITAS application (map-based survey toolpermission given from Polygon Inc.) for a fictional participant; the house icon locates the participant's residential address and the pin icons symbolize the visited places located by the participant days (Fig. 2). As previously described, VERITAS-Social is an interactive map-based questionnaire that jointly collects an individual's social network and activity locations [46]; it is an adaptation of the VERITAS tool, an interactive questionnaire for geo-locating places, and related information of interest (e.g., frequency of visit, transportation modes used) [47]. It uses a Google Map module to facilitate the location of activity places. The social module asks if an activity location is generally visited alone or with someone else; participants can identify one or more individuals, or a group of people (see S1a-b Figs). In other words, it is a name generator that identifies network members based on their copresence at reported destinations [48]. Data on network members include age, gender, type of relationship (e.g., friend, acquaintance), frequency of interactions, and duration of the relationship; for groups, data includes the number of people in the group, and the duration of the relationship. Once all activities, corresponding locations, and all people with whom these activities are carried out have been reported, participants are asked to identify members of their social network from whom they receive support or with whom they enjoy spending time with, including members who may not have been reported among the people seen at usual activity venues. Finally, participants were able to indicate interpersonal relationships between network members (i.e., who knows whom), and whether some specific individuals belonged to documented groups. In Phase 1, the VERITAS-Social questionnaire was mandatory for all participants. To optimize the representativeness of our sample, we adapted our approach in Phase 2 by making this questionnaire optional. --- Optional mobile application Participants enrolling in the mobile phone arm of the study were invited to download Ethica Data mobile application (cf. 3.2.1), used successfully in previous research projects [49]. Once installed and launched, the application passively monitors location and mobility (e.g., stationary, in vehicle, walking, or biking) using GPS data (1 min of data collected every 5 min), physical activity (step counter), and social contacts (other smartphones), derived from listings of other Bluetooth discoverable devices in the participant's surroundings (for more details see [50]). The app further prompts participants to complete Ecological Momentary Assessment (EMA) questionnaires three times a day for one week every month. EMA questionnaires include short self-reports (<unk> 1 min) on well-being, sleep, mood (Short Mood Scale, 6 items) [51], and social interactions (see S2 Fig). --- Environmental data Because some of the data collected is spatial (e.g. place of residence, VERITAS-Social locations, mobile app GPS data), we are able to add area-level environmental data to our dataset. This allows to explore links between individual-level measures and social and environmental contextual conditions. Numerous environmental datasets covering Canada are available through the Canadian Urban Environmental Health Research Consortium (CANUE), which can be linked to our dataset using the 6-position postal code -a key identifier for all participants. Contextual variables of interest include measures of neighborhood deprivation, such as the Material and Social Deprivation Indices (MSDI; data 2016) available at the Canadian Census dissemination area level (i.e., the smallest Canadian standard geographic area, with a population of 400 to 700 persons) [52]. These two composite indexes combine Census data on educational attainment, employment ratio, average income, and household composition. The urbanization degree is measured using Statistics Canada classification (at the four-digit code area level; data 2016), based on the number of inhabitants in population centers [53]. "Small", "medium" and "large" urban population centers correspond to areas embracing between 1,000 and 29,999, between 30,000 and 99,999, and 100,000 and more inhabitants, respectively, while "rural area" is a residual value gathering all areas located outside population centers. Greenness is evaluated using the growing season Normalized Difference Vegetation Index (NDVI) (at the six-digit code area level; data 2019), based on Landsat 8 satellite data [54,55]. Area-level walkability is measured using the Canadian Active Living Environments (CAN-ALE) database [56]. Additional localized and temporalized data on COVID-19 pandemic conditions, including lockdowns, curfews, vaccination plan, number of cases, and emergence of variants is also available through the Canadian Institute for Health Information (CIHI) compilation [57]. --- Ethics and data management plan Before completing the eligibility questionnaire, potential participants are first invited to read the consent form and provide an electronic written consent to participate in the study. Informed consent was then obtained from all subjects and/or their legal guardian(s). In Phase 2, a second consent will be required from participant wishing to register for the prospective follow-ups after having completed baseline questionnaire. Phase 1 COHESION was approved by the ethics board of the Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM; MP-02-2021-8924) and by the Public Health Agency of Canada (PHAC) ethical review board (REB 2020-016P). Phase 2 COHESION was approved by both the ethics board of the Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM ; 2022-2327) and PHAC (REB 2020-016P). All methods used in the project were carried out in accordance with relevant guidelines and regulations. For data security and privacy proposal, all data are hosted on Compute Canada servers with secondary backups on hospital-grade internal servers. All data has been stripped from any personally identifying information, with only the principal investigator being able to track the records back to one participant. Researchers can access anonymized individual level records by connecting directly through a Secure Shell (SSH) to the database hosted on Compute Canada (a SSH allows remote machines accessing data in a secure way since the connection is encrypted). They can also access aggregated data for analysis through a secure online platform hosted by Tableau [58]. A document listing all the data management policies governing data access and storage has been submitted to the ethic board for approval. --- Results --- Recruitment and participants Among the 2,557 people who completed the COHESION Phase 1 eligibility questionnaire, 2,346 (92%) met the selection criteria (Fig. 3). Among these ones, 1,268 (54%) completed the baseline questionnaire and have been enrolled in the COHESION Study, and among the latter, 557 (44%) opted for the Ethica mobile application in addition to the online self-administered questionnaires. Although recruitment was continuously open during the Phase 1 timespan, the major part of participants joined the study during the first months following the study launch: 832 (66%) recruitments after three months of follow-up, 1,136 (90%) after six months (Fig. 4). COHESION Phase 1 participants are distributed all across Canada; they live mainly in Ontario (597, 47%) and Quebec (417, 33%) (Fig. 5), and 910 (72%) declared English as their first language. They are in average 48 <unk> 16 years (mean <unk> standard deviation, SD) and are mainly women (78% [vs. 50% in the total Canadian population]), White (85% [vs. 72%]), born in Canada (85% [vs. 78%]), with university or post-graduate level degree (63% [vs. 28.5%]), and in a relationship (67% [vs. 58%]) (Table 2). The majority of participants are homeowners (62%) and reside in a house (66%), living with their partner or family (74%). Most do not have children living at home (72%), have access to private outside space (97%), and own pets (56%), and are located in large urban centers (i.e., areas with over 100,000 inhabitants). However,ugh participants exhibit considerable contrasts in the greenness of their home surroundings and the level of material and social deprivation in their neighborhoods (Table 3). In descending order, participants employed (58%), retired (19%), unemployed (14%), on leave or disabled (5%), or students (2%). The majority are satisfied with their household annual income (77%) (Table 2). Regarding their health, 44% have been affected by at least one physical chronic disease (i.e., heart disease, lung disease, cancer, high blood pressure, diabetes, severe obesity, and/or autoimmune disease), and 35% have been affected by at least one mental chronic disease (i.e., depressive disorder and/ or anxiety disorder). A monthly consumption of alcohol, cigarettes and/or vape, and cannabis was reported by 72%, 14%, and 18% of participants at baseline, respectively. Lastly, they are 27% and 38% considering their selves and/or someone in their household at a high risk of being infected by-or of complications of COVID-19, respectively. --- Prospective follow-up and attrition Throughout the first year of follow-up, i.e., from May 2020 to July 2021, up to 17 follow-up questionnaires were administered to participants (Fig. 4), and 758 (60%) participants completed at least one (Fig. 3). Depending on their date of recruitment, participants were contacted between one and seventeen times as part of the prospective follow-up waves (Fig. 4), and they filled out in average 29% <unk> 36% (mean <unk> SD) of the follow-up questionnaires they received. Among the first year of follow-up, in average 298 <unk> 68 participants completed the follow-up questionnaire by wave (Fig. 6, see S1 Table ). Attrition rate throughout the Phase 1 follow-up appeared statistically distinct in some specific groups (Table 4). The older the participants were and the higher the education level was, the less the attrition was (p <unk> 0.001 and p = 0.069, respectively); average age was 50 <unk> 16 years and 45 <unk> 16 years (mean <unk> SD) in people participating or not in the longitudinal follow-up, respectively (p <unk> 0.001). Attrition appeared higher in employed people and lower in retired ones (p <unk> 0.001) (Table 4), and also higher in people living in family (p = 0.005), with children (p = 0.013), with pets (p = 0.001), in a house (p = 0.001), and not owner (p = 0.001) (see S2a Table ). --- Well-being and mental health From June 2020 to July 2021, we administered to participants well-being, sleep credit, loneliness, anxiety, depression and psychological distress -related standardized modules 5, 9, 13, 8, 8, and 11 times, respectively (Table 1). During this period, each thematic module was completed at least once by 481 (38%), 630 (50%), 658 (52%), 612 (48%), 612 (48%), and 692 (55%) Phase 1 participants, respectively (see S3a-b Tables). The median of the 5-WHO well-being Index ranged from 44% (interval interquartile, IQR: 24-65; wave 21/27) to 52% (IQR: 32-72; wave 20/52) depending on the wave. Well-being appeared decreasing waves after waves, the median index value from the last two administered waves (21/23 and 21/27, corresponding to June and July 2021), being significantly lower than those from the initial three waves (20/52, 21/15, and 21/19, corresponding to December 2020, April, and May 2021, respectively) (Fig. 7a; see S4a Table ). Sleep duration remained stable throughout the first year of the Phase 1 follow-up (mean <unk> SD: from 7.9 <unk> 1.3 to 8.0 <unk> 1.4 h; waves 21/23 and 20/30, respectively), with no statistically changes observed. During the prospective follow-up, the median of the UCLA 3-item loneliness score oscillated between 5 (IQR: 3-6; wave 21/27) and 6 (IQR: 4-7; wave 21/15). These variations were statistically significant, with heightened feeling of loneliness occurring from October 2020 (wave 20/44) to April 2021 (wave 21/15), except for wave 20/52, which coincided with the holiday season. Moreover, all UCLA 3-item loneliness scores during the follow-up were significantly higher than the retrospectively assessed median score for the pre-pandemic period (4; IQR: 3-6). Concerning mental health, the first year of Phase 1 follow-up showed statistically significant changes between questionnaire waves in reporting of anxiety symptoms, depression symptoms, and psychological distress (Fig. 7b; see S4b Table ). The GAD-7 median score ranged from 4 (IQR: 1-7; wave 21/27) to 5 (IQR: 2-10; wave 21/15), while the PHQ-9 median score varied between 4 (IQR: 1-7; wave 21/27) and 6 (IQR: 3-9.3; wave 20/30). For both composite indexes, the lowest median value was observed in wave 21/27 (2021, July), with some a According to Statistics Canada classification, "small", "medium" and "large" centers correspond to areas including between 1,000 and 29,999, between 30,000 and 99,999, and 100,000 and more inhabitants, respectively, while "rural area" is a residual value gathering all areas located outside population centers (at the four-digit code area level; data 2016) [ ). Follow-up questionnaire waves are named according to their week and year of release (for instance, "20/26" for the follow-up questionnaire proposed to participants in the 26 th week of 2020). Green flow shows participants responding for the first time to a follow-up questionnaire, blue flow shows participants responding again to a follow-up questionnaire, and grey flow shows participants not responding to follow-ups statistically significant differences noted among the waves. Lastly, the Kessler-6 psychological distress median score oscillated between 4 (IQR: 1-9; wave 20/52) and 5 (IQR: 2-10; wave 20/44); numerous comparisons of the psychological distress median scores from wave 20/52 (2020, December) to other waves showed statistically significant contrasts. --- Discussion --- Overview of findings More than 1,200 people enrolled in the Phase 1 of the pan-Canadian COHESION cohort, and about 60% of them participated in the prospective follow-up. The COHESION Study overrepresents women, White and graduated people. The first year of follow-up reveals significant temporal variations in standardized indices of well-being, loneliness, anxiety, depression, and psychological distress. --- Challenges. Lessons learned from phase 1, and proposed adaptations for phase 2 Addressing attrition Loss to follow-up is an issue in any longitudinal study. In Phase 1, attrition was related to age, education level, employment, housing conditions, and some health conditions, similar to other longitudinal studies [59,60]. To try to reduce attrition in Phase 2 and better retain those that are at greatest risk of loss to follow-up, we have devised the following strategies: (1) Reminders: Our questionnaire platform provides automated reminders for online follow-up survey completion including for EMA; (2) Flexibility: Phase 2 will offer easier participation options, relying on a multi-stage on-boarding process, which includes a short initial 10-min questionnaire and easy-to-sign-up longitudinal follow-ups, with possible 'light' or 'complete' choices. To increase accessibility, participation and retention (notably with younger participants), we have also optimized the online questionnaire for ease of use through smartphones. (3) Gifts: While enrollment and participation to the COHESION Study are free and voluntary, a lottery of 3 monthly prizes ($100 gift cards) is organized for active participants. In Phase 2, participants who choose the full participation (by completing the optional follow-up questionnaire modules) will be entered twice in the raffle to increase their chance of winning. (4) Improved feedback: In December 2020, an opinion survey was sent to participants to gather feedback on the experience of COHESION Study Phase 1, including on perceived complexity, length, and usability of the questionnaires, interest in surveyed topics, interactions with the mobile application. Suggestions for improvement included better messaging on the purpose of the study, including through regular updates and better recognition of their contribution, and sharing stories to increase the sense of belonging. These elements were considered when re-designing the study for Phase 2, in collaboration with the Center of Excellence 2013), promising approaches based on persona principles as those used in marketing strategies might help. Thus, we plan to tailor the content of newsletters, to strengthen the sense of belonging of those most at risk of dropping out, a strategy that has proved effective for re-engaging young and busy people [62]. Despite all these methodological efforts to minimize it, the risk of attrition can hardly be eliminated. One way to account for the potential effect of residual attrition bias is through various analytical strategies, including the use of inverse probability weights for trajectory analyses (e.g., growth curve models) on mental health and well-being. Beyond these measures, to further understand and adjust for any potential biases in our results, we have planned analyses stratified by age, gender, and specific individual socio-demographic characteristics. --- Inclusion of marginalized populations It is important to include marginalized populations better. We have worked in collaboration with public health partners to identify best recruitment strategies, including by building connections with local partners (e.g., Médecins du Monde, Red Cross, Food banks) that are working directly with various priority groups and have established trust with these individuals and communities [63]. The use of high-precision targeted social media campaigns, provided by partnering consumer research company Potloc Inc., along with continuous monitoring of stratified targets by region, age and gender, should also contribute to optimize sample representation. Now, because the survey uses online technologies that may be a barrier for participation in remote communities and for more marginalized groups, we will also offer computerassisted phone interviews (CAPI) during working hours through our study helpline. CAPI refers to a data collection method in which an interviewer conducts a structured survey over the phone while using a computer or digital device to guide the interview process and record responses [32]. --- Addressing the lack of pre-pandemic baseline One critical issue with our cohort that was launched in mid-spring 2020 is the lack of a true pre-pandemic baseline. This can partly be circumvented with retrospective questions, but as time goes by, the recall bias increases, particularly for subjective mental health measures [64]. In response to this, starting in fall 2020, we employed a two-fold strategy to reduce cognitive effort and bias. First we asked broader questions about psychological changes since the pandemic's onset (improvement, deterioration, no change). Second, we incorporated more factual questions with a lower likelihood of recall bias, such as the use of mental health services and substance use in the prepandemic year, which will be factored into our trajectory analyses. Despite these adaptations, the risk of recall bias remains, meaning that interpretation about change from pre-pandemic measures should be done with caution. --- Adapting surveys and advantages of prospective cohort design An advantage of a prospective cohort design is the potential for adapting surveys to new or unforeseen circumstances, including evolving priorities of public health authorities. As months passed by and the situation evolved, we developed and administered new modules to address such needs, including on substance use, a priority identified by our partner the Public Health Agency of Canada, or on parent-related stress during the back-to-school periods. Repeated surveys also provide the opportunity for timely dissemination of findings. To facilitate dissemination and use of data by our public health partners, we developed an online dashboard for real-time monitoring of key indicators (www. cohes ionst udy. ca/ dashb oard). Throughout phase 2 of COHESION, we will continue adapting our survey content with timely themes, helping uncovering key pathways linking individual trajectories, environmental contexts, and health and equity outcomes. --- Local adaptations and contributions to public health policies An important contribution of this project is to offer both a pan-Canadian portrait while allowing local oversampling and providing very contextualized information. An example of local adaptation is planned for public health territory of CIUSSS Nord-de-l'Île-de-Montréal (NIM) in Québec [65], with a target local sample of 1,000 participants. Data will be used to support the co-construction of tailored local intersectoral interventions towards mental health and more broadly to support activities towards health equity as part of a longer-term pandemic recovery strategy. While COHESION Study Phase 1 aimed to understand the mechanisms linking residential living conditions (built environment, surrounding greenness, neighborhood deprivation) to differential trajectories of mental health and well-being since the outbreak of the pandemic, Phase 2 is designed to offer decision support for public health authorities across Canada in varying context, including the pandemic recovery period. This period presents a valuable opportunity to apply the lessons learned from the peak of the pandemic and to examine how the social and physical environments continue to influence mental health in a post-pandemic context. By conducting our study across two distinct phases, we aim to capture a comprehensive understanding of these relationships in different pandemic contexts. This contextualized information on a potential representative sample of general population would be particularly important for policy makers as they address health inequities related to income, housing, daily mobility and social interactions, intimate partner violence, childhood, access to food and health care, and racism that have been exacerbated over the past two years. Ultimately, our findings will contribute valuable insights to the urban health field and inform future public health interventions. --- Limitations Regarding limitations, our recruitment methods and sample characteristics might compromise generalizability, even though Phase 2 intensified efforts to bolster representativeness. In this phase, we employed quota sampling across Canadian provinces and territories, anchoring our selection to demographics such as age, gender, and education. This aimed to align

Background With the advent of the COVID-19 pandemic, in-person social interactions and opportunities for accessing resources that sustain health and well-being have drastically reduced. We therefore designed the pan-Canadian prospective COVID-19: HEalth and Social Inequities across Neighbourhoods (COHESION) cohort to provide a deeper understanding of how the COVID-19 pandemic context affects mental health and well-being, key determinants of health, and health inequities. Methods This paper presents the design of the two-phase COHESION Study, and descriptive results from the first phase conducted between May 2020 and September 2021. During that period, the COHESION research platform collected monthly data linked to COVID-19 such as infection and vaccination status, perceptions and attitudes regarding pandemic-related measures, and information on participants' physical and mental health, well-being, sleep, loneliness, resilience, substances use, living conditions, social interactions, activities, and mobility.The 1,268 people enrolled in the Phase 1 COHESION Study are for the most part from Ontario (47%) and Quebec (33%), aged 48 ± 16 years [mean ± standard deviation (SD)], and mainly women (78%), White (85%), with a university degree (63%), and living in large urban centers (70%). According to the 298 ± 68 (mean ± SD) prospective questionnaires completed each month on average, the first year of follow-up reveals significant temporal variations in standardized indexes of well-being, loneliness, anxiety, depression, and psychological distress.The COHESION Study will allow identifying trajectories of mental health and well-being while investigating their determinants and how these may vary by subgroup, over time, and across different provinces in Canada, in varying context including the pandemic recovery period. Our findings will contribute valuable insights to the urban health field and inform future public health interventions.

designed to offer decision support for public health authorities across Canada in varying context, including the pandemic recovery period. This period presents a valuable opportunity to apply the lessons learned from the peak of the pandemic and to examine how the social and physical environments continue to influence mental health in a post-pandemic context. By conducting our study across two distinct phases, we aim to capture a comprehensive understanding of these relationships in different pandemic contexts. This contextualized information on a potential representative sample of general population would be particularly important for policy makers as they address health inequities related to income, housing, daily mobility and social interactions, intimate partner violence, childhood, access to food and health care, and racism that have been exacerbated over the past two years. Ultimately, our findings will contribute valuable insights to the urban health field and inform future public health interventions. --- Limitations Regarding limitations, our recruitment methods and sample characteristics might compromise generalizability, even though Phase 2 intensified efforts to bolster representativeness. In this phase, we employed quota sampling across Canadian provinces and territories, anchoring our selection to demographics such as age, gender, and education. This aimed to align our results more closely with the national population's makeup. Moreover, using elements from standardized tools, while tailored to ease participant burden and refine assessments, may bring potential uncertainties. However, we commit to thoroughly assessing the reliability and validity of these measures during our data analysis phase, striving for robust conclusions. Furthermore, our method of collecting pre-pandemic mental health data, while providing essential comparative value, might not fully portray our participants' pre-pandemic mental health scenarios. Transitioning from these lessons, Phase 2 includes refined strategies in response to our Phase 1 experiences, particularly the challenges posed by the mandatory VER-ITAS-Social data collection. In COHESION 2.0, we have adapted by making VERITAS optional. This adaptation enables us to strike a balance. While numerous studies predominantly zero in on residential determinants, we envisage a broader canvas -capturing the intricacies of individual activities and the wider environmental influences. This approach, naturally, poses its representativeness challenges, but we remain vigilant and proactive in addressing them. --- Conclusions Recognizing the interconnected nature of various factors impacting mental health, real-time monitoring and evaluation of the unintended consequences on mental health and health inequities of the pandemic is essential for shaping and adapting effective public health policies and programs targeting contextual living conditions (e.g., pedestrianization of streets, securing access to parks, housing renovation programs, permanent supportive housing programs, neighborhood greening program) [32,66]. We will benefit from the support of the Uni-Cité Collaboratory [67] which specializes in science-to-policy approaches -to equip research teams and cities with tools for better incorporation of scientific findings into urban public policy. Our study aims to provide valuable insights into the key pathways of the COVID-19 impacts on mental health and wellbeing across Canada while acknowledging potential limitations. Our flexible infrastructure ensures adaptability to local needs and the evolving situation as we transition from the pandemic to the post-pandemic recovery period, ultimately contributing to informed public health interventions. supervised data collection. SG wrote the initial draft of the manuscript. GM, YK, BT, RW, GS, CH, LL, ED and BN did critical review and revision of the draft. GM and YK supervised the research project. GM and YK obtained funding for the study. --- Funding The COHESION Study is supported by thePublic Health Agency of Canada(PHAC, Ref # 4500416825-450041483) and theFonds de Recherche du Québec en Santé (FRQ-S)and theMinistère de l'Économie et de l'Innovation du Québec(Ref # 52266), and has benefited from infrastructure support from theCanadian Foundation for Innovation (CFI, Ref # 41072). These governmental organizations were not involved in the study design, data collection, or decision to publish this manuscript. The content and views expressed in this article are those of the authors and do not necessarily reflect these organizations. --- Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available because they contain highly detailed individual location data about participants, but are available from the corresponding author on request. Sharing of location data will also require ethics approval from the requesting author's institution. --- Abbreviations --- COHESION COVID-19: HEalth and Social Inequities across Neighbourhoods --- Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s12889-023-17297-w. Additional file 1: Table S1. Participation in the COHESION Study Phase 1 throughout the first year of prospective follow-up (June 2020 to July 2021): detailed statistics (N = 1,268). Table S2a. To be continued. Table S2b. Comparison of participants enrolling or not in the prospective follow-up according to residential social and environmental measures (N = 1,268). Table S3a. Participation to the thematic questionnaire modules on well-being, sleep credit, and loneliness in the COHESION Study Phase 1 throughout the first year of prospective follow-up (June 2020 to July 2021, N= 1,268). Table S3b. Participation to the thematic questionnaire modules on anxiety symptoms, depression symptoms, and psychological distress in the COHESION Study Phase 1 throughout the first year of prospective follow-up (June 2020 to July 2021, N = 1,268). a I.e., headcount and percentage of participants having completed at least the corresponding number of follow-ups. Table S4a. WHO-5 Index, sleep duration, and UCLA 3-item loneliness score throughout the first year of prospective follow-up of the COHESION Study Phase 1: detailed statistics. Table S4b. GAD-7 score, PHQ-9 score, and Kessler-6 score throughout the first year of prospective follow-up of the COHESION Study Phase 1: detailed statistics. Figure S1a. Collecting data on each activity place with VERITAS-Social. There is the example of a fictional participant. Screenshot from the VERITAS application (map-based survey tool -permission given from Polygon Inc.). Figure S1b. Identifying people related to each activity place with VERITAS-Social. There is the example of a fictional participant. --- Authors' contributions GM and YK contributed to the study conception. SG performed data analyses. GM, YK and BT performed the project administration. GM, YK and BT --- Declarations Ethics approval and consent to participate Before completing the eligibility questionnaire, potential participants are first invited to read the consent form and provide an electronic written consent to participate in the study. Informed consent was obtained from all the participants and/or their legal guardians. In Phase 2, a second consent will be required from participant wishing to register for the prospective follow-ups after having completed baseline questionnaire. Phase 1 COHESION was approved by the ethics board of the Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM; MP-02-2021-8924) and by the Public Health Agency of Canada (PHAC) ethical review board (REB 2020-016P). Phase 2 COHESION was approved by both the ethics board of the Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM ; 2022-2327) and PHAC (REB 2020-016P). --- Consent for publication Not applicable. Competing interests YK holds shares in Polygon Research Inc., the data collection platform that is used for the COHESION study. Other authors have no competing interests to declare. --- Author details 1 Département de Médecine Sociale et Préventive, École de Santé publique de l'Université de Montréal (ESPUM), Québec, QC, Canada. 2 Centre de Recherche en Santé Publique (CReSP), Université de Montréal (UdeM), Québec, QC, Canada. 3 Univ. Lille, CHU Lille, Institut Pasteur de Lille, ULR 4483-IMPacts de l'Environnement Chimique sur la Santé (IMPECS), Lille 59000, France. 4 Centre for Surveillance and Applied Research, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada / Government of Canada, Ottawa, Ontario, ON, Canada. 5 Département de Médecine, Université de Montréal (UdeM), Québec, QC), Canada. 6 Centre de Recherche du Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal (CIUSSS-NIM), Québec, QC, Canada. 7 Département de Médecine de Famille et Médecine d'urgence, Université de Sherbrooke (UdeS), Québec, QC, Canada. 8 Département des sciences de la santé, Université du Québec à Rimouski, Québec, QC, Canada. 9 Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada. 10 Centre de recherche du CHU de Québec, Université de Laval, Québec, QC, Canada. • 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 --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background With the advent of the COVID-19 pandemic, in-person social interactions and opportunities for accessing resources that sustain health and well-being have drastically reduced. We therefore designed the pan-Canadian prospective COVID-19: HEalth and Social Inequities across Neighbourhoods (COHESION) cohort to provide a deeper understanding of how the COVID-19 pandemic context affects mental health and well-being, key determinants of health, and health inequities. Methods This paper presents the design of the two-phase COHESION Study, and descriptive results from the first phase conducted between May 2020 and September 2021. During that period, the COHESION research platform collected monthly data linked to COVID-19 such as infection and vaccination status, perceptions and attitudes regarding pandemic-related measures, and information on participants' physical and mental health, well-being, sleep, loneliness, resilience, substances use, living conditions, social interactions, activities, and mobility.The 1,268 people enrolled in the Phase 1 COHESION Study are for the most part from Ontario (47%) and Quebec (33%), aged 48 ± 16 years [mean ± standard deviation (SD)], and mainly women (78%), White (85%), with a university degree (63%), and living in large urban centers (70%). According to the 298 ± 68 (mean ± SD) prospective questionnaires completed each month on average, the first year of follow-up reveals significant temporal variations in standardized indexes of well-being, loneliness, anxiety, depression, and psychological distress.The COHESION Study will allow identifying trajectories of mental health and well-being while investigating their determinants and how these may vary by subgroup, over time, and across different provinces in Canada, in varying context including the pandemic recovery period. Our findings will contribute valuable insights to the urban health field and inform future public health interventions.

Introduction Attracting graduates was recommended as a means of diversifying the UK medical student population. Graduates now make up nearly a quarter of the total medical student population. Research to date has focused on comparing the sociodemographic characteristics of applicants to and/or students on traditional and graduate entry programmes (GEMs), yet GEMs account for only 40% of the graduate medical student population. Thus, we aimed to compare the sociodemographic characteristic and outcomes of graduates and non-graduate applicants across a range of programmes. Methods This was an observational study of 117 214 applicants to medicine who took the UK Clinical Aptitude Test (UKCAT) from 2006 to 2014 and who applied to medical school through Universities and Colleges Admissions Service (UCAS). We included applicant demographics, UKCAT total score and offers in our analysis. Applicants were assigned as graduates or nongraduates on the basis of their highest qualification. Multiple logistic regression was used to predict the odds of receiving an offer, after adjusting for confounders. results Irrespective of graduate or non-graduate status, most applicants were from the highest socioeconomic groups and were from a white ethnic background. Receiving an offer was related to gender and ethnicity in both graduates and non-graduates. After adjusting for UKCAT score, the OR of an offer for graduates versus nongraduates was approximately 0.5 (OR=0.48, 95% CI 0.46 to 0.49). Discussion Our findings indicate that the aim of diversifying the medical student population on socioeconomic grounds by attracting graduates has been only marginally successful. Graduate applicants from widening access backgrounds are less likely than others to be offered a place at medical school. Different approaches must be considered if medicine is to attract and select more socially diverse applicants. --- IntroDuCtIon Despite much activity, investment and policy directives, people from backgrounds perceived as disadvantaged and minority, ethnic and cultural groups, remain under-represented or excluded from medicine worldwide on the basis of, for example, their social class or ethnic origin. [1][2][3][4][5] In UK, the vast majority of medical students come from the highest socioeconomic groups, [6][7][8][9] and more than 20% of medical students have attended independent (usually fee paying) schools, compared with an average of 7% of all school pupils. 10 The professions have traditionally been dominated by those in high socioeconomic groups and this issue was summarised concisely in a report by the Independent Reviewer on Social Mobility and Child Poverty: 'Medicine... has a long way to go when it comes to making access strengths and limitations of this study <unk> A large multicohort study to look at the population of graduate applicants to UK medical schools, including those on graduate entry programme and traditional programmes. <unk> The study uses a contemporary dataset to examine the socioeconomic differences of those who apply to medical school; and it is important to know more about who applies, as medical schools can only select from the pool of applicants. <unk> The study examines what sociodemographic factors are associated with receiving an offer to study medicine and whether these differ in graduates and non-graduates. <unk> Measures of socioeconomic status are self-declared and there was a large proportion of missing socioeconomic data for the graduate subgroup. <unk> Allocating students to an occupational group that depends on their family circumstances (area, parental occupation) can be problematic, especially for mature applicants. Open Access fairer, diversifying its workforce and raising social mobility'. 10 In UK, most students enter medicine as school-leavers aged 17-20 years. In 1997, the UK Medical Workforce Standing Advisory Committee recommended that one way of diversifying the medical student population was to attract graduates into medical schools. 11 The assumption behind this was that, by accepting students with more life experience, the diversity of students and hence doctors would be increased [12][13][14][15] and this would result in more doctors willing to work in deprived and underserved areas. [16][17][18] This recommendation led to the introduction (in 2000) of the first 4-year graduate entry medical courses (GEM) as well as a more general drive to encourage graduates into medicine. Graduates now make up nearly a quarter of the contemporary UK medical student population. 13 19 However, to date, there is relatively little information relating to whether, or not, attracting graduates has increased the diversity of medicine in the UK. Earlier studies tend to be single-site and/or focused on the relative performance of graduates versus school-leaver entrants. [20][21][22][23][24][25][26] In an exception to this, Mathers and colleagues carried out a large-scale study of applicants to 31 UK medical schools between 2002 and 2006 in order to determine whether the newly introduced GEM programmes had widened access to medicine. 6 They concluded that graduate entry programmes do attract more students from less affluent backgrounds than traditional 5-year programmes but overall GEMs had not led to significant changes to the socioeconomic profile of UK medical student population. It is possible, however, that this study was undertaken too soon after the establishment of the first GEM programmes to assess their true impact, given the typical time lag between policy implementation and impact on practice in education. 27 Moreover, GEM programmes only account for about 10% of all medical programmes: there are more graduates in traditional 5-year programmes than in GEM programmes. Yet, to the best of our knowledge, no previous studies have looked directly at the whole population of graduate medical students-that is, those on both GEM and traditional programmes. Finally, most studies have only looked at those graduates who were successful in obtaining a place at medical school. 6 28 It is also important to know more about who applies, as medical schools can only select from the pool of applicants. 8 In one of the few studies looking at both applicants and admissions, Garrud found some differences between both applicants and admissions to graduate-entry and traditional programmes, mostly in terms of ethnicity, but did not examine differences in terms of socioeconomic markers. 29 This is, however, a complex area to investigate. There are issues surrounding these markers in graduate students, particularly given parental occupation is taken into account for school leavers, but occupation for graduates and older applicants may be that of the applicant themselves, particularly if they have been employed after leaving school or after a first degree. This ambiguity also holds for area of domicile (Index of Multiple Deprivation (IMD): measured by postcode) as again that may be of the parental home or the home of the applicant for mature students and graduates. However, to attempt to address these gaps in the literature, we used a contemporary dataset to compare the sociodemographic characteristics of graduates and non-graduate applicants to medicine. The main objective was to determine whether graduate and non-graduate applicants to medicine differ on a range of sociodemographic variables. Our second aim was to examine what sociodemographic factors are associated with receiving an offer to study medicine and whether these differ in graduates and non-graduates. --- MethoDs study context Data were obtained from the UKCAT database which comprises data from two sources: UCAS and UKCAT (http://www. ukcat. ac. uk/). UKCAT is the UK Clinical Aptitude Test for applicants to medical and dental schools. UCAS is the Universities and Colleges Admissions Service, a UK-based organisation whose primary role is to operate the application process for British universities. Through the UCAS system (https://www. ucas. com/), candidates can apply to up to four medical courses out of five options in any one cycle, but there is no preference order of course choice. We compiled data for all candidates who sat the UKCAT between 2006 and 2014 and who applied to medical school through UCAS. The UKCAT database only holds UCAS data relating to UKCAT candidates who have applied to a UKCAT University. Therefore, the data is a subset of graduate applicants to UK Universities. A number of graduate entry programmes use other admission tests (both BioMedical Admissions Test (BMAT) and Graduate Australian Medical School Admissions Test (GAMSAT)). Of the 16 graduate entry programmes in the UK, seven require the UKCAT, four require GAMSAT and 1 programme requires a BMAT. 30 The other four graduate entry programmes do not use any of these admission tests. Where UKCAT candidates have applied to non-UKCAT Universities, these choices and the outcome of these choices are not known. Although individuals can have multiple applications, within and between years, the sociodemographic variables presented in this study are per unique applicant. These variables include gender, ethnicity, secondary school attended, domicile (UK, International, EU). The socioeconomic status (SES) of the candidates was determined by parental National Statistics Socio-Economic Classification (NS-SEC) and IMD, an area-based measurement of material deprivation. --- Design and procedures Access to the data was via a safe haven 31 Open Access confidentiality when storing, handling and analysing identifiable data). Ethical approval was not required because the focus of this study was a secondary analysis of anonymised data. Applicants who took the UKCAT were notified that their data would be used for research purposes. Data files were merged into a single SPSS file for cleaning and analysis. The online supplementary file 1 illustrates a flow diagram showing how the data files were merged from different source documents. The applications were assigned into two categories, graduate or non-graduate, at the time of application. This was primarily based on applicants' highest qualification but some amendments were necessary. For example, where this information was missing, we imputed the outcome variable based on applicants' age and programme applied. For instance, all applicants aged less than 20 on their final UKCAT attempt were assumed to have applied shortly after leaving school; these were classified as school-leavers or non-graduate applicants. Similarly, applicants with missing information on academic qualification, aged over 21 and had applied for a graduate entry programme were classified as 'graduates'. The outcome measures were the UKCAT score and whether the applicant received an offer or not. We also considered all conditional and unconditional offers as an 'offer'. --- statistical analysis All the data were analysed using SPSS (IBM SPSS Statistics for Windows V.22.0, Armonk, New York, USA). The results are reported in terms of numbers, percentages and mean (SD) or median (IQR) as appropriate. The UKCAT scores were normally distributed. Therefore we used independent-samples t-test to compare the means between two groups. One-way analysis of variance was used to compare means between more than two independent groups. A binary logistic regression analysis was employed to predict the odds of getting an offer from an application based on an applicant's graduate status. The specific factors we adjusted for in the regression models were: socioeconomic status (NS-SEC and IMD), gender, graduate status, ethnicity and the total UKCAT score. The purpose was to assess the odds of receiving an offer for a graduate relative to a non-graduate after accounting for any differences in total UKCAT score. The analysis considered only the final application of each applicant to ensure independence (ie, to control for those who made repeated applications). --- results From 2006 to 2014, the UKCAT database comprises 117 214 applicants to medicine, applying through UCAS on a total of 146 146 occasions (ie, some applied in more than one cycle and hence sat the UKCAT more than once). The time-trend analysis shows that the proportion of graduate applicants to UK medical schools has risen from 8.5% in 2006 to 26.9% in 2013 (see online supplementary file 2, time-trend analysis). While dramatic, this increase is at least in part due to the increase in the number of institutions joining the UKCAT consortium and thus more data supply. 23.6% of the applicants were graduates and 76.4% non-graduates. In general, there were more female graduate applicants than male applicants. The median age for the non-graduate applicants was 18 years and it was 23 years for the graduate applicants. Table 1 summarises a comparison of graduate and non-graduate applicants by different sociodemographic factors. The main pattern across the two groups was that most applicants were from the highest socioeconomic group, with nearly 80% of all applicants having a parent/guardian in the managerial and professional occupations. The groups were also similar in that one-fifth of the graduate and non-graduate applicants had attended a fee-paying (independent) school. (However, note that type of school was only available for one-third of graduates and so this was not included in the later multivariable regression analysis with other covariates due to concern about bias and a lack of representativeness among graduates.) The sample was predominantly of candidates from white ethnic backgrounds, for both graduates (64.3%; n=14 014) and non-graduates (61.9%; n=47 103). Around 7.7% of the graduates were classified as international applicants, as compared with 12.1% of the non-graduate applicants. The number of EU applicants was similar for both graduates (6.0%) and non-graduates (7.6%). Non-graduate applicants performed significantly better on the UKCAT (2535.4 points, SD=268.2) than graduate applicants (2498.5 points, SD=285.7), P<unk>0.001. Graduates and non-graduate applicants from the top 20% affluent neighbourhoods (IMD 'I') obtained better UKCAT scores than applicants from the 20% most deprived areas (IMD 'V'). The difference was approximately 200 points for graduate applicants and the same margin was observed in the non-graduate group. A similar pattern was also observed with parental occupation classification (NS-SEC) categories with the difference of over 100 UKCAT points between managerial and professional occupations and routine/semiroutine occupations. The proportion of applicants who received offers was substantially lower for graduates (27.7%) than it was for non-graduates (47.9%). Graduate applicants who received offers had significantly better mean UKCAT scores (2697.7 points, SD=244.39) compared with their non-graduate colleagues who received offers (2657.7 points, SD=235.3), P<unk>0.001. The preadmission attainment information (UKCAT scores) is summarised in table 2. A binary logistic regression analysis was employed to predict the odds of getting an offer based on the applicant's highest qualification (graduate or not) and total UKCAT score. After adjusting for UKCAT score alone, the OR of an offer for graduates versus non-graduates was approximately 0.5 (OR=0.48, 95% CI 0.46 to 0.49). Several variables that were considered to be representative of widening participation backgrounds were included in univariate analyses. The multiple logistic regression analysis was repeated including, in addition to UKCAT Open Access and graduate status, only those variables that were statistically significant (P<unk>0.05) when associated with offer status. The specific factors were gender, ethnicity and socioeconomic class (IMD and NS-SEC). We also tested for interaction of these factors which enabled us to ask whether graduates from different socioeconomic backgrounds were more or less likely to receive offers. The overall model performance, using Nagelkerke's R 2 ranged from 0.20 to 0.23 across the models developed. Results of the two-way interaction terms (table 3) showed that after adjusting for other factors, the additional effect of socioeconomic disadvantage for graduates (compared with non-graduates) was small and did not reach statistical significance (P=0.69 for the interaction of graduate status and IMD; P=0.22 for the interaction of graduate status and parental occupation (NS-SEC)). The result suggests that the association between socioeconomic disadvantage and the likelihood of getting an offer for medical school affected graduates and non-graduates in a similar way. Figure 1 gives a graphical summary of the results from final model. In general, the odds of getting an offer to study medicine were lower if the applicant was male, graduate, from black and minority ethnic background and from lower socioeconomic groups (NS-SEC II-V and IMD 'V' -least affluent neighbourhood). Figures 2 and3 give a graphical summary of the OR after separating Open Access graduates and non-graduates, to help further illustrate the difference between the two groups. For the non-graduates, the pattern is almost the same as the combined model in that the odds of getting an offer were higher if the applicant was female, from white ethnic background and from high socioeconomic groups (NS-SEC1 and IMD I-most affluent neighbourhood). Some explanation for this pattern is because the non-graduates were in such a high proportion of the whole group. In comparison, for graduates, the predictor values that stand out are gender Open Access and ethnicity. However, notably, nearly a quarter of graduate applicants had a missing combination of socioeconomic profile data (NS-SEC and IMD) which may explain why SES measures were less important predictors for graduates. --- DIsCussIon In this analysis of a large, multicohort contemporary dataset, we examined differences between graduates and non-graduate applicants to UK medical schools. Unlike previous studies in this area, we compared a larger sample of graduate applicants with non-graduates, rather than comparing by course (traditional vs GEM). This allowed us to capture the characteristics of a broader group of graduate applicants compared with earlier studies. Our results show that graduate and non-graduate applicants to UK medical schools are very similar on a range of sociodemographic markers, including multiple markers of SES. This indicates that, even with time and much investment in GEM courses, the aim of diversifying the medical student population on socioeconomic grounds by attracting graduates has not been successful. 6 Interestingly, unlike previous studies, 29 we did not identify any differences across graduates and non-graduates in terms of ethnicity. This may represent a change in the medical student population overall or may be an artefact of study design given that we looked at graduates in all medical programmes, not just GEM programmes. We also looked at who received an offer. Put simple, non-graduates were twice as likely to receive an offer as graduates. The patterns across non-graduates and graduates were similar in terms of gender and ethnicity but, in non-graduates, offers to study medicine were higher if the applicant was from a higher socioeconomic group. However, measures of SES are self-declared and there was a large proportion of missing socioeconomic data for the graduate subgroup. This reflects patterns seen in other similar studies. [32][33][34][35][36] Given the high proportion of missing data, it would be misleading to conclude that IMD and NS-SEC are weaker predictors for assessing the likelihood of getting an offer among graduate applicants because many graduate applicants were excluded from the logistic regression analysis and the missing data could also have led to insufficient power to detect smaller effects. Moreover, allocating students to an occupational group that depends on their family circumstances (area, parental occupation) can be problematic, especially for mature students. 37 38 However, we had no other measures available to us: no matter how limited, 32 34 those used are the 'basic units' that indicate educational disadvantage in UK. We urge organisations such as UCAS and UKCAT to explore ways of improving self-declared data reporting and government bodies such as the UK's Office for National Statistics to explore more effective measures of SES. Overall, we found that graduates were proportionally less likely to receive an offer than non-graduate applicants and those graduates who were offered places had significantly higher UKCAT scores than their non-graduate equivalents. We know from earlier studies 29 and contemporary routine data that the average competition, or selection, ratios for GEM programmes are significantly higher than for traditional 5-year programmes. Moreover, GEM selection processes also tend to place more weight on UKCAT performance than do traditional programmes typically (this is associated with school leaving examinations being potentially less discriminatory for graduateswho would have taken these exams in earlier years, when it was less common to achieve top grades 39 ). These factors may explain this outcome. However, future research which compares selection ratios for non-graduates and graduates by programme would provide a more nuanced understanding of differences across groups. Additionally, future studies could also look more closely at graduate and non-graduate patterns of performance in the various stages of medical school selection for the high number of graduates applying to traditional programmes. For example, we do not know whether graduates and non-graduates with equivalent grades and UKCAT scores are invited to interview, then graduates 'fall down' at that stage. These studies would address concerns in the wider education literature that graduates and non-graduates are judged differently. 40 The present study has various limitations that must be taken into consideration when interpreting findings. It was not possible to compare prior attainment across graduate and non-graduate groups with any confidence in this study because of the different weightings given to school and degree qualifications. However, this is a tricky comparison at the best of times (see above-graduates by their very nature have taken the school leaving examinations which are typically used in medical selection to indicate prior attainment some years previous to their non-graduate counterparts). The issue of comparing 'apples and oranges' arises as over recent years the average A level score has progressively risen ('grade inflation'). 39 41 42 In conclusion, the aim of diversifying the medical student population on socioeconomic grounds by attracting graduates has been only marginally successful, with very minor positive trends in all areas. It may be that to draw a more diverse group of graduates into medicine requires different selection criteria for this group, one that places appreciable weight on the degree qualification and other graduate attributes, such as experience and passion for medicine. However, to change the selection process of graduates or indeed any group requires a shift towards affirmative action and/or a commitment to increase diversity. There appears to be little appetite for the former in the UK even though there is some evidence from other contexts that students from minority populations enrich the teaching environment of a medical school and may be more likely to practice in underserved areas. [43][44][45] on May 6, 2024 by guest. Protected by copyright. --- Competing interests None declared. Patient consent Not required.

Data sharing statement No additional data are available as the datasets are held in safe haven.

Introduction Respect for autonomy or respect for persons has tended to be the leading principle of biomedical ethics or research ethics, respectively. This principle historically has its roots in the liberal moral and political tradition of the Enlightenment in Western Europe. Within this tradition, the ethical justification of actions or practices strongly depends on the free decisions of individuals, i.e. an action or practice can only be ethically justified when undertaken without any coercive influence and entered by free and informed agreement. While there have always been disagreements on the details, all theories of autonomy agree on two essential conditions: the first is liberty, specifying the independence from controlling influences; the second is agency, referring to the capacity for intentional action [1]. Used in clinical ethics, autonomy functions primarily to examine decision-making in health care and serves to identify actions that are protected by the rules of informed consent, informed refusal, truth telling, and confidentiality [1]. Autonomy-based approaches are strongly expressed in Tom Beauchamp and James Childress' classic text Principles of Biomedical Ethics for clinical bioethics and, for research ethics, the influential Belmont Report [1,2]. Many criticisms of autonomy-based bioethics have appeared over the past thirty years from a number of different angles, such as feminism, casuistry, disability rights, multiculturalism, cultural studies, and ethnography. In this article, we take a different approach by exploring what we will call the'medical individualism' that autonomy-based bioethics largely assumes, and by raising questions about the relevance and impact of autonomy-based bioethics in developing countries (and communities within developed equitable ones), especially in light of initiatives to 'build capacity' in research sites and to ensure access to healthcare in resource-poor settings. This paper argues that the medical individualism underlying autonomy-based bioethics renders the latter incapable of addressing some of the most pressing bioethical issues in resource-poor settings, which have to do with social justice. The first section of this paper considers some of the limitations of principlism. The second section examines the inability of this approach to address social justice concerns in resource-poor countries. Finally, the third section attempts to offer an alternative approach by exploring the contribution of the sociological model of disease causation to research ethics, health justice and health policy. --- A brief anatomy of autonomy-based bioethics One of the major defenders of the centrality of autonomy in bioethics, the British medical ethicist and pediatrician, Raanan Gillon argues that respect for autonomy should hold a primary place among the four principles of biomedical ethics [3]. Other proponents of autonomy, Beauchamp and Childress, define autonomy as a form of personal liberty of action where the individual determines his or her own course of action in accordance with a plan chosen by himself or herself [1]. In application to clinical medicine, respect for autonomy dictates that patients with decision-making ability have a right to voice their medical treatment preferences, and physicians have the concomitant duty to respect those preferences [4]. Like Beauchamp and Childress, Gillon embraces a Millian understanding of autonomy, understanding it as deliberated self rule; the ability and tendency to think for oneself, to make decisions for oneself about the way one wishes to lead one's life based on that thinking, and then to enact those decisions-is what makes morality-any sort of morality-possible [3]. Given its supreme ethical importance, autonomy is not merely a value to be respected, but a virtue or trait that ought to be actively developed, nurtured and promoted. According to Gillon, other ethical principles (beneficence, non-maleficence, and justice) presuppose (and can be reduced to) respect for autonomy. Beneficence and non-maleficence toward autonomous moral agents presuppose respect for the autonomy of these agents even when they choose to refuse medical interventions which are life-saving. Gillon also takes an autonomycentered approach to justice, arguing that responding to people's needs justly will require respect for those people's autonomous views, including autonomous rejection of offers to meet their needs; and, more importantly, because providing for people's needs requires resources, including other people's resources [3]. To conclude his praise for autonomy, Gillon writes that respect for autonomy contingently builds in a prima facie moral requirement to respect both individual and cultural moral variability [3]. While it is true that not all autonomy-based approaches in bioethics take the explicit and extreme form expressed by Gillon, autonomy continues to be treated implicitly as a primary value in many controversial clinical and research debates, from end of life issues (such as the Terri Shiavo case) to questions of exploitation of research subjects in international health research. When ethical principles conflict, it is often thought that the conflict can be resolved in an ideally impartial way by asking, for example, what the patient wants (or would have wanted) or whether the research subject really understood and freely consented to the procedures described in the research protocol. In this way, the multifarious values involved in the practice of medicine and biomedical research tend to be reduced to the principle of respect for persons, itself narrowly understood as respect for autonomy. Furthermore, the preeminence of autonomy as an ethical value within bioethics is deeply related to the increasing commoditization of medicine in developed countries. For the more that medical practices are justified by reference to patient choice, the more that patients will be viewed as 'clients' and health care professionals perceived as'service providers'. This model of patient as 'client', which is prevalent in the United States of America and some parts of the western world, assumes affluence and power: the (literate) patient has to be capable of understanding and rationally weighing his/her options-possibly even in disagreement with the physician-and be in a position to pay in exchange for services chosen. --- Autonomy, exaggeration of human agency, and ethical pluralism An autonomy-based ethics places the responsibility for medical decision-making largely in the hands of the patient. This raises the descriptive question of whether this conception accurately depicts how clinical decisions are actually made, as well as the normative question about whether such a conception of responsibility should (or should not) function as a universal ideal. In regard to the descriptive issue, patients in resource-poor settings are often not concerned with their ability to determine and shape the course of cure. Their arrival at the local health center is the outcome of a long family discussion that led to the collection of money. Sometimes, the patient arrives at the dispensary when the disease has reached its critical stage because the cost of care is too high. The primary expectation of both patient and family is to get the medicine or undergo a medical procedure they need and go back to their workplace. Spending time at the hospital means loss of earnings for them and their families or the diminishment of financial resources. When people can barely afford the cost of care or satisfy the nutritional requirements for a good recovery, the ethics of medical encounter should be understood differently and expressed in different terms than patient choice. Instead of developing a highly-organized medical bureaucracy that cares for the enforcement of patients' rights and protects medical professionals from accusations of malpractice, it would be more helpful to develop new sets of values that guide medical practice and promote patient participation in the healing relationship. The framing of these values may encourage and foster a non-confrontational relationship between health professionals and patients in the clinical setting, and include social challenges that influence health in the bioethics agenda. The role of bioethics will then consist in identifying social values and laws that may guide clinical work, restore the social dimension of medicine, connect the macro-determinants of health to medical practice and health system delivery, avoid the fragmentation of healthcare, and advocate for good health policies. The challenge facing bioethics in resource-poor settings is not then to mislead people with unrealistic promises of autonomy that very few people can indeed achieve, but to articulate moral principles and societal values that are oriented around the promotion of equitable access to care and which broaden the goals of medicine and public health. The goals of medicine cannot be confined to the alleviation of suffering within the clinical setting. Medicine needs to be concerned with the determinants of good and bad health outside the clinical context in order to contribute to evidence-based clinical and public health interventions and education. The major bioethical questions prevalent in resource-poor countries do not essentially revolve around the provision of informed consent at the individual level, but rather around the burning social questions of access to care, commodification and quality of medical care, the relationship between income disparities and health inequities, the impact of poverty and underdevelopment on population health, priorities in biomedical research, and impacts of gender discrimination on women's health [5,6]. Once the focus is shifted away from the individualistic 'patient as client' paradigm, the social problems connected with the domination of medicine by market forces become apparent. If the goal of medicine is to restore health functioning, bioethics should avoid adopting a conception of autonomy that can be used to justify the domination of healthcare delivery by market forces alone and (wittingly or unwittingly) legitimizing health care systems that exclude the needy sick because the latter are unable to pay (or co-pay) for services or afford hefty medical insurance premiums. Even those bioethicists who promote market-driven medicine based on a libertarian anthropology [7,8] ought to carefully articulate alternative ethical values for health care and biomedical research, if they not to be lured into a'self-defeating' conception of medicine. As an example of the latter tendency, Robert Sade considers medicine as a market commodity and understands medical practice as sets of skills that physicians are entitled to sell on the marketplace to make as much money as possible. Even the cries of the destitute sick or government regulatory function cannot restrict the physicians' appetite for greater financial reward. Sade's anthropology and approach to medicine is based on the assumption that individuals have the right to select the values that they deem necessary to sustain one's own life. They are also entitled to exercise their judgment to take the best course of action to achieve chosen values. Finally, they have the right to dispose of those values, once gained, in any way one chooses, without coercion by other men [7]. Similarly, Tristram Engelhardt protects human freedom to the point of ignoring the fact that the concern that we have for each other makes life in society possible. For him, as long as freedom functions as a side constraint, and as long as the moral community is based on respect for freedom and not force, individual persons will have the possibility of holding entitlements [8], Engelhardt's suggestion is paradoxical because, in trying to protect freedom of individuals to use their resources to access health care and other goods, he does not ensure that those with few resources have the freedom to obtain health care. Realistically, a genuine affirmation of autonomy cannot result in action informed or motivated by the desire to avoid being a responsible member of one's moral community [9]. Here, responsibility means that one should not exploit others by using autonomy as a warrant to market-driven medicine or profit-seeking attitudes. Once medicine is understood as a commoditized product like any other, those who cannot afford services are merely unfortunate consumers. In this way, a strong emphasis on autonomy can contribute to a culture in which healing and health promotion are no longer at the center of clinical practice and biomedical research. One can hardly refute the fact that complex social and economic forces have placed patient autonomy at the center of medical ethics, and thereby undermined the age-old ethic of physician beneficence [10]. This change is sustained by waning trust in the traditional patientphysician relationship. With the control of medicine by the forces of the market, patients have become consumers of a market commodity called medical care. As a result of this change, the clinical relationship between the patient and physician begins to be seen as a contract and not as a covenant of care as it was in the past. Autonomy-based bioethics has a tendency to distort the relationship between individuals and the world. On the one hand, it exaggerates the power and range of individual agency; furthermore, it underestimates the impact of society, culture and environment, both on individual decision-making and on health. If persons are regarded as atomistic, certain defensive notions of individualistic rights-based autonomy prevail. If a relational construction of personal identity is employed instead, then respect for autonomy becomes part of a wider morality of relationship and care [1]. 'Atomistic autonomy' is divisive and lacks social rootedness while relational autonomy brings about trust and communality. The second version of autonomy, which reveals our true self in society, presents the possibility of placing trust and partnership at the center of the patient-physician relationship. With such an understanding of personhood, bioethics can better balance its concerns over choices and actions with those of relationship and responsibility. A more plausible philosophical anthropology would conceive individuals as entangled in the world, both capable of acting on it and subject to being affected by it. Reflection on the notion of disease, both infectious and chronic, can contribute to a more plausible philosophical anthropology for bioethics. Infectious diseases question our understanding of autonomous agency in two important ways. First, as both a victim and a vector, a patient cannot be simply seen as a rational agent who has the final ethical word on his own decisions. Both vulnerability to infection and threat of transmission to others should shape our understanding of patient agency. Second, the concept of choice that shapes our conception of agency in bioethics can no longer be understood in isolation from society. Risk of acquiring and transmitting infectious diseases reflects the patient's interconnectedness with others and the biological environment, an interconnectedness which is always there even when infectious disease is not present [11]. Although the values and desires of the patient obviously need to be considered, the ideal of the autonomous agent will remain a fiction unless the social context of the patient's vulnerability is also considered. For other reasons, chronic disease also challenges our understanding of autonomy, especially when the patient finds it hard to manage his or her chronic condition. Family or friends stand as important resources for decision-making and long-term daily care for chronic diseases. We should then recognize that the family and community, which may play an important role in patient care, are part of the resource needed by the patient to exercise agency [12]. More and more, it is becoming obvious that the promotion of patients' agency requires serious consideration of patients' best interests in a broader way. Against the backdrop of contemporary institutional medicine, family solidarity is more important than ever to help maintain patient's dignity and agency throughout stressful time [13]. Exclusion of family and relatives from the sphere of decision-making on account of respect for individual autonomy does not necessarily serve patients' best interest. Furthermore, primary care, because of its focus on treatment and prevention of chronic and infectious diseases, is the domain of medicine that goes beyond techno-medical solutions to consider patients as persons with their stories, relationships, and social environment in which they live. Consequently, primary care should essentially rely on socially-grounded values rather than on desocialized principles [14]. Family and social relationships are important in the context of clinical medicine. However, we cannot undermine the importance of individual freedom. We simply reject strong claims that do not have any social rootedness. It would be almost unsound and socially untrue to radically endorse autonomy to the detriment of an ethic of responsibility and socially-based care because they are mutually interdependent, and a complete account of medicine's moral axis requires that they be integrated. This reorientation is crucial for reasserting the ethos of clinical medicine, whose fundamental mandate remains the care of others [10]. --- Autonomy ethics and the'moral vacuum' For Immanuel Kant, respect for persons never refers to the freedom to be left alone. Kant's understanding of respect for autonomy provides the ground for the categorical imperative, which he formulated in five different ways. The third formulation, ".act so that you treat humanity whether in your own person or in that of another, always as an end and never as means only" [15] cannot be reduced to the respect for autonomy often found in the bioethics literature. The view of autonomy commonly found among individuals and in some of the bioethics literature in North America or Western culture is more in tune with John Stuart Mill's formulation of liberty: do not intrude on the freedom of any person by an invasion foreign to his or her own wishes and values. When Kant talks about autonomy, he does not imply that one should act according to one's own desires, unconstrained by a balanced consideration of one's situation as a being-among-others [9] Instead, he refers to the dignity of humans who are capable of making for themselves and others universal law. Hence, autonomy, rightly construed... results in action informed and motivated by the desire to be responsible member of one's moral community (the ground of one's beingamong-others) [9]. Kantian autonomy is tied the moral agent's search for the truth and respectable conduct. The autonomous subject does not act in accordance to his or her primary inclination. Kantian autonomy is applied to actions performed when the will is freed from any selfish determination. When humans treat each other as ends and never as means merely, there arises a systematic union of rational beings under common objective laws. Physician and patient, each with their own needs, desires, capabilities, must find those principles that allow them to coalesce into a helping alliance to achieve a common goal. Contemporary readings often accept a Millian version of autonomy that is associated with self-seeking attitudes. This approach to respect for autonomy refers to the capacity to act on needs, wants, or wishes; a capacity shared by many creatures. Since the person's action is informed by instrumental reasoning, it constricts the scope of reason so that it is subject to any desire or disposition that one happens to endorse at the time one acts [9]. Focusing essentially on individual choices sets up a false and pernicious opposition between persons and the community to which they belong. It is reasonable, on both conceptual and empirical grounds, to suppose that individuals acquire their values through engagement with a concrete moral tradition, rather than through a private and self-directed process. Instead of providing ethical decision-making with an objective and rational process, the obsession with individual autonomy tends to create what McCormick calls a'moral vacuum', i.e. the disappearance of the network of shared and established goods and values that make the choices of individuals right or wrong, moral or immoral [16]. --- Balancing autonomy and community in ethical decisionmaking It is hard to undermine the influence of social, cultural and environmental factors on moral decision making. We have to take these factors into account in order to fully appreciate the moral dilemmas and health challenges in settings and traditions where individualism does not prevail. Writing from their Jewish background, Barth-Rogers and Jotkowitz note that within Jewish tradition, the idea of unlimited human autonomy is not a defining value; Judaism deems the intrinsic human value of each individual's life to take precedence over patient autonomy [12]. Similarly, the Confucian culture from East Asia understands the person not only as a rational, autonomous being but also as a relational and altruistic entity whose self-actualization involves participating in and promoting the welfare of fellow persons [4]. In the same line of thought, African traditions present a view of the human person that is essentially relational; it is within the social network that the individual lives and acts as a free person. The Jewish, Confucian, and African cultures convey an understanding of the human person and society which is different from individualism operative in some cultures. This is where the shortcomings of Gillon's autonomycentered conception of bioethics become the most obvious. Gillon does not reject the view that particular cultures should be respected, instead he theorizes that the prima facie nature of autonomy requires that both the individual and cultural moral variability be respected [3]. But this sense of respect for culture does not adequately reflect the social rootedness of the human person. Despite making 'concessions' to culture, Gillon continues to view societal relationships, determinants and influences to be peripheral to human reason and, because of the danger of ethical relativism, something to be transcended by a universal ethic. Hence, the four principles (with autonomy as supreme among them) can account for all our moral worries and being applied straightforwardly to all situations and contexts [17]. Gillon contends that any other moral principle or value can be explained by one or some combination of the four principles. In fact, however, Gillon's quest for a universal discourse is nothing more than the promotion of one approach to ethics among others, one which reflects specific cultural assumptions concerning individual choice and future-oriented action that are associated with class position and social opportunities and foreign to the lived reality of the poor, the marginalized, and people of color in a multicultural society like the United States [18]. Any attempt to universalize an ethnic particularity fails the test of respect for pluralism in bioethics and in our ever-globalizing world. In resource-poor countries where medical paternalism prevails on account of patient beneficence and sharedresponsibility for health promotion [19], the necessity to create the conditions that improve, for example, patientphysician communication in ways that favor patient agency needs to be acknowledged. Very often, the physician does not even tell the patient what is going on with his or her health. However, the one-sided view of the human person which prevails in autonomy-based bioethics should not be adopted as a model to correct paternalism; a more fruitful alternative would be a combination between a community-and tradition-oriented view and autonomy that conceives decision-making as guided by important human values such as partnership, trust and solidarity, in addition to autonomy. This view would acknowledge the embedded and relational nature of human choices, behavior, ways of expressing emotions and feelings, patterns of thinking, and conceptions of disease and healing. --- Autonomy, biomedical individualism, and social justice Some criticisms of autonomy-centered bioethics have been purely conceptual. Others have emerged from reflections on its limitations in dealing with collective macro-problems including social, sanitary and environmental problems that mark everyday life in poor countries. Autonomy-based bioethics fails to engage the lived worlds of diversely constituted and situated social groups, particularly those that are marginalized [18]. Similarly, in clinical medicine, broad issues such as the common good, distributive justice and the spirituality of the patient are ignored for the sake of the primacy of secular business concerns. To guide clinical practice, laws have been developed to reduce risk for malpractice and protect patients. However, emphasis placed on the principle of autonomy has led to an excessive control of clinical practice by judicial institutions. Consequently, this obsession with the law has led to the elimination of a wide range of moral concerns from public consideration [16]. To emphasize this point, McCormick criticizes clinical ethics for being preoccupied with cost control that focuses narrowly on matters of financial efficiency, thus exiling the more basic ethical questions (ends of medicine, the meaning of life, death, illness and health) [16]. Furthermore, any public health intervention that adopts the biomedical model fails to address issues of wider social injustices that are responsible for healthrelated vulnerability and risk. --- Autonomy ethics and medical individualism The biomedical model is premised on individualism, because it adopts an abstract view of the body and mind of an individual person from a liberal model of economy and politics [20]. In this model, individuals choose health behaviors. Thus, poor health is largely due to exposures to health risks that the individuals have decided not to avoid. This approach to health risks disregards the role of social structures in structuring the array of risk factors that individuals are supposed to avoid [18], and fails to explain how social inequalities can be embodied in poor-health outcomes [21]. Thus, autonomy-focused bioethics, rather than presenting an objective perspective, deprives itself of theoretical tools to adequately address non-pathological causes of ill-health. Similarly, in research sites, much effort is often invested in securing the informed consent of individual participants while often ignoring the broader issues of justice in places where research takes place [22]. Consequently, the absolutization of autonomy with the unreal and distorted picture of the person helps explain why so much bioethical writing is concerned with procedures that protect choice, rather than more substantive issues, with consent itself rather than what is consented to [16]. This tendency to make the social causes of poor health (and the broader ethical problems related to health improvement) invisible can even be seen among those working in public health to the extent that they subscribe to the biomedical model [20]. --- Biomedical model and the social gradient in health Health differentials between individuals cannot be explained simply by their health behavior or lifestyles, but also by their social position and economic status, the social networks to which they belong, and the levels of education that provide them with the means to avoid health risks, deal with adversity, and have access to lifeprotecting information. The pervasiveness of the social gradient in health remains even when well-designed public health interventions are implemented. Even when these public health interventions may reduce health risks and mortality, they do not eliminate the social gradient because individuals in the lower socioeconomic groups take less advantage of health interventions than those who are better off. When we compare the health statistics between poor and rich within countries or between countries, the differentials are striking. HIV/AIDS statistics provide us with striking examples of the impacts of socioeconomic status on risk differentials and chances of survival between groups within countries and between countries. Even in developed countries, the geography of HIV/ AIDS challenges us to investigate the social causes of its distribution. Risks and survival differentials prompt us to consider a view that places political-economic critiques of global resource distributions, and criticism based on the higher and qualitatively different disease burdens in poor countries within a common framework of international and internal socio-economic structure [23]. At the local level, income inequality in poor countries affects health and can be an indicator of life expectancy [24,25]. Poverty affects individuals' ability to have access to goods which are instrumental for well-being. At the country level, poverty limits government's ability to found social programs and provide people with basic social goods such as safe drinking water, electricity, good public health coverage, healthcare institutions, schools, social services, and economic opportunities. These structural causes are steady and they include access to basic resources that can be used to avoid all sorts of health risks or reduce the negatives outcomes of diseases when they occur [26]. Most public health interventions focus on individual risk factors and behavior. To lessen vulnerability and risk, health professionals will need to address income differences between individuals and population groups. Otherwise, they will only address the symptoms and not the root-causes of poor health. As public health practitioners and other health professions'resocialize' their conceptions of health and disease, bioethicists should join and inform their efforts. A sociological approach to disease can increase the social relevance of bioethics because it provides an acute perception of disease etiology and pathology that includes the social and material conditions in which people live. --- Sociological model and autonomy-based bioethics To underscore the difference between Western and non-Western conception of illness, Bowman writes that most non-Western cultures tend to perceive illness in a much broader and far less tangible manner. Illness is often viewed as being linked to social, spiritual, and environmental determinants [27]. The sociological model of disease explanation shares some important connections with many non-Western cultures in which disease representation and explanation is not primarily understood in biomedical terms, but in social ones. Autonomy-based bioethics is premised on the view that disease is located in the individual. The focus on the individual person often reduces the scope of justice in clinical medicine and health research to an equal treatment of individuals involved and a fair distribution of available resources and burden regardless of people's social status, age, race, gender or religion. In the clinics, for example, justice requires that patients whose circumstances are the same deserve the same level and quality of care. Conversely, the sociological model perceives the disease as an integrated social-physiological process which includes the person's relation to the environment. In addition to its bio-physiological dimension, a disease is a relational phenomenon; as a subjective and socially-constructed reality, a disease develops out of the omnipresence of symptoms and bodily feelings in everyday life. The sociological model allows us to develop a sociallyrelevant approach to health justice, a new set of principles that may guide research as well as an approach to health policy based on the features of the site where research is done. Thus, this model points to the fact that there are two reminders of our embeddedness in the world relevant to bioethics: first, biological embeddedness and infectious disease and second, social embeddedness, particularly (but not exclusively) in contexts where people are obviously dependent on one another and traditional behavior and customs are strong. --- Contribution of medical sociology: Sociological model and social justice The current formulation of ethical principles as they are applied to medical research in poor countries is inappropriate for capturing some crucial implications of medical research since they ignore the roots of health crises with which these countries are confronted [28]. Analyzing the health crises in African countries in the late 1980s, the Cameroonian sociologist Jean-Marc Ela argues that disease and malnutrition never exist by themselves; rather they come from a system characterized by violence, by a pattern of impoverishment of the majority, and by the monopoly by a minority of the means to live with dignity [29]. Health interventions should not merely address the symptoms of a diseaseproducing society, but also its structures. Social structures not only shape distribution of disease across population, but they also determine societal and individual responses to suffering. When the major determinants of health are far from being addressed by a conceptual framework that prioritizes individual problems and morality, there is a need to call its relevance into question. The high rates of infectious diseases in poor countries are linked to poor living conditions and structural problems. These primary sources of exposure and vulnerability to health hazards should necessarily be considered in any attempt to develop bioethical standards for research or any bioethical agenda. The poverty that permeates all spheres of society should be studied because poverty never exists in isolation from societal influences, but rather is integrally a product of the inner workings of each society's political economy. Minimizing the contribution of poverty to the production of disease and disability in poor countries makes suffering invisible and limits our understanding of the etiology of disease. Medical sociology scrutinizes patterns of diseases and pathways through which social inequalities are embodied in individual vulnerabilities and major epidemics. Thus, the model of disease causation that comes from sociological investigations challenges us to move beyond the clinics or research sites to broaden the scope of justice. Similarly, the prevalence of infectious diseases in resource-poor countries challenges the way justice is understood in research sites. If we consider the patient as a potential victim and vector, we need to shift our gaze from the healthcare that might be most desirable for the individual patient to broader social concerns and the worldview distribution of care that might enable all to achieve opportunities over a reasonable life span [11]. The extension of care to all not only aims at serving individual needs for care, but more importantly it addresses infectious diseases as a threat to population health. Opting out from an intervention of this kind would simply mean that the individual remains a threat to the entire population [3]. The sociological explanation of disease incorporates a distinctive view of etiology, prevention, pathology, treatment, and justice. This approach to disease explanation tacitly promotes a conception of responsibility for infection or disease causation which is not only individual. This approach questions the uses of individualism as methodology and framework for analyzing disease occurrence, and thus criticizes the one-sidedness of the anthropology that sustains the biomedical model. --- Sociological model and justice in current biomedical research Documents such as the Declaration of Helsinki issued by the World Medical Association and the International ethical guidelines for biomedical research involving human subjects (CIOMS) as well as the work of the National Council on Bioethics in 2002 and that of the National Bioethics Advisory Commission (NBAC) in 2001 all take material poverty as the main reason for developing bioethical standards that apply to medical research conducted in poor countries. Surprisingly, the bioethics standards they promote hardly reflect the physical, social, and cultural environment of poor countries. This is another important area for revision [28]. Given the substantial differences in individual exposure to health risks and the availability of health protective resources as well as differences in the disease burden and mortality and morbidity at the population level, it is clear that illness in poor countries can be better understood using a'social causation of illness' perspective. The principles of respect for persons, beneficence, and justice that shape the Belmont Report are all built on the biomedical model. The principle of respect for persons reinforces individual agency and protection in the research setting by ensuring that participants are properly informed about the research or the course of care that will be taken to restore normal functioning. The principle of beneficence extends the latter by insisting that research protocols should maximize potential benefits and minimize harm. Finally, the principle of justice ensures that those with diminished autonomy are protected and that participants share in the benefits of the research. Agency, benefit, participation, risk, and vulnerability are all understood from the standpoint of the individually-focused disease management whether in the clinical setting or the research site. To be of broader global significance, ethical principles of biomedical research should be responsive to the context of poverty and social inequities, since these structural factors can lead to increased vulnerability and exploitation. For example, the incapacity of poor people to satisfy their basic needs can lead to increased participation in clinical trials without true understanding of risk and benefit at least in part due to financial incentives. Thus, even if these people 'consent' to participation in a trial, is that decision truly autonomous? It is then clear that'research protections' cannot be ensured solely through the use of the consent form and the provision of information to the subject. A formal provision of consent by the research subject can simply mask the misery that inhibits his or her ability to consent freely. Similarly, what counts as 'benefits' can be tied to different levels of poverty and disease burden in different resource-poor countries. Ethical principles and guidelines that oversee biomedical research can be defined in terms of public good rather than merely as an improvement in individual health status because public good and social policy transcend the framework of individual-based ethics [28]. In resource-poor countries, death-rates are high and infectious diseases contribute significantly to the burden of disease-as opposed to richer countries, where cardiovascular disease and cancer are the leading causes of mortality-the difference in exposure, health risk, mortality, and morbidity between poor and rich countries challenges us to develop a new approach to the concept of benefit in biomedical research. We need to think of 'benefits' as running to the whole community in which research takes place, and not just to single research subjects. Therefore, the availability of and access to modern health services is a substantial issue for evaluating the impact of biomedical research benefits in poor countries since the outcomes of health initiatives are largely determined by some structural arrangements that transcend the benefits of research subjects. These arrangements are based upon national and international patterns of control over society's resources. Current ethical guidelines continue to be inappropriate because they do not address the international context of exploitation within which research is done. People's health status cannot be separated from the capitalist system of resource distribution and exchanges which favors the rich countries or high socioeconomic groups and reinforces the impoverishment of the poor ones. The economic exploitation that prevails in the capitalist system shapes the global and local distribution of resources and diseases as well as the health risks and vulnerability of those who live on the margins of the global market. The concepts of 'benefit

Through its adoption of the biomedical model of disease which promotes medical individualism and its reliance on the individual-based anthropology, mainstream bioethics has predominantly focused on respect for autonomy in the clinical setting and respect for person in the research site, emphasizing self-determination and freedom of choice. However, the emphasis on the individual has often led to moral vacuum, exaggeration of human agency, and a thin (liberal?) conception of justice. Applied to resource-poor countries and communities within developed countries, autonomy-based bioethics fails to address the root causes of diseases and public health crises with which individuals or communities are confronted. A sociological explanation of disease causation is needed to broaden principles of biomedical ethics and provides a renewed understanding of disease, freedom, medical practice, patient-physician relationship, risk and benefit of research and treatment, research priorities, and health policy.

the difference in exposure, health risk, mortality, and morbidity between poor and rich countries challenges us to develop a new approach to the concept of benefit in biomedical research. We need to think of 'benefits' as running to the whole community in which research takes place, and not just to single research subjects. Therefore, the availability of and access to modern health services is a substantial issue for evaluating the impact of biomedical research benefits in poor countries since the outcomes of health initiatives are largely determined by some structural arrangements that transcend the benefits of research subjects. These arrangements are based upon national and international patterns of control over society's resources. Current ethical guidelines continue to be inappropriate because they do not address the international context of exploitation within which research is done. People's health status cannot be separated from the capitalist system of resource distribution and exchanges which favors the rich countries or high socioeconomic groups and reinforces the impoverishment of the poor ones. The economic exploitation that prevails in the capitalist system shapes the global and local distribution of resources and diseases as well as the health risks and vulnerability of those who live on the margins of the global market. The concepts of 'benefit' and 'justice' have been inadequately extended to biomedical research in poor countries because the possibility of exploiting the underprivileged is more complex than an exploitative relationship with vulnerable populations in developed countries, where at least the rule of law and the respect due to every citizen have already been institutionalized. Furthermore, the number of research studies conducted in poor countries is increasing because regulatory measures are often less strict; this situation may facilitate the exploitation of the poor, non-respect for basic ethical standards, and unlimited search for benefit. Bioethics scholarship that focuses on the sociological model considers local as well as global issues of social inequality, because this model is premised on the intimate connection that exists between social inequality and health inequality. The distribution of illness is likely to reflect the geography of inequality. A social approach to bioethics emphasizes distributive justice and benefits at both the population and individual level. Three important principles flow from this analysis. The first one can be called principle of public benefits (community-based approach to benefits); it is a context-based principle which derives from factors that contribute to ill-health and vulnerability to preventable diseases in poor countries. It states that risks, benefits, and equity can no longer be defined in terms of individual health, but also in relation to the international, national and local contexts [23]. Such a principle challenges the individualistic understanding of benefits in places where exploitation and inequality are at the center of research. Consequently, a community-based understanding of benefits calls for a large-scale distribution of the benefits of research as an important requirement of justice. This principle is relevant for political and socioeconomic critiques of the ethics of carrying on research in poor countries, given well-established patterns of exploitation and oppression of the underprivileged. Reliance on the sociological model brings out the fact that the health conditions under study originate in socioeconomic conditions that need to be treated to have an impact on the health status of research participants [28]. Thus, the notion of population or community-based benefits is related to that of health as a public good which is, in turn, linked to the global-capitalistic system that significantly contributes to the health conditions found in poor countries. The second principle, the principle of social justice, is rooted in a broad approach to justice that places poor health at the center of public and research policy and seeks to correct systemic injustices. This principle is related to the principle of public benefit since it states that the distribution of benefits should take into account the poverty of local healthcare systems and people's disempowerment as a function of social structures [23]. Here, the challenge is that the distribution of benefits should address the root-causes of poor health and not only its symptoms. The third principle underscores the need for building local capacity. This principle states that building capacity to promote healthcare sustainability will have a lasting effect on people's health. This principle emphasizes the need for building local capacity and improving human capital to reduce the burden of preventable diseases. For example, research on AIDS vaccine often uses existing facilities or new ones built by funding agencies to conduct research or administrate the vaccine on trial. Building capacity may involve researchers and funding agencies improving the training of local medical professionals and reinforcing existing facilities to reduce the burden of disease; and, if a new medical facility has been built for the research study, local communities can still use it even after the research project comes to an end. To avoid exploiting the underprivileged and reinforcing an existing system of oppression, the distribution of benefits should be determined by the context within which diseases occur, the state of the healthcare system, and available resources. Therefore, research institutions and their financial sponsors are morally obligated to contribute to the development of a healthcare system and the improvement of human resources that can benefit the whole population. Carrying on research in impoverished parts of the world where people have been enduring a systemic marginalization would not be ethical if our understanding of benefit will not address the root causes of poor health. Thus, it is no longer enough to avoid not doing harm; addressing health challenges that prevail in the research site is consistent with a broader view of justice [28]. --- Sociological model, bioethics, and health policy An autonomy-centered ethics places the burden of prevention and access to healthcare on the moral agent. In doing so, it frames disease within a model that limits political intervention in the health domain strictly to biomedical solutions or behavior change. This leads to the perpetuation of the social status quo within which risks for poor health are greater, and lends legitimacy to the social forces that increase health risks. This failure to promote social justice contrasts with John Lynch's understanding of public health intervention. Lynch believes that elements of the social fabric should shape the conception, framework, and implementation of public health intervention. Discussing the influence of socioeconomic status on behavioral and psychosocial risk factors for cardiovascular disease, he argues that the public health community should consider the potential for a broad array of social, educational, and economic policies as effective public health interventions to reduce the unequal distribution of risk factors and the unequal burden of disease [30]. Similarly, bioethicists need to study health-promoting effects of structural interventions to determine which ones are ethically acceptable and justified. Such a move requires bioethicists to look at broad issues of social equity and advocate for a shift in public policymaking. In a population-based study examining the associations between socioeconomic status measures (education, income, and occupation) reflecting different stages of the lifecourse of 2674 middle-aged Finnish men, health behaviors, and psychosocial characteristics in adulthood, Lynch et al. conclude that: understanding that adult health behavior and psychosocial health orientations are associated with socioeconomic conditions throughout the lifecourse implies that efforts to reduce socioeconomic inequalities in health must recognize that economic policy is public health policy [31]. The sociological model within which Lynch's understanding of public health intervention is built challenges us to advocate for a shift in policymaking mindset because health is not a sphere of justice which is separate from other aspects of human life. Since disease is a social process, a policy vision that focuses on the individual and individual risk factors fails to promote social justice and to address structural elements that create conditions favorable to the production of disease. Hence, we need to move from healthcare policy to health policy, or rather, a healthcare policy that is responsive to facts explaining why (certain) people with (certain) diseases from (certain) communities require medical care. Health policy should embrace healthcare policies but include considerations regarding welfare, work, occupational, economic development, employment, and educational policies. --- Conclusion Sociologists and social epidemiologists challenge bioethicists, especially those working in developing countries, to be socially and culturally relevant. The sociological theory of disease explanation starts with a concrete analysis of the social setting within which illness occurs or research is carried on. Since societal factors shape patterns of mortality and morbidity, principles of biomedical and research ethics need to be framed within the context of the social inequalities that shape vulnerability to illness. Aligning bioethics to perspectives, concerns and information in the fields of public health, health policy and medical sociology could vastly improve its global significance. Thus, bioethicists should be challenged to develop a philosophical anthropology that goes beyond radical affirmations of the individuality to acknowledge both the communal and the individual dimension of the human person. --- Competing interests The authors declare that they have no competing interests.

Through its adoption of the biomedical model of disease which promotes medical individualism and its reliance on the individual-based anthropology, mainstream bioethics has predominantly focused on respect for autonomy in the clinical setting and respect for person in the research site, emphasizing self-determination and freedom of choice. However, the emphasis on the individual has often led to moral vacuum, exaggeration of human agency, and a thin (liberal?) conception of justice. Applied to resource-poor countries and communities within developed countries, autonomy-based bioethics fails to address the root causes of diseases and public health crises with which individuals or communities are confronted. A sociological explanation of disease causation is needed to broaden principles of biomedical ethics and provides a renewed understanding of disease, freedom, medical practice, patient-physician relationship, risk and benefit of research and treatment, research priorities, and health policy.

superstructure constitute a sociocultural system. A change in any one of the system's components usually leads to a change in the others. In this regard, cultural materialism is compatible with all those varieties of functionalism employing an organismic analogy to convey an appreciation of the interdependencies among the "cells" and "organs" of the social "body". (2) <unk> "The mode of production in material life determines the general character of the social, political and spiritual processes of life. It is not the consciousness of men that determines their existence, but on the contrary, their social existence determines their consciousness"... However in the context of modern anthropological research, the epistemological ambiguities inherent in the phrase "the mode of production", the neglect of "the mode of the reproduction" and failure to distinguish emic from etic and behavioral from mental impose the need for reformulation." (5) <unk> "In short this power is exercised rather than possessed, it is not the privilege, acquired or preserved, of the dominant class, but the overall effect of its strategic positions-an effect that is manifested and sometimes extended by the positions of those who are dominated." (6) <unk>

Cultural Materialism theory is proposed by an American Anthropologist Marvin Harris. This theory has a scientific strategy to find the facts about human cultures. This theory suggests that in every sociocultural system, three major parts, infrastructure, structure, and superstructure, interact with each other. Infrastructure refers to material resources of the culture that man established to get energy and food from his physical environment. Structure refers to the laws and procedures of social institutions which regulate the distribution of food and power among the members of the society. Superstructure refers to the soft images of society like art, music, language, literature, and behaviors of individuals in a social setup. This theory provides a comprehensive analysis pattern of any literary text by finding the infrastructure in the base of structure and superstructure. In this article, it is tried to formulate theoretical bases and practical dimensions of cultural materialism.

INTRODUCTION Despite numerous years of anti-tobacco campaigns, including US-based efforts such as the American Legacy Foundation 'Truth Initiative', the Centers for Disease Control and Prevention (CDC) 'Tips From Former Smokers', and the Food and Drug Administration (FDA) 'The Real Cost', use of conventional tobacco continues to be the largest preventable source of morbidity and mortality worldwide [1][2][3][4]. An estimated 0.48 million people die prematurely each year in the US due to smoking conventional cigarettes and exposure to secondhand smoke. Conventional cigarette use, as well as use of other forms of conventional tobacco, are on the decline. The CDC has estimated that the number of current adult conventional cigarette users has dropped from about 42.4% in 1965 to 15.5% in 2016 15,16. Further reports reveal that the number of current youth conventional cigarette users has also dropped considerably, from 4.3% in 2011 to 1.8% in 2018 among middle school students, and from 15.8% in 2011 to 8.1% in 2018 among high school students 7,8. As conventional tobacco use declines, other methods of nicotine consumption have risen, most notably electronic nicotine delivery systems (ENDS) 9,10. Originally developed in the early 2000s 11, ENDS first arrived in the US marketplace in 2007 in the form of electronic cigarettes 12,13. Since then, numerous other electronic nicotine products have emerged. ENDS comprise a group of products that include e-cigarettes, vape pens, hookah pens, personalized vaporizers and mods, e-cigars, e-pipes, and e-hookahs. As ENDS evolved, longlasting batteries and designs allowing for use of an assortment of flavored e-liquids have become common. These e-liquids are heated, producing an aerosol that is inhaled. Although some e-liquids do not contain nicotine, many do, and the nicotine content of these liquids can vary greatly and is not currently subject to strict government oversight. The scientific community is divided on the potential benefits and harms of using ENDS, with some research findings mixed and too little time having passed to amass a body of research on long-term outcomes. Advocates for ENDS suggest that they can be useful tools for the cessation of conventional cigarette use, especially as the use of ENDS closely mimics the hand-mouth motions associated with smoking conventional cigarettes 13. Further, in some studies, ENDS use has been found to help reduce cigarette cravings in adult smokers and reduce the likelihood of relapse in those who are in the process of quitting 14,15. Additionally, some researchers note that exposure to secondhand ENDS aerosol differs from exposure to secondhand smoke 13. Despite the possibility of some beneficial uses, the exact nature of ENDS toxicity, potential benefits from use and associated health concerns have not been thoroughly elucidated. A growing body of literature suggests that ENDS are not as innocuous as once thought 16. Increasing evidence indicates that ENDS use is not an effective means of quitting combustible cigarettes and is associated with increased levels of conventional tobacco use initiation and dual use among youth 10,17. Even when ENDS have been shown to be more effective than traditional nicotine-replacement therapy (NRT) for the cessation of smoking, those who used ENDS as their means of quitting were much more likely to maintain usage at one year of smoking abstinence than those who used NRT 18. Further, ENDS use may be predictive of future cigarette use in high school youth, and continued use of ENDS across time may result in increased frequency of consumption 19. Despite the dangers, ENDS are aggressively marketed to adolescents through targeted marketing schemes, often touting varied flavor options and potentially resulting in adolescent use of nicotine products that might not have occurred otherwise 9,12,17. More recently, cases of e-cigarette or vaping product use-associated lung injury (EVALI), resulting in several deaths and hospitalizations, have led the CDC to recommend against using ENDS and to emphasize that youth should never use these products 20. It is not yet clear whether the same populations considered vulnerable to conventional tobacco use are equally affected by ENDS use 21. In studies to date, ENDS use has been consistently associated with being male and non-Hispanic White as well as with increasing age among youth [22][23][24][25]. It is clear that youth are susceptible to initiating ENDS use, given the substantial rise in prevalence in recent years. The National Youth Tobacco Survey (NYTS) findings noted an increase in ENDS ever use among middle schoolers from 1.4% in 2011 to 4.9% in 2018, and an increase in ENDS ever use among high schoolers from 4.7% in 2011 to 20.8% in 2018 7,9. In 2018, ENDS were the most commonly used nicotine-containing product among middle and high schoolers 7. The purpose of this study is to elucidate the relationship between population characteristics, perceptions of nicotine-containing products, and the likelihood of initiating ENDS use among US youth aged 13-18 years. In doing so, susceptible populations may be revealed, and ENDS education efforts can be correspondingly targeted in a more efficient and effective manner. --- METHODS Between August and October 2017, an online survey of US youth ENDS users and non-users, aged 13-18 years, was conducted. Ypulse, a research and marketing firm specializing in preteen, teen, college student, and young adult panels, fielded the survey. To obtain data, Ypulse manages an incentive-based online research panel called SurveyU, with approximately 65000 members, as well as recruits through buzz campaigns, ads in newspapers, and social networking. Study methods and materials were approved for use by the Chesapeake/Advarra Institutional Review Board (IRB), and privacy guidelines outlined in the Children's Online Privacy Protection Act (COPPA) were followed. Participation in the survey was voluntary. Parental/guardian consent was required for participants under the age of 18 years, with those participants completing assent forms. Participants who were 18 years old completed consent forms. De-identification of data was not necessary, as no identifying information was gathered. The study consisted of 3174 participants. Two groups were recruited: a) ENDS users, defined as youth who had ever tried e-cigarettes or other ENDS, with a subset of dual users (had tried ENDS and another tobacco product); and b) a control group, defined as youth who had never tried ENDS. Quotas were established for participant recruitment based on gender, age, race, and ethnicity. Non-Hispanic Black and Hispanic individuals were oversampled to ensure sufficient sample sizes for comparisons by ethnicity and race. Researchers tracked age, gender, and race/ethnicity across respondents to enable accurate weighting of the results. Post hoc blocking was used to evaluate other issues of interest, and the data were weighted to be representative of the overall US population. Weighting was based on 2017 US Census data. Proportions for each group to be weighted were calculated using census data along with corresponding proportions from the study sample, which allowed the calculation of the final weight. Of the 3174 total survey participants, 2654 participants were included in the analytic sample after accounting for missing observations and prior to weighting. Missing observations were removed from the variables ethnicity, parent education level, participant education level, race, sexual orientation, and use of lunch assistance programs. Specifically, missing data were: 125 observations for ethnicity due to participants indicating 'don't know' when asked if they identified as Hispanic; 219 observations for parent education due to participants answering 'not sure' when asked about parent/guardian education level; 7 observations for participant education due to inadequate responses to the 'other' option; 88 observations for race due to participants answering 'don't know' when asked about their racial identity; 32 observations for sexual orientation due to participants indicating 'prefer not to answer'; 176 observations for lunch program due to participants answering 'not sure' when asked if they were currently utilizing a financial assistance program for school lunch. After weighting, the sample population was composed of 2501 youth. The final sample size after weighting was lower due to the weight being less than one. Non-users served as the control group. All results are based upon the weighted sample. Unweighted data are provided for reference. --- Measures Tobacco use status ENDS use status was defined based upon responses to the question: 'Which of the following types of tobacco have you ever tried (even one time or two times)?'. Eleven response categories were provided, each with the opportunity to answer either 'yes' or 'no'. The categories were: electronic nicotine products, conventional cigarettes, conventional cigars, little or filtered cigars, cigarillos, smokeless tobacco, dissolvable tobacco, hookah, bidis and kreteks, other, and never used. Product examples and images were provided for all but the last two categories. Those who reported ever using an electronic nicotine product were categorized as ENDS ever users, and those who did not report ever using an electronic Tob. Prev. Cessation 2020;6(March):20 https://doi.org/10.18332/tpc/117477 nicotine product were categorized as ENDS never users. Participants who had ever used any non-ENDS nicotine product were grouped together into a single conventional tobacco ever use variable. --- Sociodemographic variables Several variables were taken into consideration to determine which were associated with ENDS use among youth. Sociodemographic variables included age, household size, living status, parental education level, participant education level, race, ethnicity, gender, sexual orientation, residence location, and use of lunch assistance programs. Age was defined in years. Household size was defined by the number of people living in the participant's household. Living status was defined as living with both parents, one parent, an alternative guardian or caretaker, or none of the previous. Parental education level was split into six subgroups: less than a high school education, high school graduate or GED, some college, Associate's or technicial degree, Bachelor's degree, and graduate or professional degree. Participant education level was subdivided into three categories: being in middle school or less, in high school, and a high school graduate or greater. Race and ethnicity were combined to form a single variable with four categories: Non-Hispanic White, Non-Hispanic Black, Hispanic, and Non-Hispanic Other. The Non-Hispanic Other category included those who indicated their race as Asian/Pacific Islander, American Indian, other, or multiple races. Gender was defined as female or male. Sexual orientation was defined as straight or LGBTQ. Residence location was classified as urban, suburban, or rural. Use of lunch assistance programs was defined as either yes or no, depending on whether the participant currently utilized lunch assistance resources at school. --- Tobacco use health and safety Participants were prompted to answer four ordinal scale items that provided information about perceived safety and risk involved with tobacco and ENDS use. The items were: 'How knowledgeable are you about health risks linked to tobacco use?'; 'How much do you know about health risks linked to using electronic nicotine products?'; 'How safe or dangerous do you think electronic nicotine products are?'; and 'How safe or dangerous do you think electronic nicotine products are compared with other tobacco products?'. The first three items were answered using a scale of 0-10, with the first two items ranging from 'not at all' to'very much' and the third ranging from'very dangerous' to'very safe'. The fourth item was answered in one of three ways, with respondents indicating that ENDS are safer than other tobacco products, that there is no difference in safety, or that ENDS are more dangerous than other tobacco products. --- Advertising Participants who had heard of ENDS were also asked whether they had been exposed to advertising for ENDS and/or had been exposed to media messages concerning the health effects of ENDS use. --- Self-esteem Participants were asked about their perceived selfesteem. The item 'I have high self-esteem' was answered using a scale 1-7; with 1 being 'Not very true of me' and 7 being 'Very true of me.' --- Statistical analysis Population characteristics, categorized by diachotomous ENDS ever use status, were compared using chi-squared tests. Simple and multiple logistic regressions were used to examine the relationship between sample population characteristics and perceptions and likelihood of ENDS ever use. A sampling weight variable was used during analytical procedures. Initial and final regression models are reported. The initial model included all of the variables previously discussed. The final model included only those variables that had a significant association at alpha <unk>0.05 with the outcome variable of ENDS ever use determined using backward elimination. Backward elimination was used due to the reasonably large sample size. Results are reported significant at alpha <unk>0.05. Statistical analyses were carried out using SAS statistical software (version 9.4 with SAS/ STAT 14.1, SAS Institute Inc., Cary, NC). --- RESULTS Among the youth sample population, 22.0% were aged 13 or 14 years, 34.5% were 15 or 16 years, and 43.5% were 17 or 18 years (Table 1). The sample was roughly equal parts male (45.1%) and female (54.9%), and 61.0% Non-Hispanic White, 13.3% Non-Hispanic Black, 18.9% Hispanic, and 6.8% Non-Hispanic Other. Regarding tobacco use, 1346 (53.8%) reported having ever used ENDS while 1093 (43.7%) reported having ever used a form of conventional tobacco. Of those who had ever used a form of conventional tobacco, conventional cigarettes were the most common (75.8%) product, followed by cigarillos (47.8%) and hookah (41.4%) (Table 2). Also, 977 (39.1%) reported having ever used both ENDS and a form of conventional tobacco. Of those who had tried any of the nicotine-containing products discussed, ENDS were the most commonly tried first (44.4%), followed by conventional cigarettes (35.5%) (Table 3). Results of the initial and final binary logistic regression models are presented in Tables 4 and5. In the final model, for every one year increase in age, participants were 1.3 times more likely to have ever used an ENDS product (adjusted odds ratio, AOR=1.30; 95% CI: 1.20-1.40). Males were far more likely, 2.25 times, to have ever used ENDS than females (AOR=2.25; 95% CI: 1.77-2.85). Participants who identified as Non-Hispanic Black were 0.57 times less likely to use ENDS than Non-Hispanic White participants (AOR=0.57; 95% CI: 0.40-0.82). Participants who identified as Non- Hispanic Other were also less likely (i.e. 0.58 times) to use ENDS than Non-Hispanic White participants (AOR=0.58; 95% CI: 0.37-0.93). Those participants whose parents were either in the lowest education category or the highest two education categories were less likely to have ever used ENDS compared to those in the reference group of high school graduate/GED recipients. Not surprisingly, those who had ever used some form of conventional tobacco were far more likely to have ever used an ENDS product as well (AOR=19.96; 95% CI: 15.30-26.05). Participants' comparative knowledge of conventional tobacco and ENDS use safety, as well as health effects of these products, was found to be significantly associated with the likelihood of ever using ENDS. For every one unit increase on the knowledge of tobacco health risks ordinal scale, participants were 0.93 times less likely to have ever used an ENDS product (AOR=0.93; 95% CI: 0.89-0.98). Interestingly, for every one unit increase on the knowledge of ENDS health risks ordinal scale, participants were 1.11 times more likely to have ever used ENDS (AOR=1.11; 95% CI: 1.06-1.15). Participants who believed ENDS to be safe were 1.26 times more likely to have ever used ENDS for every one unit increase on the perceived safety of ENDS ordinal scale (AOR=1.26; 95% CI: 1.21-1.32). Similarly, those who believed that ENDS were safer than conventional tobacco were much more likely to have ever used ENDS (AOR=2.37; 95% CI: 1.82-3.08). --- DISCUSSION These findings suggest that certain sections of the US youth population are at greater risk for initiation of ENDS use than others. As research on the health outcomes of ENDS use continues, it is vital to emphasize the importance of education and prevention campaigns and to know which groups may benefit most from these efforts in order to maximize impact. Study findings indicate that age is a significant factor in determing the likelihood of ENDS ever use, with the odds of ever use substantially increased for every one year increase in age. Thus, by the time US youth reach the age of 18 years, their odds of having ever used an ENDS product are quite high. This finding also suggests that education and prevention campaigns might be most effective when introduced earlier rather than later in adolesence. Exposure to anti-tobacco media campaigns in younger students has been shown to result in reduced cigarette and smokeless tobacco use, which suggests a similar outcome may be achievable with ENDS prevention 26. ENDS use is increasingly pervasive within the US youth population, and exposure to these products is undoubtedly high during middle and high school, likely compelling many non-users to initiate use as personal and social pressures mount. In addition to age, other sociodemographic factors, including gender, parental education level, and race/ethnicity, are also significantly associated with likelihood of ENDS initiation. Males are much more likely to be ever users than females. Participants whose parents are either not high school graduates or who hold a Bachelor's or higher academic degree are less likely to be ever users. Participants who identify as Non-Hispanic Black or Non-Hispanic Other are less likely to be ever users as well. Modeling also revealed that those who report utilizing lunch assistance programs, a potential proxy for familial socioeconomic status (SES), may be less likely to initiate ENDS use. These sociodemographic factors are important considerations as tailored education and prevention messages are developed. Our findings on associations between SES and ENDS use warrant investigaton in future research. In this study, participants using lunch assistance programs and those whose parents did not complete high school, both potential proxies that might indicate lower SES, as well as those whose parents had a Bachelor's or higher degree were less likley to use ENDS. Although past examinations of SES and tobacco use are not conclusive, some evidence suggests associations between higher SES and elevated ENDS use, as well as between lower SES, higher combustible cigarette use, and lower ENDS use 27,28. It is possible that the likelihood of using ENDS products is shaped by different factors for these groups of youth. For example, perhaps youth who may be lower in SES make choices based on disposible income. It may be easier to procure traditional tobacco products because they may cost less than ENDS (e.g. buying a 'loosie') 29. Alternatively, tobacco use patterns of family members or friends may shape the product choices of youth or the products that they have most easily available to them. That is, if the family members of lower SES youth are more likely to smoke cigarettes, then they may be more likely to try combustible tobacco and less likely to use ENDS. Our finding that youth with college-educated parents are less likely to use ENDS is surprising, as it differs with some past research findings showing connections between higher income and ENDS use. One possibility is that parent education level may not be a good indicator of SES (e.g. student debt rising, wages stagnating). Another possibility might be that awareness has increased among higher income parents, lower income parents, or both groups, and that they are talking with their children more about these products and/or monitoring their use. Ever use of conventional tobacco products is significantly associated with a substantial increase in odds of being an ENDS ever user. Those who are least familiar with the health risks associated with conventional tobacco use are also most likely to be ever users of ENDS. As our study results underscore, harm perceptions such as these are highly important. Participants reporting that ENDS are safer than conventional tobacco products have significantly greater odds of being ENDS ever users. Similarly, those reporting that ENDS are'very safe' as opposed to'very dangerous' are significantly more likely to have initiated ENDS use at some point in their lives. Interestingly, those indicating that they are most familiar with the health risks associated with ENDS use are also most likely to be ever users of these products. Actual ENDS health-risk knowledge held by participants was not tested, so it is possible that Tob. Prev. Cessation 2020;6(March):20 https://doi.org/10.18332/tpc/117477 those who felt they knew more about the health risks of ENDS also felt that they were better equiped to evaluate the safety of these products, and ultimately concluded that they were safe in many cases. The potential for misinformation leading to a perceived sense of elevated ENDS health risk knowledge in ENDS ever users is a strong supporting factor for education and prevention campaigns that highlight the current body of literature surrounding ENDS health-risk data. In our sample, ENDS were the most common first-used nicotine-containing product, followed by conventional cigarettes. As perceptions of knowledge and safety of nicotine-containing products were significantly associated with likelihood of ENDS use, it seems possible that topic-related information deficiencies may be partially to blame for escalating patterns of use. When this information is coupled with the noted association between increasing age and ENDS ever use, introducing education and prevention campaigns early in middle school or prior to middle school seems warranted. Overall, the results support the existing literature suggesting that those youth at greatest risk for ENDS use are Non-Hispanic White males in their late teens [22][23][24][25], and that ENDS are surpassing conventional tobacco products as the predominant nicotine-containing product used by US youth 5,6,9,30. Paralleling findings in other studies, Non-Hispanic Black youth in our sample were generally less likely to use ENDS 31,32. Also consistent with the existing literature was the finding that perceiving ENDS to be safe or safer than conventional tobacco products increased the likelihood of ENDS ever use 33. Though examining ever use behaviors does not allow temporality assessment, the association between conventional tobacco ever use and ENDS ever use in our study is consistent with the literature suggesting ENDS use may increase the likelihood of uptake of a conventional tobacco habit in former non-users or users of both types of products [34][35][36]. --- Limitations When evaluating the findings, it is important to note the limitations associated with the study. First, its cross-sectional design negated the possibility of assessing the effects of temporality on the observed relationships. Second, the sample was recruited non-randomly, as certain subgroups were oversampled to ensure that adequate comparisons could be made, and the questionnaire was adminstered online; thus, qualified individuals lacking sufficient Internet access may have been excluded. Third, recall bias may have influenced self-reported responses, which, for example, may have led to under-reporting of nicotine product usage (e.g. if such use was not recent). Fourth, sample size was reduced in some cases due to missing or incomplete data. Also, after removal of missing or incomplete data, only participants who identified as male or female remained in the analysis; thus, persons who identify with other gender identities may not be represented by these findings. --- CONCLUSIONS The study findings suggest that certain US youth subpopulations have an elevated likelihood of being ENDS ever users. The subpopulation at greatest risk for ever use of ENDS appears to be Non-Hispanic White males in their mid to late teens. Furthermore, perceptions of the health effects and safety of nicotinecontaining products are significantly related to odds of ENDS ever use. With increasing evidence suggesting potential harms associated with ENDS use and the prevalence of ENDS use steadily rising in the US, prevention efforts may consider precisely targeting groups most vulnerable to use, as well as starting educational initiatives at or prior to middle school. Prevention campaigns coupled with increasingly stringent regulations on the marketing and sale of ENDS being implemented by the US Food and Drug Administration (FDA) will likely prove beneficial. Future research efforts are needed to further examine why certain groups are more susceptible than others. --- PROVENANCE AND PEER REVIEW Not commissioned; externally peer reviewed.

INTRODUCTION Electronic nicotine delivery systems (ENDS) are a relatively new type of nicotine-containing product that has risen greatly in use within the past decade, displacing conventional tobacco products as the dominant source of nicotine exposure by many groups. Among those impacted are large sections of US youth. Though health outcomes associated with ENDS use are still being assessed, several potential harms have been noted in the extant literature. The purpose of this study is to examine which US youth subpopulations are at greatest risk for ENDS ever use and how perceptions pertaining to nicotine-containing products relate to this risk. METHODS A nationwide online survey was administered to US youth ENDS users and non-users aged 13-18 years. A total weighted sample of 2501 participants was obtained. Statistical analyses included binomial logistic regression and a likelihood ratio test. RESULTS Of these youth, 1346 (53.8%) reported having ever used an ENDS product. Those most likely to have used ENDS were White males in their late teens. Those who reported ever using a conventional tobacco product were much more likely to have reported ever using ENDS (AOR= 19.96; 95% CI: 15.30-26.05). A number of perceptions related to nicotine-containing products, including product safety and health effects, were significantly associated with an increased likelihood of ENDS use. CONCLUSIONS Certain sections of the US youth population have elevated odds of being ENDS ever users. As increasing evidence supports the need to combat ENDS use by youth, effectively targeted education and prevention campaigns will be necessary.

INTRODUCTION The black-white test score gap is an empirical problematic that dates back to the 1940s. In many standardized tests the mean scores of black students on average are typically at least 1 standard deviation below the mean scores of white students. As Roland G. Fryer Jr. and Steven D. Levitt (2004) point out, -a wide variety of possible explanations for the test-score gap have been put forth. These explanations include differences in genetic make-up, differences in family structure and poverty, differences in school quality, racial bias in testing or teachers' perceptions, and differences in culture, socialization, or behavior. The appropriate public policy choice (if any) to address the test score gap depends critically on the underlying source of the gap<unk> (447). For the most part, conservative thinkers emphasize the former two approaches, i.e., genetic make-up and differences in family structure and poverty, and prescribe standardization of curriculum, testing, extra assistance programs for blacks, school choice, and teacher training (in standards) as the basis for resolving the problem. Conversely, the latter three, differences in school quality, racial bias in testing or teachers' perceptions, and differences in culture, socialization, or behavior, are emphasized by Afrocentric, postmodern, and liberal thinkers under the banner of identity politics and the opportunity gap, and as such they prescribe head-start programs, multicultural education, teacher training (cultural sensitivity and multicultural training), and equitable funding of schools and resources as the solution for the problem (Wilson, 1998; Yet in spite of these public policy efforts, which have been dialectically recycled over the past forty-years in the US, blacks continue to academically underachieve vis-à-vis their white and Asian counterparts (Wilson, 1998;Carter, 2005;Gordon, 2006). The problem for this continual academic underachievement, according to William Julius Wilson (1998), is based on the fact that both analyses are incomplete. One approach, the conservative position, places the emphasis for the problem on the individual, while the other, the liberal position, on societal or environmental factors. Neither position, however, are able to adequately demonstrate the dialectical interaction between the individual and the social or environment, which can eventually lead to better solutions to resolving the gap (Wilson, 1998). Paul C. Mocombe's (2005Mocombe's (, 2010Mocombe's (, 2012Mocombe's (, 2013) ) -mismatch of linguistic structure and social class function<unk> hypothesis seeks to highlight this dialectic by emphasizing both the opportunities afforded to blacks in the American economy, i.e., the American social relations of production, and individual black responses to its reproduction, differentiation, and ideological apparatuses as the basis for understanding the origins and nature of the black-white test score gap. His Reading Room curriculum and Mocombeian Strategy are offered as solutions to resolving the gap based on the aforementioned dialectical processes. --- BACKGROUND OF THE PROBLEM Given the chants of racism against conservative arguments that emphasize black inferiority such as the ones prescribed by Charles Murray and Richard Herrnstein (1994) in The Bell Curve, postmodern and liberal approaches have dominated recent arguments regarding the black-white test score gap. Contemporarily, the public policy choices of equitable funding of schools, quality educational resources, multicultural education, multiple modes of teaching/intelligences, standardization of curriculum, mentoring, and afterschool programs of school boards throughout the nation to resolve the black-white test score gap have been implemented in light of the predominance and influence of post-structural and postmodern theories of identity politics on education, John Ogbu's cultural, socialization, or behavior explanation, -burden of acting white,<unk> and the opportunity gap hypothesis (Erevelles, 2000;Carter, 2003Carter,, 2005 Postmodern and post-structural theories of identity politics on education highlight education as a -discursive space that involves asymmetrical relations of power where both dominant and subordinate groups are engaged in struggles over the production, legitimation, and circulation of particular forms of meaning and experience (Erevelles, 2000, pg. 30). As such, postmodern and post-structural theorists of education -examine the discursive practices by which student subjectivity (as intersectionally constructed by race, class, gender, and sexuality) is produced, regulated, and even resisted within the social context of schooling in postindustrial times<unk> (Erevelles, 2000, pg. 25). Academic underachievement from this perspective is viewed as the by-product of marginalization, domination, and alienation based on identity and learning styles/multiple intelligences. The idea behind the postmodern/post-structural assumption is that different groups, ethnic, racial, and gender, have different learning styles, and the rational/logical basis of the schooling systems in postindustrial economies marginalize and discriminate against different groups and their learning styles, i.e., tactile, emotive, etc., learners, in favor of white middle class standards and auditory and visual learners. Be that as it may, pedagogically, the public policy choice of postmodern and post-structural theorists are for the most part multicultural education and multiple modes of learning and teaching, which addresses the intersection and diversity of subjective positions and multiple intelligences found among the diversity of students in schools (Kunjufu, 1990;Asante, 1991;Erevelles, 2000;Carter, 2003Carter,, 2005; Mocombe and Tomlin, 2012; Wright, 2013). In keeping with this postmodern/poststructural logic, Afrocentric scholars in the likes of Asa Hilliard, Jawanzaa Kunjufu, Molefi Asante, among many others, attempt, through kinestic pedagogy, the teaching/using of Ebonics, and African American history, to incorporate African-American inner-city linguistic and cultural identity into school curricula as a basis for offsetting the cultural marginalization they experience in the classrooms and closing the achievement gap. However, in under analyzing the capitalist relational (ideological) framework within which what they deem to be the Afrocentric paradigm/worldview of African people in America emerged they overlook the class origins and basis of that worldview, which has in-turn exacerbated black American academic underachievement. In other words, the Afrocentric worldview many scholars attempt to attribute to predominantly the cultures of the inner-cities have their relational origins in the capitalist ideological superstructures of the South and urban inner-cities, which they reify as black culture in an effort to use in classrooms throughout the nation so that black students can achieve economic gain, status, and upward mobility, via education, in the larger society. But the consequence of that reification process is that in the capitalist postmodern and postindustrial world-system within which the Afrocentric reification of Southern and black inner-city (underclass) culture as African culture The Academic Achievement Gap of Black American Students Vis-à-vis Whites and Asians has taken place, white finance capital, in keeping with the postmodern/poststructural logic of identity politics, equality of opportunity, recognition, and distribution, has commodified that reification of inner-city black/Southern underclass culture as both a commodity and the means to status, economic gain, and upward mobility in the larger society for young African American youth. As a result, efforts to achieve economic gain, status, and upward economic mobility amongst black American youth pales in comparison to their efforts to achieve those aims via what has been reified and commodified as black culture, i.e., speaking black English, playing sports, entertaining, hip-hop culture, etc., by Afrocentrists and finance capital. So whereas Afrocentric scholars attempt to use what they deem black culture and their history to instill pride and self-esteem among blacks to offset their underachievement in schools, finance capital utilizes that same culture as an alternative means for blacks to achieve economic gain, status, and upward mobility in the society through black athletic, entertainment, and street cultural productions for consumption in the American post-industrial economy. Be that as it may, whereas Afrocentric scholars in the likes of Asa Hilliard, Jawanza Kunjufu, Molefi Asante, etc., with their emphasis on incorporating the Afrocentric worldview, i.e., African-American English Vernacular, history, and so-called culture, into mainstream curricula throughout the nation in order to offset the linguistic and cultural marginalization many blacks of the inner-cities experience, John Ogbu (1986) argues that it is due to that very culture blacks academically underachieve. In keeping with this postmodern/post-structural notion of identity politics, marginalization, and alienation, John Ogbu's burden of acting white hypothesis suggests that African American students academically underachieve for fear of being labeled -acting white<unk> by their black peers. Ogbu posits that as a result of their marginalization and alienation in the larger society, African Americans have come to perceive academic success as the status marker of whites. Therefore, many African American students, especially black males, conceal their academic prowess for fear of marginalization and alienation, i.e., being labeled acting white, from their black peers. As a result, they are more likely to downplay their intellectual prowess, and identify with the innercity street-life, athletic, and entertainment culture and language as the most authentic representation of black identity. A more recent variant of this hypothesis is the oppositional culture theory approach as proposed by Bourdieuian reproduction theorists in the likes of James Coleman (1966,1988), Prudence Carter (2003,2005), and Karolyn Tyson (2005). Although Coleman and Carter are in agreement with Ogbu, and view the interplay between dominant, middle-class values and norms, and non-dominant -black<unk> cultural capital as real, albeit from a sociological perspective. They do not view this new -blame the victim<unk> paradigm as the overwhelming reason for the locus of causality for black academic underachievement and lack of mobility in mainstream American society. Carter and Coleman and many other liberal scholars, for the most part, emphasize the opportunity gap, i.e., lack of quality schools, teachers, resources, and standards, as the basis for the black-white test score gap. Whereas Carter highlights the latter processes, Coleman emphasizes social segregation. Contemporarily, the opportunity gap with its emphasis on equitable funding of schools, quality teachers, resources, and teaching standards, etc., postmodern and post-structural logic of identity politics, marginalization, and alienation in school based on ability, learning styles, and subjective positions coupled with John Ogbu's hypothesis, which suggests that black Americans intentionally academically underachieve vis-à-vis their white and Asian counterparts for fear of being labeled -acting white<unk> by their black peers who view academic achievement as the status marker of whites, virtually dominate how teachers, educators, and school administrators address the black/white academic achievement gap. Teachers, educators, and school administrators throughout the American nation prescribe equitable funding of schools, teacher training, multicultural education, multiple learning and teaching styles, standardization of curriculum, mentoring, and after-school programs as appropriate policy prescriptions to combat the marginalization, alienation, and effects of the opportunity gap, identity politics, and the burden of acting white on the academic achievement of black American students. The intent behind these policy prescriptions is based on the assumption that equitable funding of schools and resources, the representation of educated blacks in school curriculums through mentoring programs and multicultural (Afrocentric) curriculum materials coupled with kinesthetic pedagogical approaches to teaching black American students, the standardization of curricula, and added assistances, head-start and after-school programs, offered to blacks will increase their academic achievement vis-à-vis their white and Asian counterparts. --- THEORY AND METHOD More than 40 years have passed since the opportunity gap, postmodernism and poststructuralism made identity politics fashionable, and Fordham and Ogbu initially gave credence to the -burden of Acting white<unk> and the -oppositional peer culture<unk> hypothesis in their essay -Black Students' School Success: Coping with the -Burden of Acting White<unk> (1986). Although social scientists have produced very little empirical evidence to substantiate either the correlation between identity politics and academic achievement on standardized tests or the validity for a -burden of acting white,<unk> there is still strong public support and belief in their assertions for explaining the academic underachievement of black American students and the black/white achievement gap (Wilson, 1998;Carter, 2005;Tyson et al, 2005). In fact, as Tyson et al further observed in their assessment of eight North Carolina secondary public schools, -the acting white theory significantly influences how schools address problems related to black underachievement, which, in turn, helps to determine whether these solutions ultimately can be effective<unk> (2005, p. 582). Schools and school boards have introduced multicultural education (Afrocentric materials in the case of blacks), head start programs, mentoring and counseling programs, and black achievement in education has been stressed above all things else in the school curriculum in order to combat the effects of black marginalization in school and the burden-of-acting-white. Moreover, to offset the opportunity gap, funding of inner-city schools, head-start, after-school, and in-school programs, standardization of curricula (The Common Core State Standards) across the nation, and teacher training programs have dominated public education over the last 40 years. Yet in spite of these efforts, the black/white academic achievement gap has widen since the 1980s, and blacks everywhere on average score disproportionally poorly on standardized tests compared to their white counterparts. In the United States, for example, just 12% of African-American 4th graders have reached proficient or advanced reading levels, while 61% have yet to reach the basic level. In a national assessment of student reading ability, black children scored 16% below white children. Forty-six percent of black adults, compared with 14% of white adults, scored in the lowest category of the National Adult Literacy survey. The results indicate that blacks have more limited skills in processing information from articles, books, tables, charts, and graphs compared with their white counterparts (Gordon, 2006, p. 32). More perplexing, the students who lose the most ground are the higher-achieving black children. -As black students move through elementary and middle school...the test-score gaps that separate them from their better-performing white counterparts grow fastest among the most able students and the most slowly for those who start out with below-average academic skills<unk> (Viadero, 2008, p. 1). The numbers among British Caribbean blacks are far worse in places like the United Kingdom (Mocombe andTomlin, 2010, 2013). Given this continual reliance on the opportunity gap, identity politics, or a burden of acting white hypothesis to explain the academic underachievement of black students and the blackwhite achievement gap in the face of persistent black academic underachievement on standardized tests, further assessment of this cultural incompatibility hypothesis is critical to understanding and addressing the problem. Using longitudinal Florida Comprehensive Assessment Test (FCAT) data from a Florida after-school program covering the periods 2003-2007, Paul C. Mocombe analyzed and evaluated the origins and nature of the black/white achievement gap. Demonstrating and concluding that the origin of the black/white academic achievement gap is not a result of a lack of opportunities to adequate schools and resources, black marginalization, or a burden of acting white. But is grounded, for the most part, in what Mocombe (2005Mocombe (, 2008Mocombe (, 2013) ) refers to as a -mismatch of linguistic structure and social class function,<unk> which is an epiphenomenon of capitalist racial-class divisions and social relations of production. That is, Mocombe argues that the data suggests that black American students academically underachieve vis-à-vis their white and Asian counterparts because of two epiphenomena of the American capitalist social structure of racial-class inequality. First, early on in their academic careers black American youth academically underachieve on standardized tests because of comprehension, which is grounded in the generative grammar of their linguistic structure, African American English Vernacular (AAEV). Lastly, they underachieve due to the social functions associated with their over-representation in social roles as criminals, athletes, and entertainers in the American capitalist social structure of racial-class inequality as speakers of AAEV. Black American students, contemporarily, have more limited skills in processing information from articles, books, tables, charts, and graphs, and the students who lose the most ground visà-vis their white and Asian counterparts are the higher-achieving black children because of two epiphenomena of American capitalist racialclass structural reproduction and differentiation, according to Mocombe. Early on in their academic careers the poor black social class language game, -black American underclass<unk> (who have become the bearers of ideological and linguistic domination for black youth the world over), created by ideological apparatuses, i.e., prisons, poor schools, the streets, athletic and entertainment industries, of the social relations of capitalism in the US, produces and perpetuates a sociolinguistic status group that reinforces a linguistic structure (Black/African American English Vernacular-BEV or AAEV), which linguistically and functionally renders its young social actors impotent in classrooms where the structure of Standard English is taught. Thus early on (k-5th grade) in their academic careers, many black American inner city youth struggle in the classroom and on standardized test because individually they are linguistically and grammatically having a problem with comprehension, i.e., -a mismatch of linguistic structure,<unk> grounded in their (Black or African American English Vernacular) speech patterns or linguistic structure (Mocombe, 2007(Mocombe,, 2009(Mocombe,, 2010;;Mocombe andTomlin, 2010, 2013). This mismatch of linguistic structure argument is not a reiteration of the -linguistic deficit<unk> hypothesis of the 1960s and 70s, which suggested that working-class and minority children were linguistically deprived, and their underdeveloped slangs' and patois' did not allow them to critically think in the classroom (Bereiter and Englemann 1966; Whiteman and Deutsch, 1968; Hess, 1970). On the contrary, as Labov (1972) brilliantly demonstrated in the case of African American youth they are very capable of analytical and critical thinking within their linguistic structure/system (BEV/AAEV). What Mocombe posits through his Chomskyian mismatch of linguistic structure hypothesis is that the pattern recognition in the neocortex of the brains of many poor African American inner-city youth is structured by and within the systemicity or -generative grammar<unk> of Black/African-American English Vernacular (BEV/AAEV), which is a distinct linguistic system from Standard American English (SE). As a result, when they initially enter school, which is an ideological apparatus for bourgeois (cultural and linguistic) domination, there is a phonological, morphosyntactical, and semantical mismatch between BEV/AAEV and the Standard English (SE) utilized in schools to teach and test them. Given the segregation and poverty of blacks growing up in the inner-cities of America, they acquire the generative grammar of Black English and early on in their academic careers lack the linguistic flexibility to switch between BEV/AAEV and SE when they take standardized tests. As a result, many black American youth have a syntactical problem decoding and understanding phrases and sentences on standardized tests written in Standard English (Kamhi, 1996 Later on in their academic careers as these youth become adolescents and acquire the linguistic flexibility to code switch between BEV/AAEV and SE, the test scores close dramatically and then widen again by the time they get to middle and high school. This widening of test scores from middle school onward, Mocombe posits, is not due to a lack of access to quality educational resources. But is a result of the opportunities afforded to blacks by the capitalist social structure of class inequality. Black American youth are further disadvantaged by the social class functions (a mismatch of function of the language) the power elites of the black American underclass, reinforces against those of middle class black and white America. That is, success or economic gain and upward mobility amongst the -black underclass,<unk> who speak BEV/AAEV, is not measured by status obtained through education as in the case of black and white American bourgeois middle class standards. On the contrary, athletics, music, and other activities not -associated<unk> with educational attainment serve as the means to success, economic gain, and upward economic mobility in the US's postindustrial society. Thus given the choice black adolescent students make to pursue other means, i.e., athletics, the streets, and entertainment industries, to economic gain, status, and upward economic mobility in the society, effort in school in general suffers, and as a result test scores and grades progressively get lower. Grades and test scores are not only low for those who grow-up in poor inner-cities, it appears to have also increased as academic achievement and/ or social-economic status (SES) rises. -In other words, higher academic achievement and higher social class status are not associated with smaller but rather greater differences in academic achievement<unk> (Gordon, 2006, pg. 25). It is this epiphenomenon, -mismatch of linguistic social class function,<unk> or the social bases of classspecific forms of language use (Bernstein, 1972) of the -mismatch of linguistic structure<unk> many scholars (Ogbu, 1974(Ogbu,, 1990(Ogbu,, 1991;;Coleman, 1988;Carter, 2003Carter,, 2005) ) inappropriately label -the burden of acting white<unk> or oppositional culture amongst black adolescents, who as they get older turn away from education, not because they feel it is for whites or identify more with the cultural capital of the black poor, but due to the fact that they have rationalized other racialized (i.e., sports, music, pimping, selling drugs, etc.) means, financed by the upper-class of owners and high-level executives, to economic gain for its own sake other than status obtained through education (Carter, 2003;Mocombe, 2005Mocombe,, 2007Mocombe,, 2011; Mocombe and Tomlin, 2010). In America's postindustrial economy, black American youth (black boys in particular) identify with and look to athletes, entertainers, players, gangsters (criminals), etc., many of whom are from the black urban underclass, as role models over professionals in fields that require an education. Historically, Mocombe concludes, this is a result of racial segregation and black social relations to the mode of production in America, and not their cultural ethos, which is no different from white America, or the so-called opportunity gap. --- DISCUSSION AND CONCLUSION Although, paradoxically, Mocombe views education as an ideological apparatus for capitalist domination which ought to be eliminated along with the state, to correct this mismatch of linguistic structure and social class function structural phenomenon and help close the academic achievement gap, in 1999 Mocombe, as part of his doctoral work, developed The Mocombeian Strategy and Reading Room Curriculum for the Russell Life Skills and Reading Foundation, Inc., an after school reading and mentoring program located in Ft. Lauderdale, Florida. The latter, Reading Room Curriculum, is a reading curriculum of seven books, published as Mocombe's Reading Room Series, developed by Paul C. Mocombe based on the theoretical cognitive linguistic assumptions of Noam Chomsky. Against the behaviorist approach to the acquisition of language, Noam Chomsky's cognitive linguistics, -generative grammar,<unk> suggests that the syntactical structure of a language is an innate tool hardwired in the brain that helps human beings experience the world and communicate with others. By assuming, as William Labov building on the theoretical linguistics of Chomsky posits in his seminal work Language in the Inner-cities, BEV/AAEV of inner-city black American students to be a distinct linguistic system with its own deep and surface structure, i.e., generative grammar, through which many black Americans of the inner-cities comprehend and make sense of the world, Mocombe concludes that African or black American students should be assessed and taught as though they are ESOL (English Speakers of other Languages) students when they initially enter school. In other words, Mocombe suggests, because young black Americans grow up knowing and speaking a distinct linguistic system (BEV/AAEV) with its own syntax, lexicon, phonetics, semantics, etc., generative grammar or syntactical structure in Chomskyian terms, which is distinct from the generative grammar of Standard English (SE), when African American or black American students enter school, teachers should attempt to restructure their linguistic structure from BEV/AAEV to SE, by teaching them reading via phonics and language arts, the rules/syntax of Standard English, and using reading passages as practice so as to demonstrate their mastery of the new language system. In other words, teach them the rules of Standard English with a heavy emphasis on phonics, language arts, and use reading passages as practice to demonstrate that they can comprehend in, and have acquired the mastery of the second language, in this case, Standard English. Mocombe's Reading Room Series books of the curriculum attempt to do just that restructure the deep and surface structure of speakers of BEV/AAEV to that of SE through the phonics, language arts, and reading activities of the workbooks so as to increase their comprehension levels on standardized tests. --- Essentially, Mocombe's Reading Room Curriculum offers an analytical phonetic approach to teaching black American students reading, over a whole language approach, in order to teach them the generative grammar of a new language, Standard English, and match their linguistic structure with that of the Standard English utilized on Standardized tests to assess their academic abilities. In the whole language approach to reading, which grew out of Ken Goodman's (1967) attempt to apply Chomsky's generative grammar hypothesis about language acquisition to reading, the assumption is that reading, like language, is an innate ability that can be improved upon without placing much effort on phonics, spelling, and learning the grammar rules of a language outside of its pragmatic usage. As such, whole language approaches, i.e., culturally-diverse literature, integrating literacy into other areas of the curriculum (math, science, etc.), frequent reading, reading out loud, and embedded phonetic learning, to reading and understanding is usually juxtaposed against analytical phonetics, language arts, and spelling approaches to reading, writing, and understanding. That is, in teaching students how to read in the whole language model, the emphasis is on meaning and strategy instruction to develop knowledge of language including the graphophonic, syntactic, semantic, and pragmatic aspects of it that the students bring with them to and in the learning process. Language is viewed as an innate complete meaning-making system, which students improve upon in sociocultural context beginning in their early socialization with their parents and other young people. Be that as it may, reading involves the entire components of a language system, and students because they already know it innately rely more so on taught strategies, semantic, syntactic, and pragmatic cues that make it possible to understand a passage meaningfully. Essentially, students when they read guess meaning and understanding based on their grasp of the phonetic, semantic, syntactic, and pragmatic cues of a language system, which they know innately, to comprehend. Conversely, an analytical phonetic approach to reading emphasizes learning the syntactical, grammatical, semantical, and phonetic parts of a language system in order to string them together to grasp meaning and understanding within a language system. Whereas the latter, phonetic approach to reading, approaches reading through the acquisition and building the parts of a language in the brain to grasp meaning and understanding holistically, whole language approaches reading and language holistically and attempts to understand its parts contextually and via cues, strategies, taught and learned. Mocombe's Reading Room curriculum builds on the former, phonetics and language arts, and utilize some of the Vygotskian sociocultural techniques and tools, reading aloud, vocabulary development, culturally diverse reading passages, etc., of whole language to assess for mastery of the rules of the language system. In other words, Mocombe suggests teaching reading to black American academic underachievers through the building of the language system, through its lexical, phonetic, semantic, and syntactic rules, to restructure the linguistic structure of innercity black American youth from BEV to SE, as though they are foreign speakers of the language, in order to increase their comprehension when they take standardized tests. Mocombe's theoretical assumption behind the intent of the Reading Room curriculum workbooks is to combat the mismatch of linguistic structure hypothesis he views as the initial basis for the black/white achievement gap. That is, per Mocombe, when black American inner-city students initially (K-5th grade) enter school many of them struggle in the classroom and on standardized test because individually they are linguistically and grammatically having a problem with comprehension, i.e., -a mismatch of linguistic structure,<unk> grounded in their (Black or African American English Vernacular) linguistic structure and speech patterns (Mocombe, 2005(Mocombe,, 2007(Mocombe,, 2009(Mocombe,, 2010)). In other words, their brains are preprogrammed with the generative grammar of BEV/AAEV. As such, there is a phonological, morphosyntactical, and semantical mismatch between the generative grammar of BEV/AAEV and that of the Standard English (SE) utilized in schools to assess them. Given the segregation and poverty of blacks growing up in the inner-cities of America, they acquire the systemicity of Black English and early on in their academic careers lack the linguistic flexibility to switch between BEV/AAEV and SE when they take standardized tests. As a result, many black American youth have a problem decoding and understanding phrases and sentences on standardized tests, which explains their poor test scores vis-à-vis their white counterparts (Kamhi, 1996;Johnson, 2005;Mocombe, 2005Mocombe,, 2010;;Mocombe and Tomlin, 2010). Teachers, for the most part, because they view the BEV/AAEV of black American students as broken English/slang as opposed to a distinct linguistic system, do not view them as speakers of another language, and assume that they are English speakers. As a result, in the contemporary education system in which multiculturalism and dialogical processes, cooperative group works, projects, etc., to learning are taught and emphasized, few emphasis is place on teaching African American students to learn, via rote memorization, the rules and grammar of SE so as to restructure their linguistic structure (BEV/AAEV), which is viewed, by Afrocentric theorists, as their multicultural contribution to the American melting pot. The Reading Room Series books attempt to restructure the linguistic structure of black American students through a phonetic and syntactic approach to teaching reading in order to increase their comprehension levels when they take standardized tests written in Standard English. Coupled with the reading room curriculum, Mocombe also offers the Mocombeian Strategy as a pedagogical tool to combat the black/white achievement gap. The Mocombeian Strategy (2005), published under the title of the same name, suggests that if the education and professionalization of black American students via education is the modus operandi of American bourgeois society as opposed to the capitalist emphasis on money, class, status, economic gain, and upward social mobility, school systems should also invest, in conjunction with the Reading Room Curriculum, in a comprehensive mentoring program that pairs black American students (especially black boys), throughout their academic careers, with educated professionals in the fields of science, mathematics, medicine, teaching, and other professions that require an education. Contrary to the position of many Afrocentric scholars, Mocombe does not assume African Americans to have a distinct identity and worldview from their white counterparts. That is, there are no distinct Afrocentric ideological apparatuses African Americans are socialized in to prescribe to them a distinct worldview and purposive-rationality from that of their European counterparts in the larger society. The distinguishing factors for Mocombe are the racialclass position of blacks in the society, the economic opportunities they are overrepresented in, and the different ideological apparatuses the different classes are predominantly socialized in, i.e., schools, churches, the streets, prisons, and athletics and the entertainment industries, in order to achieve the overall economic gain, status, and upward mobility prescribed by the society. Whereas the bourgeoisie, whether black or white, once prescribed education as the means to status in the society, the black underclass emphasize the streets, i.e., hustling, athletics, and the entertainment industries. Today, postindustrial capital has reified and commodified the latter as viable means to economic gain, status, and upward mobility, which is paradoxically leading to black academic underachievement as black youth are less likely to place much effort on achieving in school due to other avenues or social roles and opportunities that are opened to them in the larger society. So the issues for Mocombe, contrary to the opportunity gap, oppositional culture, and identity politics positions, are ones of linguistic system, visibility, achievement, and social roles as opposed to cultural identity and opportunities or the lack thereof afforded to them by the larger society, i.e., cultural incompatibility theory. Identification with the social roles of the black underclass is not cultural it is structural or sociocultural in the Vygotskian sense. Be that as it may, the logic here is that by having Standard English speaking educated black American professionals as social role models for young black American students to interact with and learn from throughout their academic careers, school systems will be able to combat the effects of the visibility, achievements, and social roles associated with the social class functions of the power elites of the black American underclass and BEV/AAEV in the society. The logic behind this approach is grounded in Mocombe's theoretical assumption that later on in their academic careers black American students academically underachieve because of what he refers to as a mismatch of linguistic social class function, which is tied to the aforementioned mismatch of linguistic structure construct. As previously mentioned, for Mocombe two dominant black American social class language games, for the most part, dominate the American capitalist social landscape, a Standard English-speaking black middle class of educated professionals, and an African American Englishspeaking underclass of workers and unemployed blacks living in the inner-cities of America. Whereas, status, economic gain, and upward social mobility for the Standard English-speaking black middle class are for the most part measured via their class, status, economic gain, and upward social mobility obtained through education and professions that require schooling. Class,

In response to the academic achievement gap of black American students ' vis-à-vis whites and Asians, Paul C. Mocombe developed his Mocombeian Strategy and Reading Room Curriculum, which posit a comprehensive mentoring program of educated black professionals and the restructuring of the linguistic structure of black American inner-city students via phonetic and language arts instructions, as the solutions to resolving the gap. The two approaches are based on Mocombe's hypothesis that the academic underachievement of black American students, vis-à-vis their white and Asian counterparts, on standardized tests is grounded in what he refers to as "a mismatch of linguistic structure and social class function." This work explores the theoretical, practical, and pedagogical relationships between Mocombe's "mismatch of linguistic structure and social class function hypothesis," The Mocombeian Strategy, and Reading Room Curriculum (published as Mocombe's Reading Room Series).

as social role models for young black American students to interact with and learn from throughout their academic careers, school systems will be able to combat the effects of the visibility, achievements, and social roles associated with the social class functions of the power elites of the black American underclass and BEV/AAEV in the society. The logic behind this approach is grounded in Mocombe's theoretical assumption that later on in their academic careers black American students academically underachieve because of what he refers to as a mismatch of linguistic social class function, which is tied to the aforementioned mismatch of linguistic structure construct. As previously mentioned, for Mocombe two dominant black American social class language games, for the most part, dominate the American capitalist social landscape, a Standard English-speaking black middle class of educated professionals, and an African American Englishspeaking underclass of workers and unemployed blacks living in the inner-cities of America. Whereas, status, economic gain, and upward social mobility for the Standard English-speaking black middle class are for the most part measured via their class, status, economic gain, and upward social mobility obtained through education and professions that require schooling. Class, status, economic gain, and upward social mobility amongst the power elites, i.e., gangstas, rappers, athletes, and entertainers, of the -black American underclass,<unk> who speak BEV/AAEV, is not measured by status and professions obtained through education as in the case of black and white American bourgeois middle class standards; on the contrary, the streets, athletics, music, and other professional activities not -associated<unk> with educational attainment serve as the means to social class, status, economic gain, and upward economic social mobility in the US's postindustrial society. Thus effort in school in general suffers, and as a result test scores and grades progressively get lower as black American adolescent youth place more effort in achieving economic gain, status, and upward social mobility via the social functions and roles, i.e., the streets, athletics, entertainment, and hiphop culture, tied to the BEV/AAEV linguistic structure and social function of the black underclass, over ones tied to the Standard English linguistic structure and function of the black and white middle class. Contemporarily, the former social class language game, the black underclass, has become the bearers of ideological and linguistic domination in black America and the world-over via their over-representation in the media industrial complex of corporate capital. The Mocombeian Strategy suggests combating this impact of the linguistic structure and social class function of the black underclass through a comprehensive mentoring program that pairs educated professionals with young black American students (black boys in particular) who are more likely to identify with and look to young rappers, athletes, and entertainers, the power elites of the underclass, as social role models over their more educated counterparts. The Mocombeian Strategy and Reading Room Curriculum, published as Mocombe's Reading Room Series, Mocombe suggests, together are two effective practical and pedagogical tools that can be implemented through after-school programs and school systems to help close the black/white academic achievement gap in the American capitalist social structure of racialclass inequality. Future research must continue to explore this relationship between class, linguistic structure, and social class roles as the basis for understanding and finding solutions to the black-white test score gap. Albeit for the pan-African Marxist-anarchist Mocombe, this ought to be done within an -enframing<unk> ontology in opposition to the capitalist social structure of class inequality.

In response to the academic achievement gap of black American students ' vis-à-vis whites and Asians, Paul C. Mocombe developed his Mocombeian Strategy and Reading Room Curriculum, which posit a comprehensive mentoring program of educated black professionals and the restructuring of the linguistic structure of black American inner-city students via phonetic and language arts instructions, as the solutions to resolving the gap. The two approaches are based on Mocombe's hypothesis that the academic underachievement of black American students, vis-à-vis their white and Asian counterparts, on standardized tests is grounded in what he refers to as "a mismatch of linguistic structure and social class function." This work explores the theoretical, practical, and pedagogical relationships between Mocombe's "mismatch of linguistic structure and social class function hypothesis," The Mocombeian Strategy, and Reading Room Curriculum (published as Mocombe's Reading Room Series).

The neighborhood is a key part of an older adult's environment (Barnes et al., 2007) that helps to maintain and promote participation in daily life and can contribute to deterioration in participation (Glass & Balfour, 2003;Law et al., 1996). Social participation, defined as "a person's involvement in activities that provide interaction with others in society or the community" (Levasseur, Richard, Gauvin, & Raymond, 2010, p. 2148), can be particularly affected by neighborhood characteristics. Individual characteristics and environmental barriers interact to affect older adults' participation (White et al., 2010), and individuals facing health or other challenges may experience their neighborhoods differently than individuals not facing these challenges (Glass & Balfour, 2003). The current study investigated relationships between neighborhood features, mobility limitation, and social participation, building on existing literature to identify potential directions for neighborhood change and future research. Although research examining the relationships between neighborhoods and older adults' social participation is emerging and more is needed, some trends can be identified. A recent review noted that social participation is associated Journals of Gerontology: Social Sciences cite as: J Gerontol B Psychol Sci Soc Sci, 2019, Vol. 74, No. 3, 546-555 doi:10.1093/geronb/gbw215 Advance Access publication February 1, 2017 with proximity to resources and recreational facilities, public transportation, neighborhood security, and user-friendliness of the walking environment (Levasseur et al., 2015). Social cohesion also appears to be a key facilitator of social participation. Higher levels of neighborhood social cohesion are associated with higher frequency of social participation (Bowling & Stafford, 2007;Richard, Gauvin, Gosselin, & Laforest, 2009), community participation (Vaughan, La Valley, Al Heresh, & Keysor, 2015), and overall participation (Hand, Law, Hanna, Elliott, & McColl, 2012). Older adults also report that a sense of community belonging supports their social participation (Andonian & MacRae, 2011;Gardner, 2011). Very few studies of neighborhood characteristics and social participation in older adults have utilized area-level information such as census data, thus failing to explore potential contributors to social participation that can be difficult to capture through smaller-scale studies. In particular, neighborhood demographics, population density, and area-level income may play a role in older adults' social participation. Regarding neighborhood demographics, older adults living in areas with higher proportions of age-peers are more likely to use nearby parks (Moore et al., 2010), are less likely to report poor health (Subramanian, Kubzansky, Berkman, Fay, & Kawachi, 2006), and are less likely to report depression (Kubzansky, Subramanian, Fay, Soobader, & Berkman, 2005), compared with older adults living in areas with lower proportion of older adults. In addition, residents in neighborhoods with higher proportions of older adults report higher social cohesion, compared with neighborhoods with higher proportions of families (Moorman, Stokes, & Morelock, 2016) and greater density of older adults may lead to less age discrimination (Stokes & Moorman, 2016). Older adults living in neighborhoods with higher proportions of younger age groups may have fewer social connections that might otherwise encourage them to use neighborhood facilities (Moore et al., 2010). Regarding population density, higher density is related to increased walking for transport in older adults (Shigematsu et al., 2009), increased walking in older men (Gallagher, Clarke, & Gretebeck, 2014), and increased walking in adults (Sugiyama et al., 2014). Such increases in walking may also relate to increases in social participation, for example, if leisure walking involves other people or if walking for transport involves attending social events. In fact, the presence of opportunities for social interactions is related to walking frequency (Nathan et al., 2012). Finally, low neighborhood economic status is associated with lower frequency of social activities (Bowling & Stafford, 2007), and older adults living in areas with high poverty are also more likely to report poor health (Subramanian et al., 2006). Mobility limitation may be a key individual characteristic that moderates the effect of neighborhood characteristics on social participation. Good physical health is related to frequency of social participation (Buffel et al., 2014), high physical function is related to more satisfaction with overall participation (Hand et al., 2012), and higher frequency of walking in one's neighborhood and better general health is related to increased social participation (Richard et al., 2009). Few studies, however, have explored interactions between mobility limitations and neighborhood features as they relate to social participation in older adults. The available research suggests that such interactions exist; among adults aged 45 years or older with mobility limitations, neighborhood security predicts greater frequency of socializing with others (Clarke, Ailshire, Nieuwenhuijsen, & de Kleijn-de Vrankrijker, 2011). In addition, a realist synthesis of evidence found that older adults with mobility limitations may feel more unsafe in the neighborhood, and may avoid walking in their neighborhood, compared with older adults with no mobility limitations (Yen et al., 2014), potentially affecting social participation. Finally, given that population density appears linked to walking for transport in older adults (Shigematsu et al., 2009), older adults who are able to walk in their neighborhoods may engage in more social activities in more dense neighborhoods due to more opportunities to meet with others. --- Conceptualizations of Aging and Place Relationships between and among individual and neighborhood characteristics can be understood within theories of aging and the environment. Within Lawton and Namehow's (1973) Ecological Model of Aging, behavior and function result from an individual's interactions with the physical and social environment. Further theory proposes that human action is embedded in socially constructed, dynamic places that include physical-spatial and social-cultural elements that individuals negotiate over time (Wahl & Lang, 2004). For example, an acquired mobility limitation may mean that different neighborhood features are more important than previously in supporting participation. Similarly, a transactional perspective conceptualizes place as a dynamic, complex interplay of people and various environmental elements, while also asserting that people and places inseparable from one another (Cresswell, 2004;Cutchin, 2004). Individuals and their activities do not exist within the "environment as container" but instead form a person-place whole (Cutchin, 2004). The person and environmental elements continually shape one another and change over time. For example, place can shape individual characteristics such as motivations and values, whereas individuals are elements of the environment that also shape it (Cutchin, 2004). Specific aspects of place can transact with one another (Andrews, Evans, & Wiles, 2007) and with aspects of the person to enable or constrain participation in activities, pointing to a need to examine relationships between place and specific activities, rather than categories of activities. Little research has explored interactions between and among neighborhood and individual characteristics. --- The Current Study Research regarding the relationships between neighborhoods and social participation in older adults requires exploration of a wider range of neighborhood characteristics, exploring interaction effects between mobility and neighborhood characteristics, and exploring different types of social participation separately to better understand differential impacts of neighborhood characteristics. In addition, research in this area requires analysis of large samples (Clarke & Niuewenhuijsen, 2009), especially given that neighborhood effects are often small in comparison with individual effects. Addressing these limitations and needs, the purpose of this study was to examine the relationships between neighborhood characteristics, interactions between neighborhood characteristics and mobility limitation, and frequency of participation in three specific social activities among older adults. We hypothesized that greater frequency of participating in social activities would be associated with less neighborhood socioeconomic disadvantage, greater proportion of neighborhood residents aged 65 years or older, higher population density, and greater neighborhood social cohesion. We also hypothesized that ability to walk several blocks would interact with the neighborhood characteristics population density and social cohesion, such that individuals without mobility limitation would experience greater effects of higher population density and higher social cohesion compared with individuals with mobility limitation, due to increased likelihood of walking in their neighborhoods and therefore being affected by neighborhood characteristics. Alongside this hypothesis, given the limited research in this area, we also recognized that neighborhood characteristics may have a stronger association with participation for individuals with mobility limitation, because of a potential greater need for support in participating. --- Method --- Study Design and Data This cross-sectional study used data from the 2008 Health and Retirement Study (HRS) combined with census tractlevel data drawn from the American Community Survey (ACS; Minnesota Population Center, 2011). The HRS is a longitudinal panel study of a representative sample of adults aged 50 and older in the United States. Ongoing since 1992, the HRS interviews approximately 20,000 participants every 2 years (University of Michigan, 2016). Details describing the methods have been discussed elsewhere (Juster & Suzman, 1995). Since 2006, the HRS has included a "Leave-Behind" questionnaire addressing life circumstances, subjective well-being, and lifestyle that participants complete independently and return by mail (Smith et al., 2013). This questionnaire is provided to 50% of the HRS participants who completed an in-person core interview; in each wave of the HRS, the sample is rotated. We obtained data regarding census tract of participants in the HRS, and we merged this data with the ACS data following confidentiality protocols set by the University of Michigan. Inclusion criteria for the current study were as follows: age 65 years or more, not living in a nursing home at the time of the 2008 HRS interview, and completed a 2008 HRS core interview and leave-behind questionnaire (n = 4,613). This sample size decreased based on missing data in the HRS and Leave Behind questions, such that the final sample sizes ranged from 3,985 to 3,995 across the analyses. See Supplementary Table 1 for details regarding missing data. Compared with the initial group of participants (i.e., n = 4,613), the final samples were more likely to be younger, female, White, and have high school education or more. Regarding health status, the final samples were more likely to report better health status in the analyses regarding attending meetings of nonreligious groups. The samples for the two other analyses were not significantly different from the initial group in self-reported health status. --- Measures --- Dependent variables Social participation was assessed using questions from the Leave-Behind Questionnaire of the HRS data set on the frequency of participating in four social activities. Items are phrased as "Please tell us how often you do each activity," and activities listed include "Go to a sport, social, or other club"; "Attend meetings of non-religious organizations, such as political, community, or other interest groups"; "Do volunteer work with children or young people"; and "Do any other volunteer or charity work." These activities fit within Levasseur and colleagues' (2010) taxonomy of social participation, in which social participation includes interacting with others, doing activities with others, helping others, and contributing to society. Questions are answered on a 6-point Likert scale (1 = Daily, 2 = Several times a week, 3 = Once a week, 4 = Several times a month, 5 = At least once a month, 6 = Not in the last month). These scores were dichotomized as frequent (daily/several times a week/ once a week/several times a month) and infrequent (at least once a month [but less than several times a month]/not in the last month). Volunteering with children or young people and other volunteer work were combined into a single item, such that if either or both types of volunteering were "frequent," then the new volunteering item was coded as frequent, and if both types of volunteering were "infrequent" then the new volunteering item was coded as "infrequent." --- Independent variables Four neighborhood variables were included in the analysis as follows: • Neighborhood social cohesion was measured using a four-item scale from the Leave-Behind Questionnaire of the HRS that assesses the extent to which each participant feels (a) part of the area, (b) that most people can be trusted, (c) that most people are friendly this area, and (d) that people help you if in trouble. On a 7-point scale, participants rate how strongly they agree with opposing statements, for example: I really feel part of this area versus I feel that I don't belong in this area. Lower scores indicate stronger agreement with a positive statement. An index was created by averaging the scores of the items (Smith et al., 2013) if three or four items on the scale were non-missing. The scale has an internal consistency of 0.86 (Smith et al., 2013) Physical mobility was assessed using the question "Because of a health problem do you have any difficulty with walking several blocks?" Response options were dichotomized as no difficulty versus any difficulty/don't do/cannot do. Several control variables from the HRS data set were used, including vehicular mobility, which was assessed with the question "Have you driven a car in the past month?" and was dichotomized as yes or no. Individual socioeconomic status was evaluated through financial strain and educational attainment. Financial strain was assessed with the question "How satisfied are you with your present financial situation?" Responses were dichotomized as completely/very satisfied and somewhat/not very/not at all satisfied. Educational attainment was assessed as the total number of years of education and dichotomized as low attainment (<unk>12 years) or high attainment (<unk>12 years). Demographic and health characteristics included age, gender, race/ethnicity (Hispanic, White, Black, or other), marital status (married vs separated/divorced, widowed or never married), and self-reported health status (very good/ excellent vs good/fair/poor). --- Analysis Logistic regression was used to estimate the associations between individual and neighborhood characteristics and frequency of participating in each of the three activities. The effects of interactions between independent variables on participation variables were also estimated, including mobility limitation times population density and mobility limitation times neighborhood social cohesion. Interaction terms, coded the same way as the main effects, were added to each model, one at a time. The complex survey design and weighting of the HRS data were accounted for in the SAS procedure PROC SURVEYLOGISTIC. This procedure uses Taylor expansion approximation incorporating stratification, clustering, and unequal weighting, computing variances within each stratum before pooling. HRS weights are adjusted for nonresponse and are representative of the noninstitutionalized U.S. population aged 50 years or older. In addition, in the HRS Leave-Behind questionnaire, weights are adjusted to reproduce the weighted distribution according to age (groupings of <unk>65, 65-74, <unk>75 years), gender, and race/ethnicity. Goodness of fit of the models was assessed using the Wald test (p <unk>.05; Allison, 2014). For each model, cases with missing data on any variable were dropped from the analysis. We were unable to match a number of cases with census tract-level data regarding the proportion of the tract aged 65 and older (80 cases), population density of the tract (80 cases), and proportion living in poverty (35 cases). Of those missing proportion 65 years and older, 60 had insufficient linking information in the HRS geo-identifier file and the remaining 20 could not be linked to data in the ACS data. It is possible that the data linkage provided by HRS was incorrect resulting in no match with census data or that the data were not available from the ACS for those specific geographies for the year studied. Another possibility is that data were suppressed in those geographies due to small cell sizes, data quality filtering or other rules imposed by the census. Because we had missing census tract data as well as missing HRS survey data, we performed sensitivity analyses using multiple imputation with chained equations, creating 50 data sets, and reran the analyses. The study was approved by the (omitted for anonymous review) Internal Review Board. --- Results --- Participant Characteristics Due to variations in response rates to the participation questions, this study involved three slightly different samples. We present the unweighted participant characteristics of a single group: those participants who had valid data for all independent variables used in the analyses (N = 4,283). The socioeconomic and health characteristics of this base group are described in Table 1, and the neighborhood characteristics of this group are reported in Supplementary Table 2. These data approximate those of the samples used in each of the three logistic regression analyses. The sample included roughly equal proportions of men (42%) and women (58%) and married (58%) and not married individuals (42%). Approximately one quarter of the sample reported education of less than high school, and one-half reported very good or excellent self-rated health. Supplementary Table 3 provides information about frequency of participating in social activities in the samples used in the logistic regressions. --- Logistic Regression models Tables 2-4 present the findings of the logistic regression analyses for the three social participation outcomes. All of the models demonstrated adequate goodness of fit, based on the Wald test (p <unk>.0001). --- Neighborhood Characteristics and Social Participation Living in a census tract with a higher proportion of individuals aged 65 years or older was significantly associated (p <unk>.05) with greater frequency of going to sport, social, or other clubs; attending meetings of nonreligious organizations; and doing volunteer work, with odds ratios (ORs) very close to 1.00. For every 1% increase in proportion of older adults living in an area, an individual was 1.01 times more likely to participate more frequently in these activities. For a 10% increase in older adults, the odds ratio would be 1.10 (i.e., 1.01 10 ). Living in a census tract with greater population density was associated with greater frequency of going to sport, social or other clubs (OR = 1.28, 95% confidence interval [CI] = 1.03-1.59). Finally, participants who reported greater neighborhood social cohesion were more likely to attend meetings of non-religious organizations (OR = 1.38, 95% CI = 1.05-1.80). Results of additional analyses using imputed data were very similar to the original analyses. See Supplementary Table 4 for details. --- Neighborhood Variable Interactions All interaction terms were tested for each social participation outcome, but only significant findings are reported (see Tables 234). The interaction between physical mobility and population density was significant in the models for two social participation variables. The main interaction effect for walking ability times population density for attending a sport, social, or other club was OR = 1.64 Note: BIC = Bayesian information criterion; CI = confidence interval; OR = odds ratio. a Odds ratios do not cross 1.0, p <unk>.05. b Effect testing with least squares means of fixed effects. (95% CI = 1.08-2.51), indicating that individuals with no mobility limitation and living in a higher density area were more likely to participate, compared with all other combinations of these variables. Examining more specific comparisons showed that among participants with no difficulty walking several blocks, living in a more densely populated area was associated with greater frequency of attending sport, social, or other clubs, compared with living in a less densely populated area (OR = 1.47, 95% CI = 1.12-1.92; Table 2). The main interaction effect for walking ability times population density for volunteering was OR = 0.55 (95% CI = 0.39-0.77), indicating that individuals with no mobility limitation and living in a higher density area were less likely to participate, compared with all other combinations of these variables. Examining more specific comparisons showed that among participants with mobility limitation, living in a more densely populated area was associated with more frequent volunteering, compared with participants living in a less densely populated area (OR = 1.56, 95% CI = 1.12-2.18; Table 4). The main effect of the interaction between physical mobility and neighborhood social cohesion was not significant for any outcome variable. Further effect testing showed that among participants with no difficulty walking several blocks, living in an area with higher social cohesion was associated with higher odds of attending meetings of organizations (OR = 1.36, 95% CI = 1.02-1.82; Table 3). Supplementary Figure 1 displays the results of interaction testing. Supplementary Figures 234further describe the interaction effects. In these figures, the reference category is the group of individuals with no difficulty walking several blocks and either high population density or high social cohesion. Supplementary Figure 2 shows that compared with having no difficulty walking and living in a high density area, no difficulty walking and living in a low density area was associated with reduced odds of attending sports or social clubs (OR = 0.68, 95% CI = 0.81-0.52). Similarly, experiencing difficulty walking and living in either a high or low density area was associated with reduced odds of attendance compared with having no walking difficulty and living in high density areas (OR = 0.45, 95% CI = 0.45-0.34 and OR = 0.51, 95% CI = 0.51-0.37, respectively). For attending meetings of organizations, compared with experiencing no difficulty walking and living in a high cohesion area, experiencing no difficulty walking and living in a low cohesion area was associated with lower odds of attendance (OR = 0.73, 95% CI = 0.55-0.98). The combination of difficulty walking and high cohesion was also associated with lower odds (OR = 0.63, 95% CI = 0.46-0.86). In the final comparison against having no difficulty walking and living in a high cohesion area, difficulty walking and low cohesion was associated with reduced odds of attendance, with the largest effects (OR = 0.45, 95% CI = 0.3-0.66; Supplementary Figure 3). Supplementary Figure 4 shows that the odds of volunteering for those with no difficulty walking and living in a low population density area were no different than those with no difficulty walking and high density (OR = 1.17, 95% CI = 0.96-1.42). Again taking no Note: BIC = Bayesian information criterion; CI = confidence interval; OR = odds ratio. a Odds ratios do not cross 1.0, p <unk>.05. b Effect testing with least squares means of fixed effects. difficulty walking and high density as the reference group, experiencing difficulty walking and living in either high or low density areas was associated with reduced odds of volunteering (OR = 0.73, 95% CI = 0.56-0.95 and OR = 0.47, 95% CI = 0.37-0.6, respectively). No substantial changes in the odds ratios of other variables were observed in the models that included interaction terms. In all analyses, the BIC was lowest for the models including interaction terms. --- Discussion We identified several neighborhood-level characteristics and interaction terms associated with the frequency of participating in one or more activities. Higher proportion of age-peers in the area was consistently related to increased social participation representing new knowledge regarding social participation among older adults. Having more agepeers in an area may encourage older adults to be more involved in activities, as seeing other people being active in the neighborhood can encourage physical activity (Annear et al., 2014). In addition, higher proportion of older adults may relate to greater neighborhood safety (Cagney, 2006) and promote social participation through this mechanism. The distribution of the proportion of older residents was skewed to the left with a range of 0%-98.2%. Proportions that approach 100% might reflect communities that are designed for older adults, such as retirement villages, that may affect older adults' activities in many ways. Population density as an individual variable was associated with only one social activity, attending sport or social clubs. Population density may indicate greater availability of local facilities, such as senior centers or sports clubs, whereas opportunities to volunteer or be involved in organizations may be available in both dense and lessdense areas. The finding of a larger effect of population density for people with no difficulty walking several blocks suggests that walking limitations may pose a strong barrier to participating in such clubs, for example, if they involve vigorous activity. Among those unable to walk several blocks, population density was also associated with increased volunteerism. One interpretation of this finding may be that areas with greater population density may have more physically accessible features, such as sidewalks, that enable volunteerism among individuals with mobility limitations but may not have an effect for individuals without mobility limitations. At the same time, individuals may be able to select volunteering opportunities that meet their mobility needs, which may enable participation. In contrast, attending clubs or meetings of organizations may represent more structured activities in which it may not be possible for some individuals with mobility limitations to participate. In this case, neighborhood characteristics such as density may not be as relevant to participating as individual characteristics. While further studies are needed to better understand the specific ways in which population density relates to social participation, these findings contribute new information to this area of study. Perception of greater neighborhood social cohesion was associated with greater frequency of attending meetings of non-religious organizations, supporting previous literature Note: BIC = Bayesian information criterion; CI = confidence interval; OR = odds ratio. a Odds ratios do not cross 1.0, p <unk>.05. b Effect testing with least squares means of fixed effects. showing that neighborhood social cohesion is related to social participation (Andonian & MacRae, 2011;Bowling & Stafford, 2007;Richard et al., 2009). Conversely, social cohesion was not associated with frequency of attending sport or social clubs or volunteering. This finding makes sense given that social cohesion and participation in organized groups are inter-related and are often both used to indicate the social capital of an area (Kim, Subramanian, & Kawachi, 2008). Further exploration showed that the association between social cohesion and organized group participation holds for participants able to walk several blocks and not for participants with difficulty walking several blocks. While previous research has not explored this specific neighborhood by individual interaction, some research has found that neighborhood social cohesion can be a motivator for being active (Strobl, Maier, Ludyga, Mielck, & Grill, 2016), likely in individuals who are mobile. Thus, the combination of living in a socially cohesive neighborhood and having good mobility appear to be important to belonging to organized groups. In fact, in each instance of significant interaction effects, participants who experienced the combination of difficulty walking several blocks and a less favorable neighborhood condition (i.e., lower population density or lower social cohesion) were less likely to participate, with larger effects than the neighborhood condition alone. The proportion of the census tract population living in poverty was not associated with any social participation variable, contrasting with Bowling and Stafford's (2007) work showing an association between low neighborhood economic status and less frequent social participation. These authors used an indicator of area-level affluence based on 79 census variables, which may be a more comprehensive indicator of economic status than proportion living in poverty and could explain the discrepancy in findings. Further exploration is needed to better understand how the neighborhood socioeconomic context relates to social participation, particularly in light of growing interest on how social inequalities across individuals and communities influence later life outcomes (e.g., Abramson, 2015). The variation in the associations between neighborhood features and social participation is consistent with a transactional perspective of place (Cutchin, 2004). Attending sport or social clubs, attending meetings of organizations, and volunteering can be respectively considered doing activities with others, contributing to society and helping others (Levasseur et al., 2010), and as such are distinct types of activities that may relate to environmental characteristics differently. Previous studies of neighborhoods and participation in older adults have typically used participation scales in which various items, for example regarding volunteering, are combined with other items to form a total score. By examining individual separately, the current study contributes new knowledge regarding participation among older adults in context. This study benefitted from examining multiple types of social participation, enabling comparisons of neighborhood characteristics that relate to each type. The addition of ACS data enabled a wider range of neighborhood characteristics to be examined than those available in the HRS data set alone. The generalizability of the study findings may be limited by the missing data in the Leave-Behind questionnaire, which led to excluding participants from the analysis who were different from the study sample on some demographic characteristics. Despite excluding these participants, analyses involving multiple imputation of missing data produced results that were very similar results to the original analyses. The activity questions available in the HRS data set focused on frequency of performing activity, implying that more frequent activity is better, whereas ability or satisfaction with activity level may be a more relevant way to measure participation in activities. In addition, there is a possibility of false-positive findings when analyzing large data sets. We may be overestimating the significance of some of our findings. Finally, population density may be more a useful variable if used in combination with other variables, for example availability of services and resources. --- Implications The goal of age-friendly cities and communities movements to create environments that promote participation and engagement (World Health Organization, 2007) can be realized only through understanding the neighborhood changes that are needed. Conceptually, communities and neighborhoods need to be considered dynamic places where individuals and groups engage in a variety of activities, each involving specific person-place relationships. The current study has taken some steps toward illuminating these relationships. Different neighborhood supports may be needed for individuals with differing mobility levels, and this factor can be considered within community change. Programing and neighborhood strategies to build social cohesion and promote neighborhood walking may help to promote participation in older adults. For example, community-wide planning efforts (Lehning, Scharlach, & Price Wolf, 2012) could involve development of neighborhood places that promote social interactions and build social cohesion, to promote civic engagement. Consumer-driven support networks (Lehning et al., 2012) could similarly attempt to build neighbor-to-neighbor and senior-to-senior networks, to help older adults connect with one another and potentially facilitate participation in a range of activities. Further research is needed in a number of areas, most importantly to understand the mechanisms through which the identified neighborhood characteristics affect participation, including proportion of age-peers, social cohesion, and population density. In addition, the interactions between mobility and neighborhood characteristics need further exploration, to better understand the mixed findings within this study. Continued research regarding the specific activities in the current study could help to understand whether neighborhood social cohesion is a necessary condition for older adults to contribute to society through involvement in organizations. Dissecting broad categories of participation such as attending sports or social clubs may lead to further insights regarding specific aspects of participating in clubs. Finally, data from other countries such as Canada, China, and European nations may provide useful comparisons. Further research regarding neighborhoods and participation can provide useful insight into how to create age-friendly neighborhoods and promote participation. --- Conclusion This study examined associations of neighborhood social cohesion, neighborhood socioeconomic disadvantage, proportion of age-peers, and population density with frequency of social participation among older adults. Findings suggest that neighborhood characteristics interact with mobility limitation and may relate to types of social participation in unique ways. Policy, practice, and future research is needed that considers and addresses these relationships. --- Supplementary Material Supplementary data are available at The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences online.

Objectives: Although emerging research suggests neighborhood characteristics can support and restrict social participation in older adults, further research regarding a wider range of neighborhood characteristics and interactions between individual and neighborhood characteristics is needed. This study explored associations between neighborhood characteristics and frequency of participation in three social activities among older adults and interactions between neighborhood characteristics and mobility limitation as they relate to participation. Method: Data from the 2008 wave of the Health and Retirement Study linked with American Community Survey data were used. Participants included community-dwelling adults aged 65 years or older. Analysis involved multivariate logistic regression. Results: High proportion of neighborhood residents aged 65 and older was associated with increased odds of more frequent participation in all three activities. High population density was associated with increased odds of club attendance. High neighborhood social cohesion was associated with increased odds of attending nonreligious meetings. Interactions between walking limitation and population density or social cohesion related to increased odds of participation. Discussion: Findings suggest that improving older adults' ability to participate in community life and age in place requires strategies that consider how neighborhood and individual characteristics interact and how these characteristics may differentially affect types of participation.

Introduction In many countries worldwide, there is a significant concern regarding inadequate sexual and reproductive health (SRH) among adolescents and young people [1]. This population group faces an elevated risk of acquiring Sexually Transmitted Infections (STIs) such as Human Immuno-Deficiency Virus (HIV), as well as experiencing violence and unintended pregnancies, particularly among young girls [1]. Additionally, adolescents and young people encounter various inequalities such as limited access to information, discrimination, exclusion, and violence [2][3][4]. Given that approximately 1.8 billion individuals, representing a substantial portion of the global population, fall within the age range of 10 to 24 years, addressing SRH risks is a matter of global health concern [5]. In low and middle-income countries (LMICs), adolescents and young adults aged 15-24 account for approximately one-fifth of the population [6]. However, the needs of this population, especially regarding sexual and reproductive health, are often unmet, overlooked, and underfunded [7,8]. The challenge of sexual and reproductive health risks is a concern particularly, in Sub-Saharan Africa where its young people continue to grow substantially [6]. Zambia, in line with the region, faces similar challenges regarding sexual and reproductive health risks, with 63.2% of the country's population being under 25 years old [9]. There is a growing demand on governments and key stakeholders to establish an enabling environment that empowers the younger population to fulfil their potential, which includes upholding their basic human rights and ensuring access to high-quality sexual and reproductive health (SRH) services [4,10]. Studies conducted in various settings indicate a lack of utilization of services among adolescents and young people, particularly in the areas of mental health and SRH services [11,12]. Despite governmental efforts to enhance access to SRH services, adolescents and young people continue to encounter challenges in meeting their specific health needs. Common obstacles include insufficient knowledge about adolescent sexual behaviour, cultural influences, limited access to reproductive health information, and the absence of adolescent and youth-friendly SRH services [13][14][15]. According to the Zambia Demographic Health Survey (ZDHS) conducted in 2018, only 43% of young women and 41% of young men have comprehensive knowledge of HIV prevention [16]. --- PLOS GLOBAL PUBLIC HEALTH University students are particularly vulnerable to the impact of risky sexual behaviour and experimentation [17]. The increasing presence of public and private Higher and Tertiary Education Institutions (HTEIs) in Zambia has expanded access to education, making HTEIs crucial settings for service delivery and information dissemination in the field of Sexual and Reproductive Health and Rights (SRHR) through youth-friendly health services [18]. Adolescent Youth-Friendly Health Services (AYFHS) aim to address the barriers that young people face in accessing SRH services, and these services are expected to meet established international guidelines and standards for youth-friendly services [19]. However, there is limited evidence regarding the availability, accessibility, acceptability, and quality of SRH services in HTEIs in Zambia. Current sustainable strategies for creating change are shifting towards human rights-based approaches that prioritise rights over needs [20]. The Right to Health approach encompasses the elements of Availability, Accessibility, Acceptability, and Quality (AAAQ) [21], which serve as a framework for identifying barriers throughout the entire treatment process. Availability ensures the presence of functioning health services in sufficient quantities, while accessibility guarantees non-discriminatory, physically and economically accessible services, along with accessible information. Acceptability entails that health services adhere to medical ethics, cultural appropriateness, gender and age sensitivity, and that medical treatments are explained in understandable ways. Quality necessitates that health facilities and medicines are scientifically and medically appropriate and of high quality [22,23]. Applying the AAAQ criteria is crucial for understanding how young people exercise their right to healthcare when seeking and utilising services in higher education institutions. However, there is limited evidence regarding the perceptions of adolescents and young people regarding youth-friendly SRH services using the Human Rights Based Approach to Health Care and AAAQ framework in selected HTEIs. Therefore, this study was conducted to explore the perceptions of adolescents and young people concerning youth-friendly SRH services using the Human Rights Based Approach to Health Care and AAAQ framework in selected colleges and universities in Zambia. --- Methods --- Study setting The study encompassed twelve (12) Higher and Tertiary Education Institutions (HTEIs) in Zambia, namely Evelyn Hone College (Lusaka Province), Chalimbana University (Lusaka Province), Lusaka Business and Technical College (Lusaka Province), Mulungushi University (Central Province), Kabwe Institute of Technology (Central Province), University of Zambia (Lusaka Province), Kwame Nkrumah University (Central Province), Lusaka Business and Technical College (Lusaka Province), Copperbelt University (Copperbelt Province), Nkumbi International College (Central Province), Technical Vocational Teachers College (Copperbelt Province), Northern Technical College (Copperbelt Province), and Mukuba University (Copperbelt Province). The selection of health facilities was based on students' utilisation of health services. The chosen study sites are public institutions that host majority of young people. The sites encompassed diverse locations and sizes to enhance variation and representation. --- Study design A qualitative case study design was employed to thoroughly investigate the viewpoints of adolescents and young people regarding youth-friendly health service delivery in Higher and Tertiary Education Institutions (HTEIs). Focus Group Discussions (FGDs) and In-Depth-Interviews (IDIs) were conducted with adolescents and young people and health care providers, while Key Informant Interviews (KIIs) were conducted with district level and provincial level AYFHS coordinators. This approach allowed for an exploration of the three key domains of the Rights-Based Framework: Availability, Acceptability, and Accessibility, while KIIs were specifically employed to delve into the domain of Quality. --- Sampling and recruitment of participants Purposive sampling was employed to select participants for the study, ensuring a deliberate and targeted approach. Through institutional records and with permission from authorities, young people who were available were identified and invited to take part in the study. Additionally, interviews were conducted with healthcare facility staff and AYFHS coordinators at district and provincial levels to enhance the credibility of the findings. Snowball sampling was utilised to select young individuals living with HIV and from the LGBTIQ community, taking into consideration their potentially undisclosed identities, in order to explore their knowledge and utilisation of services in-depth. This approach aimed to enhance the validity of the findings without solely relying on increasing the sample size until theoretical saturation was achieved. Adolescents and young people of age group 18 and 24 years were included in the study. All individuals who refused to sign the informed consent were excluded from the study. A total of 112 interviews were conducted. Table 1 provides a comprehensive summary of the interviews conducted and the list of participants targeted for the qualitative study. --- Data collection methods FGDs, KIIs, and IDIs were carried out during a three-month period from March to June 2021. The research team developed open-ended interview guides for respective participants after reviewing existing literature and consulting with the local research partner and the Ministry of Health. Information sheets were provided to participants prior to the guided discussions. Face-to-face KIIs, IDIs, and FGDs were conducted, and data collection involved the use of digital voice recorders and field note taking. To adhere to social distancing measures due to COVID-19, each discussion involved a maximum of six participants. Research assistants were trained in effective data collection methods and the discussions took place at agreed-upon private locations such as in the hostels. FGDs lasted for 60 minutes with up to six participants, while IDIs and KIIs lasted about 30 to 40 minutes each. --- Data management and analysis The audio recordings of interviews were transcribed verbatim by two trained research assistants. The transcribed documents in Microsoft Word were carefully reviewed and analysed to PLOS GLOBAL PUBLIC HEALTH develop a coding scheme. In vivo coding was applied, and two independent coders coded each transcript to enhance the reliability of interpretations. All transcripts were then imported into NVivo version 11, a qualitative software, for coding and ongoing analysis. The agreed-upon codes were organised to create categories and subsequently themes. A thematic analysis approach was employed to provide context to the findings of this study. --- Quality control Research assistants underwent a two-day training session before the study commenced. The research tools were pretested to identify any potential deficiencies and to ensure participants' understanding of the questions in the same way. The practice sessions and data collection were conducted in English, Chinyanja, and Chibemba languages. The fieldwork recruiters were also trained to screen participants and confirm their eligibility. --- Ethical considerations Ethical approval for the study was obtained from the University of Zambia Biomedical Research Ethics Committee (UNZABREC-Ref-1588-2021). Permissions to collect information from health facilities were granted by the National Health Research Authority (NHRA). Additionally, permissions to access the facilities and engage with young people were granted by the Ministry of Health at the national, provincial, and district levels, as well as the administrative management at the tertiary institutional level. --- Findings The aim of this study was to explore the perspectives of young people and healthcare providers regarding the accessibility, availability, acceptability, and quality of AYFHS in selected HTEIs in Zambia. The following section presents the viewpoints of young people and other stakeholders on these aspects of sexual and reproductive health services including youth friendly corners. --- Accessibility and barriers to accessing services Based on the Human Rights-Based AAAQ framework, access to health services encompasses physical, economic, and information accessibility, while ensuring non-discrimination in service provision. Physical access to services. In this study, some young people identified geographical access to public health facilities as a hurdle, especially when these facilities were not located within their educational institutions' campuses. Students attending institutions without oncampus health facilities reported challenges in accessing adolescent and youth-friendly health services (AYFHS), as they had to travel to off-campus health facilities. "We do not have a clinic on this campus, although we have clinics in the surrounding areas, it is not very easy to get there unless using a taxi or bus. Sometimes we walk though, but not at night" [Participant 1, Group Discussion, Male, Lusaka] Access barriers for young persons with disabilities. Young persons with disabilities faced specific challenges in accessing campus health facilities because of the architectural designs which did not favour them, as well as the issue of queuing for services. The existing facilities were not designed to accommodate their needs, making it difficult for them to navigate and access the services. Moreover, the processes within the health facilities were not PLOS GLOBAL PUBLIC HEALTH inclusive and posed additional difficulties for young people with disabilities. These individuals expressed their frustration with the lack of efforts to make the facilities more accessible and inclusive for them. (...) we have different challenges, some of us...we are not able to stand for a long [period of time], and when you go there you will be forced [to] stand in the queue and in the process, you become tired (...) [In-depth Interview, young person with a disability, Male-Kabwe]. Some healthcare providers acknowledged the importance of addressing the accessibility needs of young persons with disabilities and made efforts to ensure that these students were served. These providers recognised the challenges faced by individuals with disabilities and expressed their commitment to making the necessary accommodation and adjustments to meet their needs. They were aware about accessibility challenges and the need for accessible services for students with disabilities. As such, efforts to ensure that services were accessible and convenient were being made. Their efforts demonstrated a variation in the level of responsiveness and inclusivity within the healthcare system towards young persons with disabilities. "As for students with disabilities, we have those and we have tried as a facility to make it convenient and easy for them to access the services and we do certainly, we try by all means to prioritise them as they come just to make sure that they are served" [Key-Informant Interview, Healthcare Provider]. --- Affordability of services. Young people highlighted the issue of economic accessibility when accessing sexual and reproductive health services. They mentioned that they could only access services once they had paid their school fees, indicating a financial barrier to accessing healthcare. While certain medications like emergency contraception were available illicitly on campuses, other services could only be obtained within the health facility premises, where charges were sometimes imposed on the students. This financial burden compromised the economic accessibility of services. Additionally, some health facilities charged students for services during vacation periods, further exacerbating the economic challenges faced by young people in accessing necessary healthcare. "Like I mentioned, the challenge is that you cannot always get the services we are talking about unless you are a paid-up student. Otherwise, when school closes you have to pay to get the same services" [Participant 3, Group Discussion, Male-Lusaka]. The study findings revealed significant challenges in the availability of essential drugs and commodities for sexual and reproductive health services. Young people reported that drugs like fungal treatment, emergency contraception, and condoms were either not available or frequently unavailable at the health facilities on campus. As a result, they had to purchase these drugs from other sources, increasing their healthcare expenses. This situation had further implications as students had to allocate their limited financial resources to healthcare instead of other important educational needs. The study also uncovered the emergence of illicit oncampus sale of medication, as indicated by a poster advertising the sale of the "morning-after pill" in one of the hostels. Health care providers recognized challenges resulting in reduced access to services for young people. When asked what would make it easy for them to provide these services, one healthcare provider reported logistical challenges, and stated the following. "Our biggest challenge here is staffing [and] drug shortages such that most times we are not able to meet the needs of these young people at the facility" [Key-Informant Interview, Healthcare Provider]. --- Access to information. Limitations in the access to information about available services for young people were highlighted. Participants mentioned that their knowledge and use of services was restricted to those they were aware of. Commonly mentioned services included contraception (including condoms), STI screening, HIV testing, and pregnancy testing. It was observed that young people primarily relied on information shared by their peers to learn about these services. This indicates a lack of comprehensive and targeted information dissemination regarding the full range of services available at the institutions. A respondent expressed their experience, stating. "For me I think, what I can say is that, we hear about these services from fellow students and also from the health chairperson who is also a student, that is all...really" [Participant 6, Group Discussion, Female-Lusaka]. Discriminatory attitudes as a barrier to accessing services. The study findings shed light on the presence of discriminatory attitudes among some healthcare providers, leading to barriers in accessing services. Young people reported encountering poor attitudes and unpleasant experiences when seeking healthcare. Some healthcare providers were unavailable when needed, while others exhibited negative attitudes towards young people seeking certain services. The young people expressed feelings of discrimination, paternalistic control, and stigmatisation, indicating a lack of understanding and support from healthcare providers. Instances were mentioned where young people were ridiculed or admonished for seeking information on sensitive topics such as safe abortion and access to condoms. One participant shared their experience, stating: "We come to school leaving our parents' home. But then when we come here [to the health facility], we find that in the health facilities, there are nurses who want to treat us like [we are] their children, by telling us why should we be having sex when we are here to learn" [Participant 4, Group Discussion, Male, Lusaka]. As a result, many young people preferred to avoid healthcare facilities unless they were seriously ill while others felt more comfortable seeking information from their peers or avoiding seeking information altogether unless they were very sick. The study findings highlighted the particularly challenging situation faced by the LGBTIQ populations regarding access to information and services. It was observed that there was a lack of specific information tailored to their needs, indicating a bias in service provision. When asked about the availability of services that meet their needs, an LGBTIQ young person shared their perspective, stating: "No, I don't think they would even talk about that [tailoring LGBTIQ services], they wouldn't even bring it up, I know, they wouldn't just bring it up, I've been in this institution for quite a long time (...)" [In-depth Interview-LGBTIQ, Female, Ndola]. economic conditions of a country. Self-reported information on service availability was obtained from both health care providers and young persons. We have found that services were available, but they were primarily focused on curative health services and not specifically tailored to the needs of adolescents and young people. Furthermore, the availability of services varied across different facilities. All the health facilities included in the study were open seven days a week, but most of them provided services only during regular working hours, from 8 am to 5 pm. Available services. The study identified a range of services that were reported as available in the selected higher education and tertiary facilities. These services included voluntary HIV testing services, contraception, safe motherhood, cancer screening, mental health services (including for alcohol abuse), safe abortion services, sexual and gender-based violence awareness, management of chronic conditions, and discussions related to sex and sexuality. These services reflect the efforts made to address various aspects of sexual and reproductive health as well as general health concerns among the young population. Unavailable services. The study findings revealed that certain services were consistently reported as unavailable in some of the higher education institutions visited. These included mental health services, contraception (including condoms), male circumcision, cervical cancer screening, safe delivery services, and treatment for yeast and fungal infections. Among these, mental health services were mentioned most frequently as being unavailable. Additionally, young people expressed a need for more comprehensive laboratory services, particularly for STI screening. The absence of abortion-related counselling, information, options, and services was also noted as a significant gap. These findings highlight the limitations and deficiencies in the availability of essential healthcare services for young people in the studied institutions. "Services around abortion or even counselling, those are not provided here, maybe unless University Teaching Hospital" [Participant 5, Group Discussion, Female]. A key informant also confirmed non-provision of abortion services at one of the biggest institutions, saying: "I think most preventive (...) services are the ones that we provide. And also, curative [services] if somebody is sick, we do that yes. But services like uh like you mentioned maybe providing the post-abortal... care or whatever, usually we don't provide such services to those institutions." [Key Informant-District Adolescent health coordinator] Availability of awareness programmes. According to the perspectives shared by students, there is a perceived need for improved availability of Post Exposure Prophylaxis (PEP) and Pre-Exposure Prophylaxis (PrEP) services. These services were reported to be available only at one specific health facility within the institutions, indicating limited access for students in other locations. Furthermore, some students mentioned they had not accessed a wide range of services, which affected their awareness and knowledge of the available services in the health facilities. Therefore, there is a call for increased availability and accessibility of PEP, PrEP, and other services to better meet the needs of the student population. When asked what services he knew about, a young man from an institution in Lusaka said this: "It would be good to know the services that are available for us. Unfortunately, we hardly know these services including HIV prevention medication, those are important.... personally, I did not know that HIV prevention medication were available until most recently....." [Participant 2, Group Discussion, Male]. The role of guidelines in ensuring availability of services. The absence of guidelines governing the provision of Adolescent and Youth-Friendly Health Services (AYFHS) in the institutions was identified as a factor contributing to the limited availability of services. This lack of guidelines had a direct impact on the provision of services, even in the presence of healthcare providers within the facilities. A health facility in-charge expressed the belief that the availability of guidelines would enhance the provision of services and improve their availability. This highlights the importance of having clear guidelines in place to ensure the availability and effective delivery of AYFHS. Regular shortages of drugs. A common complaint among the young people interviewed was the limited availability of medical supplies and specialised services in the health facilities. It was often mentioned that only basic medications like paracetamol (Panadol) were consistently available, while other essential services such as STI screening, cervical cancer screening, and safe abortion were not accessible due to the unavailability of equipment in the facilities. Frequent stock outs and the general unavailability of medical supplies were also highlighted by the young people. A student from a college in the Copperbelt Province shared their experience, emphasising the unavailability of necessary services. Notably, the drugs for most key populations, particularly young people who identified themselves as LGBTIQ+, were not available to meet their specific needs. Almost all the facilities lacked specific services for the LGBTIQ+ community. Healthcare providers acknowledged this gap and expressed their views on the provision of LGBTIQ+-tailored health services including commodities. Their statements highlighted the need for inclusive and non-discriminatory care for LGBTIQ+ individuals. --- "For LGTBQ+s, those we don't really offer services but we just give them information on maybe how these people can be linked to support groups" [Key-Informant Interview, Healthcare Provider]. "The LGBTIQ community, ah! For those, I must be honest to say that we don't have, as a facility, we don't have a specific policy that helps us to address their needs comprehensively" --- [Key-Informant Interview, Health Facility In-charge]. Healthcare providers in all the facilities acknowledged the general availability of Adolescent and Youth-Friendly Health Services (AYFHS). However, they recognised that the available services were not specifically tailored to meet the needs of young people in HTEIs, including those with special needs. While health service provision for students living with HIV was reported to be available, there were only a few facilities that made efforts to adequately cater to PLOS GLOBAL PUBLIC HEALTH the needs of students with disabilities. A healthcare provider highlighted the importance of providing services that are inclusive and accessible for students with disabilities. "As for students with disabilities, we have tried as a facility to make it convenient and easy for them to access the services and we do certainly, we try by all means to prioritise them as they come just to make sure that they are served" [Key-Informant Interview, Healthcare Provider]. However, despite the challenges reported, interviewees mentioned that additional support in the form of funding from NGOs that support youth-friendly corners made it easier for them to provide services to young people. Healthcare providers also highlighted specific aspects that would enable them to better provide these services. A health facility in-charge emphasised the importance of adequate resources and training for healthcare staff to effectively address the needs of young people. "We do receive funds for SRH although it is not always, or should I say not consistent and this same support comes in form of 'imprest', although other partners also occasionally support us" [Key-Informant Interview, Health facility In-charge]. In confirming whether there was a budget for Youth-Friendly Services (YFS) that supported district-level programmes, a Key Informant (KI) stated that not much is happening with funding for such programmes. The KI highlighted the lack of sufficient financial resources allocated to support YFS initiatives at the district level. "Most of the time actually [the] adolescent has been left behind, in terms of the budget and also allocation of the monies. Because um... the only people that have actually now come on board to help us are our partners. But where the government is concerned, they are not supporting us much". [Key informant-District Adolescent Health Coordinator] --- Acceptability For health services to be considered acceptable, they need to be ethically and culturally appropriate, demonstrating respect towards individuals, minorities, communities, and being sensitive to gender and life-cycle requirements. Young people in the study highlighted that the acceptability of certain services varied. They mentioned that services such as malaria screening were more acceptable compared to services related to sexual and reproductive health and rights (SRHR), including contraception and safe abortion. This difference in acceptability was particularly evident in a Christian mission facility that did not provide contraception and safe abortion services. The perceived unacceptability of certain services hindered young people from accessing them. One student expressed their frustration with this situation. Contraceptives... I hear they are there [available] but they [healthcare providers] are judgemental. You know, at that point, that's where (...) there's a need of confidentiality and such services and I think... people are complaining. I have heard about that. [In-depth Interview, Male-Ndola]. However, it was observed that healthcare providers who were more supportive and welcoming towards young people had a positive impact on the acceptability of services. Their attitudes and behaviour were associated with increased demand and utilisation of services among students. Conversely, some health facility staff were perceived as unapproachable, with age differences being cited as a barrier to the acceptability of services. A young person from a higher education and tertiary institution (HTEI) in Lusaka shared their experience regarding this matter. (...) the issue of having somebody who is in a different generation from yours because when you want... When we want to access services as young people, we hope to be in a safe space where [we can be] free or open and honest. But when you find somebody who's in a different generation from yours or a different age range, it's hard for you to communicate effectively because you would think they won't understand you and you think they're going to come at you in a judgmental way (...) [In-depth Interview, Female-Lusaka]. Young people participating in the study highlighted that health facilities within their institutions were perceived as more "user-friendly" compared to external facilities. The presence of a health facility or youth-friendly space within the learning institution was seen as favourable by young people, as it increased the acceptability of using the services and facilitated access to AYFH services. Additionally, the role of peer educators was highly valued. In most institutions, peer educators were considered knowledgeable and easily accessible for information and services like condom distribution. One student expressed their appreciation for peer educators in the following statement. "For me I find peer educators to be helpful, you know for us young people, it is easy to joke with these people and I think they also understand what we as young people go through" [In-depth Interview, Male-Kabwe]. --- Quality The interviews conducted highlighted concerns regarding the quality of services provided in these institutions. Across most health facilities, issues such as inadequate supplies, insufficient space for privacy, lack of necessary equipment, and insufficient training to meet the specific needs of students were mentioned. A healthcare provider acknowledged the poor quality of services, attributing it to underfunding of programmes. This sentiment was expressed by one healthcare provider. "Our facility is always rated in red when we get assessed" [Key-Informant Interview, Healthcare Provider]. --- Lack of, and inadequate youth-friendly spaces. During the individual interviews with healthcare providers, it was revealed that the lack of, and inadequate youth-friendly spaces posed significant barriers to providing quality services. The quality of services was compromised in facilities with insufficient infrastructure or limited space for ensuring privacy. Many young people expressed concerns about the inadequacy of the spaces provided, citing them as either too small or lacking sufficient privacy. These concerns were further amplified by the ongoing COVID-19 pandemic, as open and crowded spaces were seen as potentially dangerous. I wanted to talk about it [inadequate space], it's not spacious there and there is congestion. Especially with this pandemic, so it's not that healthy because it's too small. [Participant 5, Group Discussion, Female, Copperbelt]. In contrast, in some institutions, youth-friendly spaces were completely non-existent, as reported by young people. A participant from a university expressed their dissatisfaction with the lack of dedicated spaces for health service provision, especially considering the growing student population. They highlighted the need for more private locations to accommodate the increasing demand for services. Healthcare providers supported this viewpoint, acknowledging the shortage of youth-friendly spaces, particularly during the rainy season when the open areas were more challenging to utilise effectively. A healthcare provider stated their concerns regarding the limited availability of appropriate spaces for providing quality services. "Youth-friendly spaces are a challenge because sometimes in the rainy season, the young people have nowhere to go" [Key-Informant Interview, Health Facility In-charge]. Due to the constraints of limited space, healthcare providers reported that services were scheduled on specific days and could not be provided continuously. This restricted the availability and accessibility of services to young people. In addition, a healthcare provider highlighted the inadequacy of their youth-friendly corner, describing it as very small and lacking chairs for young people to sit. This further compromised quality service delivery and the overall experience for the young individuals seeking care. "The spaces for AYP are small such that sometimes health education is provided from outside" [Key-Informant Interview, Health Facility In-charge]. During the interviews, it was revealed that healthcare providers in the institutions running health facilities separate from the Ministry of Health (MoH) lacked professional training in Adolescent and Youth-Friendly Health Services (AYFHS). When asked about their training in AYFHS, one interviewee expressed the following: This lack of specialised training further contributed to the barriers and challenges faced in delivering high-quality health services to young individuals in these institutions. Young people in institutions that rely on regular health facilities outside their institutions expressed challenges with long waiting hours to access Adolescent and Youth-Friendly Health Services (AYFHS). They highlighted the need for more tailored services that specifically cater to their needs, as they did not appreciate the long queues in general health facilities. Accessing these services often required waiting in queues with other patients, which discouraged them from seeking the services altogether. The long waiting hours were seen as a barrier to accessing timely and efficient healthcare, and young people felt that their specific needs were not being adequately addressed in the crowded general health facilities. As a result, they expressed a desire for more targeted and youth-friendly services that prioritise their unique requirements and ensure a more streamlined and efficient healthcare experience. "Sometimes you may not even access the services because [when] people get to the clinic, [they/we] have to queue up, so the thought is... I wish there was a place where we just go as students and get a service" [Participant 1, Group Discussion, Male-Lusaka]. A healthcare provider in charge of AYFHS also mentioned that she had no professional training, despite accepting the appointment as the facility's AYFHS nurse. This highlights the lack of specific training and expertise in providing tailored healthcare services for young people. Without proper training, healthcare providers may struggle to understand the unique needs and challenges faced by young individuals and may not be equipped with the necessary skills to deliver quality AYFHS. The provider's statement reflects the importance of investing in professional training programmes for healthcare providers who are involved in delivering AYFHS. Such training would help them acquire the knowledge and skills needed to effectively address the physical, mental, and reproductive health needs of young people. By enhancing their training, healthcare providers can better understand the principles of youth-friendly care, develop appropriate communication strategies, and create a supportive and non-judgmental environment for young patients seeking healthcare services. "Previously what I got (is) from the handovers they had [was too basic]. However, most of those who were in that group [at] that time, they have left. But right now, I don't have any training. I was just told to carry on, "we will train you when the time comes" [Key-Informant Interview, Healthcare Provider]. The key informants emphasised the need for training more AYFHS care providers, as many of them tend to be transferred to different facilities or pursue further training. This highlights the issue of staff turnover and the potential impact it has on the continuity and quality of AYFHS. Without a sufficient number of trained providers, the delivery of youth-friendly services may be compromised. One key informant added; Human resource, there is a gap in terms of training. People get trained but with time some get transferred, some die and some retire. We had a lot who were trained but after the 2015/ 2016 training, there has not been any training and we have a high attrition rate. People retired, others got transferred and others went to school, they are on long study leave" [Key-Informant Interview, District Adolescent Health Coordinator]. The interviews with stakeholders revealed several administrative challenges in the management of facilities providing services for young people. These challenges included insufficient funding, inadequate monitoring, and the absence of specific guidelines to ensure the provision of services at the appropriate quality. The lack of guidelines resulted in variations in the management of services across different education institutions, as the responsibility was shared between the health and education ministries. The inadequate funding posed a barrier to effectively meeting the needs of young people, including providing necessary resources, equipment, and training for healthcare providers. Insufficient monitoring mechanisms further hindered the ability to ensure the quality of services being delivered. Despite these challenges, stakeholders confirmed that there is strong collaboration between the Ministry of Education and the Ministry of Health in supporting the health facilities. This collaboration involves technical support, such as hiring and training of healthcare providers, as well as supervisory visits to ensure the provision of quality services. Addressing the administrative challenges requires increased funding allocation, development of specific guidelines for AYFHS management, and strengthening monitoring and evaluation mechanisms. By addressing these issues, there can be improved coordination, resource allocation, and overall management of health facilities, leading to better quality AYFHS for young people. In addition, funding for the facilities was dependent on the entity in charge of the management of the facility. "The health facility is owned by [the university] and not by the Ministry of Health, rendering it to be a private health facility. However, this health facility is generously supported by --- PLOS GLOBAL PUBLIC HEALTH the Ministry of Health and its partners" [Key-Informant Interview, Health Facility Incharge]. District level management recognised the limitations in funding for AYFHS in health facilities, including those in higher learning institutions. In facilities run by MoH, funding primarily comes from MoH through district-level grants. However, these facilities also receive support from educational institutions. On the other hand, facilities run by universities or colleges largely fund their operations through medical fees paid by students and support from the MoH. The statements suggest that funding for AYFHS in these health facilities is a shared responsibility between the MoH and educational institutions. However, it is acknowledged that there are limitations in the available funding, which can impact the provision of comprehensive and quality services for young people. To address these funding limitations, it may be necessary to explore additional funding sources, advocate for increased financial support from relevant stakeholders, and prioritise allocation of funds specifically for AYFHS. This can help ensure sustainable funding for the provision of youthfriendly services in health facilities, including those in higher learning institutions. "Like I said the major source of funding is through student's fees that these students contribute among the other requirements, which is medical fee. So that is the money that we use to buy drugs. Although certain times we actually use any amount that is generated by management" [Key-Informant Interview, Health Facility In-charge]. At the policy implementation level, the absence of guidelines resulted in the delivery of services for young people being similar to those provided to the general population. Health facility management and healthcare providers in

The recognition of the need for Adolescent and Youth-Friendly Health Services (AYFHS) is growing. It is important to ensure the provision of high-quality sexual and reproductive health (SRH) services that cater to the unique needs of adolescents and young people (AYP). Adolescents and young people spend a significant amount of time in Higher and Tertiary Education Institutions (HTEIs) where adolescent friendly services are needed. However, there is limited evidence on the availability of sexual and reproductive health services for young people in HTEIs in Zambia. Using the Human Rights Based Approach to healthcare availability, accessibility, acceptability, and quality of care (AAAQ) framework, this study explores young people's perceptions of youth-friendly sexual and reproductive health services in selected HTEIs in Zambia. Between March and June 2021, a qualitative case study was conducted in 12 selected HTEIs located in Lusaka, Central, and Copperbelt provinces of Zambia. The study employed In-depth Interviews (IDIs) and Focus Group Discussions (FGDs) with AYPs, as well as Key-informant Interviews (KIIs) with healthcare providers. The healthcare providers at health facility, district and provincial levels were interviewed to provide insights about the services provided in the HTEIs. A total of 112 interviews were conducted. Data analysis was performed using thematic analysis in NVivo version 11. In the study, young people reported the availability of primary health services like malaria, HIV, and pregnancy testing, as well as screening for STIs. However, their awareness of SRH services was limited. Contraception, STI testing and treatment, and HIV and pregnancy screening and testing were the most accessed services. Equipment and commodity shortages were common, hindering care provision. Young people found healthcare services in PLOS GLOBAL PUBLIC HEALTH

On the other hand, facilities run by universities or colleges largely fund their operations through medical fees paid by students and support from the MoH. The statements suggest that funding for AYFHS in these health facilities is a shared responsibility between the MoH and educational institutions. However, it is acknowledged that there are limitations in the available funding, which can impact the provision of comprehensive and quality services for young people. To address these funding limitations, it may be necessary to explore additional funding sources, advocate for increased financial support from relevant stakeholders, and prioritise allocation of funds specifically for AYFHS. This can help ensure sustainable funding for the provision of youthfriendly services in health facilities, including those in higher learning institutions. "Like I said the major source of funding is through student's fees that these students contribute among the other requirements, which is medical fee. So that is the money that we use to buy drugs. Although certain times we actually use any amount that is generated by management" [Key-Informant Interview, Health Facility In-charge]. At the policy implementation level, the absence of guidelines resulted in the delivery of services for young people being similar to those provided to the general population. Health facility management and healthcare providers in higher learning institutions, both under the MoH and the Ministry of Education (MoE), were unaware of existing guidelines for the provision of AYFHS. There was a lack of knowledge about the current strategic plan being implemented, and many providers mentioned a lack of training and dissemination of these documents. District AYFHS coordinators also acknowledged a gap in information sharing regarding AYFHS guidelines, policies, and programme implementation between the MoH and higher learning institutions. --- Discussion The findings from this study highlight notable challenges in terms of accessibility, availability, acceptability, and quality of sexual and reproductive health services for young people in health facilities within HTEIs in Zambia. These barriers are discussed, within the context of other literature. While basic services were available, our study revealed that geographical, commodityrelated, and human resource-related barriers hindered access to youth-friendly healthcare services. Geographical barriers were identified as a challenge, as some institutions lacked on-site health facilities offering youth-friendly services. This necessitated young people to travel considerable distances to access healthcare services, including sexual and reproductive health services. This finding aligns with a study conducted by Pandey et al. [24], which identified distance to the nearest health facility as a major barrier to the utilisation of adolescent and youth-friendly health services (AYFHS). Inadequate infrastructure with limited privacy was identified as another significant barrier to accessibility. Adolescents expressed hesitancy in accessing sexual and reproductive healthcare services due to concerns about their privacy being compromised. They feared that others would overhear or become aware of their personal health conditions. This finding aligns with PLOS GLOBAL PUBLIC HEALTH the research conducted by Pandey et al. [24], which highlighted the lack of privacy and confidentiality as a major deterrent for adolescents seeking to utilise adolescent and youth-friendly health services (AYFHS). Young people expressed dissatisfaction with the unacceptability of healthcare services provided at most learning institutions. They reported shortages, basic care, and a lack of healthcare providers who understood their specific needs. Negative experiences arising from poor attitudes displayed by healthcare providers further hindered adolescents' access to youthfriendly health services. Discrimination, paternalistic control, and stigmatisation were cited as major reasons for not seeking health services, as healthcare professionals exhibited these behaviours. This finding aligns with a study by Tilahun et al. [25], which found that one-third of healthcare workers held negative attitudes toward offering reproductive health services to unmarried adolescents. Services in the health facilities were not adequately tailored to meet the needs of key populations, such as the LGBTIQ community and persons with disabilities. These groups faced challenges in accessing services and information, primarily due to lack of accommodation, privacy, and understanding from healthcare professionals. Adolescents belonging to key populations, particularly those identifying as LGBTIQ, reported encountering negative attitudes and biases from healthcare providers, which deterred them from utilising the facilities for sexual reproductive health services (SRHS) [26]. A study conducted by Mu <unk>ller et al. [27] revealed that although health facilities did offer adolescent sexual and reproductive health services (ASRH), they were not inclusive or accessible to sexual and gender minority adolescents. In the institutions assessed, there were some general sexual and reproductive health (SRH) services available, but young people had limited awareness of the specific services offered. Their knowledge about reproductive health services was lacking, which affected their access to SRH services. Our study found that young people were mostly aware of, and commonly used a few services such as contraception, STI screening, HIV testing, pregnancy testing, and obtained information on these services from their peers. This lack of awareness can be attributed to the absence of health promotion and education activities conducted by healthcare professionals within the institutions. Cultural, religious, and traditional norms played a significant role in hindering open discussions about sex and sexual matters [28]. The lack of trust in healthcare providers (HCPs) also limited access to SRH services among adolescents and young people. Our study revealed that even when individuals sought knowledge about SRH without being sick, they experienced harsh treatment from Health Care Providers (HCPs), which further limited their access. Similar findings have been noted by Lutende, who emphasised that harsh treatment by HCPs can result in a lack of competence and hinder adolescents' access to healthcare services [29]. However, peer educators were recognised as valuable in increasing accessibility and acceptability of services. Overall, the limited awareness of available services, cultural barriers, and negative experiences with healthcare providers affected the accessibility and acceptability of SRH services for adolescents and young people. Institutional barriers pose challenges for adolescents in accessing healthcare services, as highlighted in this study. Pandey et al. [24] conducted a study that identified staff shortages, inadequate SRH supplies, and a lack of medicine in health facilities as institutional barriers affecting the availability and quality of healthcare. Consistent with our findings, although Adolescent and Youth-Friendly Health Services (AYFHS) were generally available as per policy specifications, certain services and specifically trained healthcare providers for those services were unavailable. Additionally, there was a lack of essential drugs needed by adolescents seeking healthcare. Furthermore, most of the services provided were not tailored to meet the specific needs of adolescents and young people, which PLOS GLOBAL PUBLIC HEALTH had an impact on the overall quality of AYFHS. These institutional barriers contribute to compromised quality in AYFHS. It is important to address these barriers to ensure that healthcare services are accessible, available, and of high quality for adolescents and young people [24]. --- Limitations A limitation of this study was the ethical concerns associated with identifying key populations and respecting privacy and confidentiality. To address this, snowball sampling was employed to identify key-population participants. Another limitation was the inclusion of only 12 out of 62 Higher and Tertiary Education institutions in Zambia, which prevented achieving theoretical saturation. Further exploration of contextually driven reasons for young people's choice of care provider could be pursued. However, the study attempted to increase the transferability of findings by including institutions that varied in type and location, reflecting the socio-economic and cultural landscape of the country [30]. Additionally, the credibility of the findings was enhanced by utilising diverse data sources and employing well-known methodologies for data collection. Transparent explanations of the data collection and interpretation processes were provided, increasing the overall trustworthiness of the research findings [31]. --- Conclusion The study findings indicate that although some Adolescent and Youth-Friendly Health Services (AYFHS) were available in HTEIs, only a few services were perceived as accessible by young people. This was due to factors such as limited opening hours, high costs, long waiting times, frequent shortages of equipment and commodities, and poor attitudes of healthcare providers. These findings suggest the need to improve programming for adolescents and young people in HTEIs by ensuring that services are readily available when needed and addressing the specific vulnerabilities of students with disabilities and key populations to achieve universal health coverage. It is crucial to prioritise funding to support a systems approach in strengthening AYFHS in health facilities within HTEIs in Zambia. There is an urgent need to address challenges in service availability and expand the range of services offered to meet the health needs of adolescents and young people. Enhancing the competencies and skills of healthcare providers in delivering AYFHS, including reaching out to minority populations, can greatly improve service uptake and health outcomes among this population. Ensuring the availability of medical supplies, providing appropriate and sufficient information, and addressing the identified issues can significantly enhance the quality of services offered. --- All data relating to the findings are included on the paper in form of quotations. However, additional data may be made available on request from the --- Availability According to the AAAQ framework, availability of services refers to the presence of public health and healthcare facilities in sufficient quantity, considering the developmental and --- Author Contributions Conceptualization: Choolwe Jacobs, Alice Saili, Remmy Mukonka, Lenard Mumbi Mwilu. Data curation: Choolwe Jacobs, Flata Mwale, Musonda Mubanga, Mwenya Kasonde, Margarate Nzala Munakampe. --- Formal analysis: Choolwe Jacobs, Musonda Mubanga, Margarate Nzala Munakampe. Investigation: Choolwe Jacobs. Methodology: Choolwe Jacobs, Flata Mwale, Margarate Nzala Munakampe. --- PLOS GLOBAL PUBLIC HEALTH

The recognition of the need for Adolescent and Youth-Friendly Health Services (AYFHS) is growing. It is important to ensure the provision of high-quality sexual and reproductive health (SRH) services that cater to the unique needs of adolescents and young people (AYP). Adolescents and young people spend a significant amount of time in Higher and Tertiary Education Institutions (HTEIs) where adolescent friendly services are needed. However, there is limited evidence on the availability of sexual and reproductive health services for young people in HTEIs in Zambia. Using the Human Rights Based Approach to healthcare availability, accessibility, acceptability, and quality of care (AAAQ) framework, this study explores young people's perceptions of youth-friendly sexual and reproductive health services in selected HTEIs in Zambia. Between March and June 2021, a qualitative case study was conducted in 12 selected HTEIs located in Lusaka, Central, and Copperbelt provinces of Zambia. The study employed In-depth Interviews (IDIs) and Focus Group Discussions (FGDs) with AYPs, as well as Key-informant Interviews (KIIs) with healthcare providers. The healthcare providers at health facility, district and provincial levels were interviewed to provide insights about the services provided in the HTEIs. A total of 112 interviews were conducted. Data analysis was performed using thematic analysis in NVivo version 11. In the study, young people reported the availability of primary health services like malaria, HIV, and pregnancy testing, as well as screening for STIs. However, their awareness of SRH services was limited. Contraception, STI testing and treatment, and HIV and pregnancy screening and testing were the most accessed services. Equipment and commodity shortages were common, hindering care provision. Young people found healthcare services in PLOS GLOBAL PUBLIC HEALTH

Issues of access to, participation in, and engagement with Science, Technology, Engineering and Math (STEM) continue to preoccupy policymakers, scholarly institutions, and employers (e.g., Australian Council of Learned Academies [ACOLA] 2013; Danish EU Presidency 2012, HM Treasury 2011; U.S. President's Council of Advisors on Science and Technology 2010). Across the Global North, there is an impetus to increase the number of people studying and working in STEM at all levels because STEM industries are deemed vital elements of the current and future economy (Confederation of British Industry 2012; Council of Canadian Academies 2015; House of Lords 2012; Landivar 2013; U.S. Chamber of Commerce Foundation 2015). Although debates remain over the number of future STEM professionals that the UK economy needs (Lowell et al. 2009;Osborne 2010;Xie and Killewald 2012), there is widespread concern from government and business about a growing gender gap in STEM skills. This gap is particularly acute in the sectors of physics and engineering (House of Lords 2012; Royal Academy of Engineering 2012). Participation rates in Bcore<unk>STEM subjects (e.g., mathematics, physics) still represent a very low proportion of the overall STEM figure, with research showing that many young people do not consider continued study of these subjects as being Bfor me<unk> (Archer et al. 2012;Brown et al. 2008;Hutchinson and Bentley 2011;Institute of Mechanical Engineers 2010;Larson 2014;Lewis et al. 2009;Tripney et al. 2010). The situation is especially acute for Physics (Institute of Physics 2012; Smith 2010a). As noted by organisations such as the UK's Equal Opportunities Commission (2006) and The Campaign for Science and Engineering (CaSE; 2014, one obvious way to increase entry to Physics and other key STEM subjects is by widening participation and access to these subjects and related careers. Widening access to STEM higher study and careers comprises an equity issue for various reasons. Scientifically literate individuals are able to access well remunerated occupations (Greenwood et al. 2011). But also, many argue the importance of science literacy for civic participation because it enables citizens to understand and shape scientific developments in society (Osborne 2010). Further, Archer et al. (2012) argue that science literacy comprises a currency for social status. Drawing on Bourdieu's (1984) theories of capital, they argue that science knowledge functions as a form of symbolic cultural capital which can facilitate agency and the re/ production of privilege. In other words, science knowledge is an asset which benefits individuals in terms of their social status and access to civic debate and influence, in addition to benefitting occupational remuneration. Furthermore, as Archer et al. (2012) argue, at present this science knowledge (Bscience capital<unk>) is too unevenly spread across society. In the UK, as in many Western nations, participation in post-16 science and mathematics varies considerably by gender, ethnicity, and social class (Gorard and See 2009;Royal Society 2008;Seymour and Hewitt 1997). Women, working-class students, and those from particular minority ethnic backgrounds (e.g., Black Caribbean, Pakistani/ Bangladeshi) are under-represented in the physical sciences, engineering and mathematics at degree level (Archer et al. 2015;Elias et al. 2006;Gibb 2015; Institute of Physics 2012; Seymour and Hewitt 1997;Smith 2010a, b). The last 40 years have seen notable improvements in gender equity within science in many Western nations (e.g., American Association of University Women 2010). However, entrenched gender inequalities still persist: Gender inequalities remain both in terms of students' perceptions of science and in their patterns of participation in post-16 physical sciences and engineering. Middle-class, White, and South/East Asian heritage young men are most likely to study the physical sciences and engineering at degree level, a pattern which has not changed for many years (Smith 2011). These gendered patterns persist despite scant gender differentiation in attainment in school science (Haworth et al. 2008;Royal Society 2008;Smith 2011) and mathematics (Boaler and Sengupta-Irving 2006). As Seymour and Hewitt (1997) showed, women and minority ethnic students are more likely to drop out of STEM degree courses despite parity in course entry levels (Seymour and Hewitt 1997). These patterns endure in spite of innumerable programmes and initiatives to encourage female participation in science study and careers over the last 40 years (Danish EU Presidency 2012;Royal Society 2008;Smith 2010a;Smith and Gorard 2011). --- Inequality in the Physical Sciences So why do these patterns of entry to the physical sciences and engineering persist? As we have seen, prior attainment is not an explanation for gendered patterns in uptake. And although differential prior attainment may contribute in part in the case of working class students and those from particular minority ethnic backgrounds, other factors have been shown to play a role in lower progression rates. For example, Strand's (2012) analysis of UK longitudinal data found that minority ethnic (but particularly Black Caribbean) students are less likely to be entered into higher tier examinations than are White students, even after controlling for prior attainment. Differential teacher expectations have also been demonstrated to impact with regard to gender: Carlone's (2003) research shows how teachers tend to attribute girls' achievement in Physics to their Bhard work<unk>but regard boys as Bnaturally bright<unk>at Physics, even when they attain less highly than their female peers. Further, Mujtaba and Reiss (2013) found that young women receive less encouragement from teachers, family, and friends to study Physics post-16 in comparison with young men. Students who are traditionally under-represented in post-16 physical sciences and mathematics (notably young women, working-class, and certain minority ethnic young men) also tend to articulate less confidence in their own abilities and are less likely to identify themselves as being Bgood<unk>at science and/or mathematics, irrespective of their actual abilities and attainment (Cheryan et al. 2011;Mendick 2005;Mujtaba and Reiss 2013). Feminist social constructionist research has explored these trends in relation to the gendered construction of science and scientists. This body of work argues that science is socially constructed as a high status, masculine domain that is appropriate for, and populated by, middle class men. As such, young women, and young men from working class and certain minority ethnic backgrounds, are discouraged from the pursuit of science, directly or indirectly. It has been shown that young people tend to associate most science careers with masculinity (Archer et al. 2012), with children perceiving science as being Bfor boys<unk>(Calabrese Barton and Tan 2009;Caleon and Subramaniam 2008;Carlone 2003;Farenga and Joyce 1999;Fennema and Peterson 1985;Francis 2000;Mendick 2005). Respondents also perceive STEM occupations to be individualistic, that is, not involving working with or helping others, which in turn has been shown to deter women (Diekman et al. 2011). The construction of Physics (especially) as masculine (Gonsalves 2014) has been shown to impede many young women's identification with Physics by challenging their construction of femininity (Archer et al. 2016a). Evidence suggests that young people continue to regard science and mathematics as White, male, middle-class pursuits-with scientists and mathematicians tending to be imagined as White middle-class men (Archer et al. 2015;Cheryan et al. 2011Cheryan et al., 2013;;Mendick 2005;Wong 2012)-which in some areas of the sciences, and particularly at senior levels, may be the case. Moreover, as feminist researchers such as Harding (1991Harding (, 1982) ) and Walkerdine (1988Walkerdine (, 1989) ) have asserted, STEM disciplines are constructed upon, and perpetuate, longstanding epistemological, enlightenment constructions of reason, intellect, and competition that are, in turn, historically associated with masculinity. Several studies have explored how such associations between STEM and masculinity impede girls/women's identification with STEM (Walkerdine 1990) and/or necessitate those engaged with STEM to adopt particular strategies to bridge this identification challenge. For example, Pronin et al. (2004) found that women invested in maths adopted Bbifurcation<unk>disassociating themselves from feminine stereotypes in relation to math. Similarly, Archer et al. (2016a) found that young women who identified with Physics tended to describe themselves as unfeminine. Critiquing the masculinist discourses that maintain such associations between STEM and masculinity, and which therefore exclude femininity, Walkerdine (1990) and others have adopted poststructuralist theoretical lenses to deconstruct the gendered discourses that perpetuate these productions of STEM. It is these conceptual understandings of the social production of gender difference and of science as a masculine domain that we build upon in our approach to our research and data analysis. In summary then, the existing literature highlights that understanding the factors which deter young people from pursuing routes into the physical sciences and engineering remains a key priority, both for Governments focused on economic productivity and in terms of equity, civic participation, equality of opportunity, and social justice. Especially, questions remain concerning the ongoing lack of access to Physics for women (and for men from working class and some minority ethnic backgrounds), as well as what might help to reverse this pattern. Research has established that STEM subjects, and Physics in particular, continue to be constructed as masculine, precipitating various practices that deter girls from pursuing these subjects for higher study. However, there has been less attention to how individuals explain these trends or the discourses underpinning such explanations. --- Theoretical Perspective Building on the feminist, social constructionist perspectives outlined previously, our theoretical approach comprises a Bdeep<unk>social constructionism informed by Foucaultian poststructuralism (Fraser and Nicholson 1990). We understand gender to be socially constructed as binarised (i.e., bodies constructed as divided into male and female, with binarised characteristics ascribed to each, and these resulting constructions of masculinity and femininity as relational to each other). This dualistic construction is maintained by gender discourses (Butler 1993;Davies 1989), with discourses being language patterns and practices that constitute the objects of which they speak and that bear power in their ability to produce objects and subjects in different ways (Foucault 1980). Butler (1993) has drawn on Foucaultian theory to analyse how gender and sexuality discourses delineate the normal and abnormal, acceptable and unacceptable. She explains how, in this sense, binarised discourses of gender and sexuality produce some subjects, and their bodies and/or behaviours, as natural (Bin-telligible<unk>) and others as unnatural and abnormal, that is, as Bunintelligible.<unk>She elaborates how these discourses order and police gender/sexuality productions and render untenable those productions which do not conform to binarised norms. Such Bunintelligible<unk>bodies disrupt the gender/sexuality order, and therefore those subjects expressing them are discursively positioned as Bimpossible subjects<unk> (Butler 1993). Such positioning placed these Bimpossible selves<unk>as at risk of social discipline and punishment. Foucaultian analysis of discourse (Burman and Parker 1993;Foucault 1980) can be applied to make visible and interrogate these discourses and thereby to potentially deconstruct the dualistic constructions that they support. We also draw on Bakhtin's (1981) constructs of monoglossia and heteroglossia. Analysing language, Bakhtin uses the term monoglossia to refer to dominant forms of language, representing the world-view/interests of dominant social groups, which are positioned or imposed as unitary and total. However, for Bakhtin, language is never static or fixed; rather it is diverse and inherently dialogic. Different meanings and readings constantly jostle in assertions or subversions as subjects use language in different ways. Hence whereas at the macro-linguistic level there may appear to be stability (monoglossia), at the micro level there is plasticity, contradiction, and resistance, that is, heteroglossia. Francis (2012) has applied these conceptual tools to the construct of gender itself. She argues that the dualistic account of gender (with its animation of the subject as masculine, and denigration of the feminine as Other, as an integral element of the dualism) is monoglossic: It authors itself as Breal,<unk>Bnatural,â nd Btotal.<unk>Yet it is infused at every level with heteroglossic contradiction and potential disruption, in both the theory and performance of gender (Francis 2010(Francis, 2012)). Application of these theoretical tools can help to explore and explain the simultaneous hegemony and fluidity of gender constructions. --- The Present Study Building on the existing literature, we seek in the present article to explore respondents' constructions of gender and access to the physical sciences, with particular attention to their explanations for gender inequality in this area. A key research question for the wider study was the extent to which our data reflect prior research findings showing gender inequalities in proportions of students' intending to pursue Physics for further study after compulsory schooling. Distinctively, we also sought to ask young people and their parents directly for their opinions on why fewer women pursue the Physical sciences in order to explore the different discourses produced in response. This approach is intended to enable identification of the range and nature of discourses that are applied on the topic of gender inequalities in access to Physics, as well as the ways in which these discourses work to construct the Physics discipline, and gendered subjects, in different ways. --- Method Overview The data we analysed were generated by the Economic and Social Research Council-funded BYoung People's Science and Career Aspirations age 14-19<unk>(ASPIRES 2) project. The longitudinal study, and its predecessor BASPIRES<unk>study, have been tracking and exploring children's science and career aspirations from ages 10-19. Methods include a quantitative online survey of the cohort and repeated interviews with a sub-sample of students and their parents. In the present project phase, these methods have been applied when students are age 15/16 years-old (Year 11). Our paper draws primarily on the qualitative interview data generated from the interviews with young people and their parents in the present project phase. The present study subscribes to the ethical standards of the British Educational Research Association, and it has been appraised and approved by the ethics committee of King's College London. The present paper reports only briefly on elements of the quantitative survey findings. Nevertheless, given that some findings from the survey are alluded to and precipitate the qualitative investigation, we briefly outline the survey method here. The survey collected a range of demographic data, and it covered topics such as aspirations (including a focus on science); subject preferences; science participation in and outside school; self concept in relation to, and perceptions of, Physics, Biology, and Chemistry; parental and peer attitudes; and careers education. All items were validated (see Archer et al. 2016b). The survey was sent to a nationally representative sample of 340 schools in England (296 state schools and 44 independent), and it was completed by 13,421 students. Schools were invited to arrange for one or more mixed attainment classes, science sets, or tutor groups of Year 11 pupils (aged 15/16 years) to complete a 30-min online questionnaire in Autumn 2014. Schools were also encouraged to invite additional classes (e.g., a spread of top, middle, and bottom sets, or entire cohorts) to participate in order to receive a more comprehensive picture of students' attitudes toward science and their career aspirations. --- Participants Of the 13,421 students who completed the survey, 6266 (46.7 %) were male and 7155 (53.3 %) were female; 6561 (49 %) were categorised as social class 1 (most affluent, professional and higher managerial), 3764 (28 %) as social class 2 (lower middle class; skilled occupations), 1498 (11 %) as social class 3 (upper working class; semi-skilled or unskilled), 761 (6 %) as social class 4 (manual working class), and 819 (6 %) were uncategorised. We gathered data on our survey relating to parental occupation, which was used in analyses as a proxy for socio-economic classification (recognising that SES and the related notion of social class are complex and contestable concepts). Pupils were asked about their mother's and father's (or caregiver's) occupations, and categorisations were assigned based on the highest recorded occupation. Due to the complexities of asking children about their parents' occupations, a simplified categorisation task was developed and used (as opposed to using the full ONS SEC categorisation system, which proved to be too cumbersome and time-consuming during piloting). Respondents selfreported as White (10,181, 75.9 %), Asian (1306, 9.7 %), Middle Eastern (122, 0.9 %), Black (503, 3.7 %), Chinese/ East Asian (205, 1.5 %), Mixed/Other (648, 4.8 %), and 456 (3.4 %) of students preferred not to answer. The present article primarily draws on qualitative data from 132 interviews (in the current project phase) with 70 15/ 16 year-old students (30 young men, 40 young women) and 66 of their parents (16 men, 50 women). All these respondents had been previously tracked since students were aged 10/11. The recruited interview respondents came from a broad range of socioeconomic classes and ethnic backgrounds: White British (15 boys and 26 girls), White European (2 boys, 3 girls), British Asian (3 boys, 1 girl), Asian (1 boy, 2 girls) and Black African/Caribbean (3 boys and 3 girls), Mixed (6 boys, 5 girls). When drawing data for our article, we recorded each respondent's pseudonym (which they chose themselves when first interviewed at age 10/11), gender, ethnic heritage, and social class category. The latter categorisation is based on information gained from interviews such as parental occupations (using the NS-SEC categorisations), housing tenure, and parental educational backgrounds. Categorisations run from 1 to 4, where 1 represents professional and/or highly educated parental backgrounds and 4 represents minimally educated/ manual unskilled parental occupations. Interview participants were originally recruited from 11 schools in England (one in the Midlands, two in the eastern region, two in the south east, four in London, and one in the south). These schools were sampled from the 279 schools that responded to the Phase 1 survey as part of the wider study (see Archer et al. 2012 for details). A sampling frame was developed to represent six target categories of school (Bmultiethnic urban/inner city schools,<unk>Bworking-class suburban,<unk>Bpredominantly White, middle-class suburban schools,<unk>and Bindependent single sex<unk>) to ensure a range of school contexts and populations. The prospective schools for interviews were purposively sampled using these target categories. Over the course of the project, students were tracked as they moved through to elementary and secondary school. --- Interviews Interviews lasting approximately 45 min were conducted by four of the paper authors, with the majority of the interviews conducted by the third author. Of the interviewers, three (BF, LA, JM) are White middle-class women (with English and Canadian national backgrounds), and one (LY) is a White woman Ph.D. student of working class heritage. We see the interview encounter as contextually situated and are interested in the discourses precipitated therein (Burman and Parker 1993). The interviews took place in a private room at school or in an alternative private location chosen by the students and their parents (e.g., the home, work office, via telephone). Two topic guides were developed and piloted with parents and students covering areas including aspirations (and sources of these aspirations), interests in school and outside school, what they like/dislike about school, attitudes toward and engagement in school science, and broader perceptions and engagement with STEM subjects. Parental interviews included additional focus on family context including perceptions and experience of the child's schooling, involvement in education and careers education provision, as well as the child's interests and aspirations. We also asked students and parents for their reflections and opinions on the under-representation of women in Physics, aiming to analyse the various discourses produced and narratives underpinning them. In this section of the interview we also asked respondents about women's under-representation in Engineering, if time allowed, given this is also a discipline within the Physical sciences wherein women's under-representation is well documented (Perkins 2013; Royal Academy of Engineering 2012). It is this latter section of the interview questions focusing on the under-representation of women in the Physical Sciences that form the focus of analysis in the present article. All interviews were fully transcribed and thematically organised via NVivo. Data were then subject to Foucaultian discourse analysis following the methods advocated by Burman and Parker (1993) and elaborated regarding the distinction between discourses and narratives by Francis (1999). As such, we use Bdiscourses<unk>to comprise the broad content and active construction of a topic that constitutes subjects and objects in particular ways (also commonly referred to as a Bgrand narrative<unk>or Bmeta narrative<unk>) and Bnarratives<unk>to capture the various, more specific sub-discourses that both articulate and support the wider discourse (Francis 1999). The analysis of emerging discourses was assessed against the original texts by Authors 2 and 4. An additional theoretical layer is applied to the analysis via application of the concepts of monoglossia and heteroglossia (Bakhtin 1981), and of gender monoglossia and gender heteroglossia (Francis 2012), in order to explain the dominance and diversity of particular gender constructions. --- Results --- Plans to Study Physics In England, compulsory schooling is concluded by GCSE examinations at the end of Year 11 at age 16. BA Levelq ualifications represent the academic study route pursued by young people in Years 12 and 13, when they are 16-18 yearsold, and they form the main entry route to university Higher Education. Our survey findings show that, of those 9216 students in our study planning to continue with full-time postcompulsory education, 23 % (n = 2143) planned to pursue Physics at A Level. This is a significantly higher proportion than is reflected in national statistics for the proportion of students pursuing Physics A Level (8 %: see Questions for Governors 2014a), likely reflecting our respondents' aspirations rather than actual registration for the course and our sample's apparent inclusion of a disproportionate number of pupils pursuing the Triple Science route (the curriculum route involving separate science qualifications for Physics, Biology, and Chemistry, which is usually open only to higher attaining students). Nevertheless, of the 2143 student respondents planning to pursue Physics, only a third (35 %, n = 756) were female (compared to 21 % nationally; Questions for Governors 2014b). Hence, even within our somewhat Bscience-focused<unk>sample, the trend for male domination of Physics is strongly evidenced. This returns us to the longstanding question as to why more men than women pursue Physics study and careers. Our quantitative findings also demonstrate that the pursuit of Physics is strongly related to social class, with almost all students planning to pursue Physics A Level coming from the highest social class 1 and 2 categories (85 %, n = 1820). Furthermore, students from certain minority ethnic groups (notably South Asian) are disproportionately represented (13.2 %, n = 282 compared to 9.7 %, n = 1306 for the whole sample). These different variables clearly intersect with gender in access to Physics. The relationship between gender and social class concerning identification with Physics (or otherwise) is explored further in Archer et al. (2016a). --- Barriers to Pursuing Physics and Engineering Although social class and ethnicity clearly pattern access to Physics in addition to gender, we did not find distinctive social class and ethnicity patterns in relation to the construction of Physics as gendered. Rather, students from different social and ethnic backgrounds appeared equally likely to subscribe to, or to reject, gendered constructions of Physics. Respondents from different ethnic and social class backgrounds also appeared no more or less likely to mobilise different discourses in their explanations. (Albeit numbers for different groups were small, so this finding should be treated with caution.) This diversity is illustrated by the quotes from the qualitative data we cite. In contrast, some gendered trends in responses were evident. Asked BDo you think there is anything that is putting women off pursuing careers in Physics?,<unk>it was interesting to see a gender discrepancy in interview responses: less than a quarter of young men (n = 7 of 30) felt there might be things that put women off pursuing careers in Physics, with more male adolescents (n = 12) either simply answering Bno there isn't,<unk>or offering equal opportunities and individual meritocracy discourses to argue that there is nothing deterring women. This was in comparison to more than half of young women (n = 22 of 40) who felt there were things that put women off-with gender discrimination and stereotyping as notable explanations among these accounts. Only 10 girls said there was nothing deterring women from pursuing Physics careers (the remaining 4 girls, and 6 boys, gave ambiguous responses or said they did not know). However, as Table 1 shows, young men were more likely to change their minds when probed about the case of Engineering. Although not all students were probed on this point (48 were asked the question, 22 not), in contrast with their responses concerning Physics careers, very few young men (n = 3) said that there is nothing putting women off pursuing engineering careers, and 12 said there were (various) reasons, with four additional young men providing ambiguous answers or Bdon't know<unk>responses. Sixteen young women agreed that there are barriers to women pursuing engineering careers, with only three saying there is nothing deterring women (a further three young women either did not know or provided ambiguous responses). These responses appear to chime with the particularly gendered profile of engineering (Perkins 2013). --- Emerging Discourses and Narratives Table 2 sets out the three key discourses identified in discussion of this issue, and the five different narratives identified as underpinning the third discourse (that of Physics as Bquintessentially masculine<unk>). Table 2 also provides details of the number of student and parent respondents using the various discourses and their gender. --- The Discourse of Meritocratic Equality Of the 22 (31 %) students and 12 (18 %) parents who claimed there is nothing deterring women from careers in Physics, those who elaborated their response tended to draw on narratives of individualism and meritocracy identified as highly prevalent in other studies (Francis et al. 2013). As Victoria2 (White Bulgarian, F, social class 4) explains: BI wouldn't think that anything is putting women off specifically because if a woman wanted to study Physics then it would be her choice.L ikewise, Gemma (Black Seychellois, F, social class 3) supplants the structural implication of the question with a narrative of individuality and agency: BNo not really, it depends on their interest and stuff.<unk>CheekyMonkey (White, M, social class 3) exemplifies how the discourse of meritocracy interweaves this narrative of Bindividual<unk>ability or choice by asserting that nothing precludes young women pursuing Physics: BI think they're [individuals] just going to just work for it.T hese accounts rest on well-analysed and closely entwined discourses of (a) neoliberal individual agency (Francis et al. 2013;Rose 1999), a discourse which interpolates individuals as agentic authors of their own outcomes depending on ability, entrepreneurship, and/or diligence (Bauman 2005) and (b) equality of opportunity, which positions gender discrimination as a thing of the past (Francis et al. 2013;Hey 2005;Volman and Ten Dam 1998). The latter was also overtly articulated in the data: BUm... I think there probably would have been in the past. But now a lot more women are taking part in pretty much anything now. I don't think there's that divide anymore( Lucy, White British, F, social class 1) (see also Jane2, quoted in Table 2). As Francis et al. (2013) argue, it is important that this widely reported, monoglossic account of opportunities as equal according to gender be acknowledged by sociological researchers and that discursive investments in individual agency be appreciated as well as critiqued. They reflect rapid social shifts in recent decades, including the impact of feminism. Nevertheless, it remains a concern that the evidence (in this case, regarding women's access to Physics careers) belies the discourse and the risk that these individualistic narratives which consign discrimination to history thus Bresponsibilise ( Rose 1999) young women for their Bincorrect choices<unk>and lack of access. For example, several respondents position access to Physics as coming down to individual attributes such as Bmotivation<unk>and Bwillpower<unk>: I don't really think there's like a thing where it puts off like females, but maybe they're intimidated perhaps like maybe of like men in Science and stuff like that. But I don't really think... as long as they have the motivation it shouldn't really be a problem. (Colin, Sri Lankan, M, social class 3) Um, to be honest at the moment no, because like girl power has got really strong recently and I think it's more girls and women are trying to put their names and faces into things that predominantly men are meant to like be good at, so I think it's actually more of like a willpower to go into things like that (Georgie, White British, F, social class 1) I think it's just themselves and the confidence to be honest-I think it's all to do with confidence. I don't believe that it's a man's world and all that nonsense anymore, I think that's well and truly died out-women are more than capable to learn what they want to learn. (Tasha, mother of Alan, Mixed Carribean/White, F, social class 3) Hence respondents' rejection of the idea that women are deterred from pursuit of Physics tended to rest on discourses of equality of opportunity and meritocracy. These discourses reject and deny gender discrimination, with the potential effect of positioning women as individually responsible for their lack of access to Physics. However, as we observed previously, a third of young men and nearly two-thirds of young women asserted that there are impediments to women's pursuit of Physics careers (and a greater portion of young men, and half of young women, felt that there are issues that deter women from engineering). These respondents provided a variety of explanations, drawing on two key discourses (and a variety of narratives articulating these): (a) continuing gender discrimination in and around Physics and (b) Physics (and Engineering) as quintessentially masculine. An additional recurrent theme was the disproportionate representation and domination of Physics by men as an explanation for women's lack of participation. We explore each, with additional attention to this latter theme of lack of women's representation in Physics: this theme could express both discourses, but it was largely articulated in critiques of sexism and discrimination and was notably recurrent in participants' responses (it was used by 61 of the 132 respondents). --- The Discourse of Gender Discrimination As Table 2 shows, in keeping with their stronger articulation of discrimination in the Physical sciences, this discourse was used especially frequently by young women and mothers (50 % of the 40 young women used this discourse, as did 44 % of the 50 mothers, compared to just under a third of young men and fathers). Some participants maintained that gender inequality and discrimination in Physics has not yet been overcome, or is taking time to shift-what Blackbird (Father of Finch, White British, M, social class 2/3) refers to as Ba historic and cultural hangover.<unk>Poppy (White British, F, social class 1) likewise asserts that Physics remains Bmale dominated.<unk>She goes on to elaborate the gender discriminatory and essentialist perceptions articulated by one of her teachers: Like today in Chemistry... we have a different teacher to normal because the other one's off... and my friend said that she wanted to do higher level Maths. And apparently that is really really hard to get a 7 in [B7<unk>refers to a high expected Blevel<unk>in the English National Curriculum, applied until officially abandoned by the Government in academic year 2015/16]. And the teacher said, (she's a girl), she said BOh I think you have to have a boy brain to do that<unk>... Really? The whole class was like BWhat?<unk>(laughs) BYou don't say that at this school.<unk>And like my friend now really just wants to do it because... to prove her wrong. We don't really understand what she was saying by a Bboy brain,<unk>She said BOh you get boys that tend to be really geeky and good at Maths<unk>but we were like BWell you get girls like that too.<unk>She's a Chemistry teacher! Indeed, several respondents had cautionary tales of sexism that female novices had experienced in seeking to access Physics and Engineering. For example, referring to the Bgreat shame<unk>that women are under-represented in Physics careers, Harris (father of Emma, English/Belgian, M, social class 1) recounts that one of his daughter's friends Bhad a really rough time doing the Sciences (inaudible) at a good university and really struggledshe was the only girl on the course.<unk>Likewise, Kate (White British, F, social class 1) explains that her brother's girlfriend is studying Engineering at university and needed to undertake a year's study in industry as part of the course: She went... I've forgotten what company it was... but in the interview they asked her how will you cope as a woman in this male company. And she was just like BWhat?<unk>And then they pretended that they hadn't asked her like such a sexist question. --- Kate's conclusion illustrates the discursive impact of such ongoing discriminatory practices on other potential female applicants: So I think you would face issues, but probably [...] So I don't think it stops you doing anything -I think it just puts pressure on you not to. I think there's probably any job you could do in Engineering as a girl, but you're less likely to probably. These Bcautionary tales<unk>of sexism from teachers and gatekeepers are especially worrying given the findings about the strong impact of teacher and other Bexpert<unk>expectations and their communication on young women' self-confidence and pursuit or otherwise of Physics (Seymour and Hewitt 1997;Spears Brown and Leaper 2010;Reiss et al. 2011). Other respondents saw additional off-putting consequences to the male domination of the field: BI think that it is a male environment, so I don't know. I think it would be harder for a woman. [...] I think it, she would feel that she has to be extra, you know work extra hard and prove herself more all the time to compete with a male<unk>(Patsy

The present article investigates explanations for gendered trends in Physics and Engineering access, reporting findings from a large-scale study funded by the UK Economic and Social Research Council and drawing primarily on data from interviews with 132 15-16 year-old adolescents and their parents. Survey results in our study and elsewhere show strong gender disparities in anticipated pursuit of Physics after completion of compulsory education. In order to explore the constructions of gender and Physics underlying these trends, we focus on qualitative interview data, applying Foucaultian analysis of discourse to investigate gendered narratives underpinning adolescents' and their parents' articulations. This analysis reveals three key discourses at work on the topic of women's access to Physics: (a) equality of opportunity, (b) continued gender discrimination in and around Physics, and (c) Physics as quintessentially masculine. We additionally identify five distinct narratives supporting the discourse of physics as masculine. These various discourses and narratives are interrogated, and their implications explored. We conclude that it is only by disrupting prevalent constructions of the Physical sciences as a masculine and Bhard^domain will we increase the presence of women in the sector. Working with young people to analyse and deconstruct the discursive assumptions made in relation to gender and Physics, as well as further work to increase accessibility and broaden representation in Physics, may be fruitful ways to challenge these longstanding associations between Physics and masculinity.

s conclusion illustrates the discursive impact of such ongoing discriminatory practices on other potential female applicants: So I think you would face issues, but probably [...] So I don't think it stops you doing anything -I think it just puts pressure on you not to. I think there's probably any job you could do in Engineering as a girl, but you're less likely to probably. These Bcautionary tales<unk>of sexism from teachers and gatekeepers are especially worrying given the findings about the strong impact of teacher and other Bexpert<unk>expectations and their communication on young women' self-confidence and pursuit or otherwise of Physics (Seymour and Hewitt 1997;Spears Brown and Leaper 2010;Reiss et al. 2011). Other respondents saw additional off-putting consequences to the male domination of the field: BI think that it is a male environment, so I don't know. I think it would be harder for a woman. [...] I think it, she would feel that she has to be extra, you know work extra hard and prove herself more all the time to compete with a male<unk>(Patsy, mother of Indiana, White British, F, social class 3; see also Sandra, Table 2). (It is worth noting that such perceptions of women's experiences in Physics are borne out by research studies such as Danielsson 2012 and Ong 2005.) Hence these respondents articulated this discourse of gender discrimination still operating in and around Physics, underpinned by a discourse of equal rights (producing such inequality as unfair ;Balbus 1987;Francis 1999), to explain the under-representation of women in Physics. Many of the respondents articulating feminist discourses and that of continuing gender discrimination and lack of equality of opportunity in relation to Physics drew on popular social science constructs such as gender stereotyping, gender roles, and socialisation to explain their answers. Allusions to Bstereotypes<unk>that men and women are suited to different jobs were especially common: BAgain, the stereotype factor, I think that plays a massive part in that [...] That only men do jobs in engineering and stuff like that<unk>(Demi, White English, F, social class 2/3); and BYeah all those stereotypes and that, that it should be men who do that kind of thing<unk>(Chloe, White English, F, social class 2). These social science constructs were used to explain how gender-distinct behaviours originate with, and are perpetuated by, society, supporting social rather than gender essentialist accounts for the lack of women in Physics. Joanne (White English, F, social class 2) provides an especially developed illustration of the application of explanatory social science constructs: J: Well there's a whole bunch of reasons really that I talked about in my essay sort of-stereotyping, women not being given jobs just because of being women [...] got some stuff about that in there. Toys can sometimes put women off science because... or particularly Physics... because boys' toys tend to encourage more spatial awareness than girls' toys do. There's stereotype threat -I don't know if you've heard of that. Interviewer: Mm J: And there's -I: What, sorry, Bstereotype threat<unk> : It's when you feel that you're covered by a negative stereotype in a situation where you may exemplify that stereotype, you will put extra pressure on yourself to try and defy it, and in the end choke and just end up exemplifying it in the end anyway. So a lot of women suffer from that, as well Bimposter syndrome<unk>where women feel like they've got where they are by luck. Hence in contrast to the elevation of agency and the relegation of structural accounts of inequality to the past produced by equal opportunities/individual choice discourses, the discourses mobilised in these accounts positioned gender dualist and discriminatory practices as ongoing and as impinging on and/or determining women's behaviour. The discourse of continued gender discrimination and lack of equality of opportunity in relation to Physics was also expressed within an especially frequent explanation for why women are deterred from pursuing Physics careers-a theme concerning the numerical dominance of Physics by men and the consequent lack of representation of women. It was notable that the concept of Brole models<unk>was mentioned by only a few of respondents (three parents and one male student). However the issue of numerical domination by men, as well as the discouraging messages this conveys to women, was an extremely strong theme in our data. There were a range of different versions of this explanation. Some young women presented the numerical domination by men as itself off-putting and intimidating: BUm... well I mean at the moment it's mostly boys, so they probably get put off being like 'Well I'm going to be in a class full of boys, so they don't want to do it'<unk>(Hannah, White British, social class 1); and BUm... I don't know, it is definitely like a male job. Like I was looking about [college] like I told you, and my brother was like 'Well if you're going to do Physics you will be the only girl in the class'<unk>(Kate, White British, F, social class 1). Whereas these statements evoke isolation, and almost a fear of obliteration as Bthe only girl,<unk>others highlighted the potential stigmatisation of being Bodd<unk>or Bweird<unk>as a minority: Bpeople might you know think a woman doing a, you know a stereotypical man's job like a builder they might find it strange or something [...] that's probably quite a big factor rather than like a small one, so...<unk>(MacTavish, White, M, social class 4); and because like in class yeah there's all the boys who do Physics and like if you're a girl and you're good at it, it would be like it just seems a bit weird [...]. I think people just see it as a bit weird. [...] Like I think the boys just like... and because like a lot of boys do it as well, so I think it would just, it's just like uncomfortable if you're a woman and you try and go there and I think like the boys in my class they don't really expect girls to be that smart, so like if you do it [...] you know. (Kelsey, Black Nigerian, F, social class 5) Kelsey's words evoke the common association between Physics, masculinity and Bcleverness<unk>to which we shall return later in our article. But her words also suggest visceral discomfort and vulnerability at Bstanding out.<unk> The lack of representation of women in science was also presented directly as excluding/precluding women's participation: BUm, yeah there's been sort of like a stigma with I don't know. It [women in Physics] doesn't seem like it's as prevalent. You don't see any female scientists being advertised in the same way that like you've got male scientists<unk>(Bobster, White, M, social class 3/4); and But I could imagine that there is still a bit of a kind of BPhysics is a man thing.<unk>Cos like for example if you take The Big Bang Theory [a television program] right, like if you think about... obviously well there's Penny, who's not even a scientist, but the two girls who are scientists-they're both biologists. And then all the guys are Physics. So like there is kind of this underlying sort of thing where you're a bit like BMm, why is Physics not a girl thing?<unk>Cos Amy Farrar Fowler could easily be a physicist right, and then like you know... for example, I don't know, like Leonard could probably be a biologist, but they've just made it so that all the guys are physicists or engineers, and then the girls... so I guess there is kind of still a little bit of a kind of gender roles sort of deal going on. (Davina, White, F, social class 1) These statements clearly suggest that the lack of women in Physics (both in actuality and as represented in popular media) sends a message about what is (in)appropriate for women. Here the theme of gender representation overlapped with the afore-mentioned concepts of gender stereotyping in young people's accounts. The frequency of references to the TV show BThe Big Bang Theory,<unk>especially from young women, to exemplify the gender stereotyping of Physics was highly notable. um, like have you ever seen Big Bang Theory? [...] It's four physicists and they're all men and people don't really think of that as being sexist, but it is because the female character Penny is like the one that isn't smart, because she's a girl and she's interested in girl things and that's a whole like running joke on the show, but it's just sexist. It's not funny. (Caitlin, White, F, social class 2/3) The prevalence of the trope of the male scientist in the popular imagination was frequently blamed on the media, and was presented as perpetuating perceptions of science as Bfor males<unk>: BI don't really know, it's probably just... I don't actually know where my view of that's come from, but it could be from like movies, the media. Like if you have a mad scientistit's always male, it's never female. It's just stuff like that I guess<unk>(Poppy, White, F, social class 1); and BI think it's more because like in the news you've got like mainly the people that do are seen as like physicists like Stephen Hawking and people like that. They're all male overall. You don't really see many female ones anywhere<unk>(Celina2, White English, F, social class 4). Such statements are supported by research analysis showing the associations between science competence and men/masculinity in the media (e.g., Orthia and Morgain 2016). Indeed, Archer et al. (Archer and DeWitt 2014;Archer et al. 2015) have catalogued in detail the exclusionary power of such imagery and its debilitating impact on the science aspirations of those not inhabiting the projected Bappropriate body<unk>(i.e., not male, middle class, and White/South or East Asian). Comments from Samantha (Indian, F, social class 1) also illustrate how this lack of representation can also be interpreted or conveyed as presenting a Bnatural<unk>order wherein men are simply better at Physics: I think in general it [Physics] is perceived as a much more male orientated area of Science. [...] I think I guess in the past women generally didn't do that much Science. Obviously there are exceptions, but it's very much like a lot of discoveries have been made by men and I think that's just carried it on and I think also boys generally tend to have a slightly more kind of BMathsy,B Physicsy<unk>brain like a lot of the intelligent boys, so... Other students critiqued such narratives, maintaining that women's presence in science has been actively masked: I don't see any reason why women should be put off Physics and you know there is no reason, but in a way... like in the same way that people view intelligence as an interest in Science, people view you know Science as all the men at NASA working at their computers with the men landing on the moon and you know people forget that you know there are several prominent women [..]. (Buddy, White English/Italian, M, social class 1) The importance of representation of women in Physics for Bevidencing<unk>the possibility and hence facilitating equity discourses (Bpossibilising<unk>the notion of the female scientist for respondents) was clear from many responses. For example, Mienie (South Asian, F, social class 2) supports her claim that women can be successful Physicists by highlighting: Bbecause there's... you know there's a lot of female physicists out there, so-.<unk>Yet equally, it was also noticeable how, rather than necessarily disrupting the monoglossic account of science as a naturally and wholly male terrain, the few heteroglossic cases of women scientists that are publically recognised or included in the curriculum could apparently be easily discounted or ignored, failing to disrupt the monoglossic facade: BCos like when you see most like discoveries... they might just take credit, but like most of them you see them as male. There's only a few like female scientists like we've heard of in science<unk>(Alan, Mixed, White/Black Caribbean, M, social class 3). Hence our data highlight the importance of representation in terms of Bim/possibilising<unk>imagined science futures for young women: their lack of representation in media and'real life' science discursively positions (White and occasionally Asian, middle class) men as 'naturally' inhabiting the science terrain, and any women as interlopers, oddities or 'impossible subjects' (Butler 1993). In answer to the question as to whether anything deters women from pursuing Physics careers, Tom3 (White, M, social class 1) replies: BUm... well I've never seen a girl do Physics so I wouldn't know.<unk>Tom appears to present the lack of young women in Physics as explanatory in itself; a phenomenon that brooks no further speculation. Likewise, for Charlie, gender representation in different subjects naturalises a binary order: Um, yeah I like I see it as more of a like guy thing. I don't know why. I just like when I hear Physics I think of like the three nerdy, well I suppose nerdy boys in my year, but they're really good at it, which is why I think of them, so I don't really think of girls like because they're all into beauty and that in my school. (Charlie, White, F, social class 2/3) Hence, the issue of representation is shown to remain key in young people's constructions of gender and science and in the im/possibilisation of Physics trajectories for girls and women. The relentless repetition of images that present male bodies in association with Physics, and hence work to embody Physics as male in the public psyche, may be identified and critiqued by respondents, but are nevertheless hard to resistand impact material practices by constituting and reinforcing Physics as masculine. Our data illustrate the symbolic violence and impact of the repetitive motif of the male Physics body on young women' perceptions of Physics as an inhospitable, Bunnatural,<unk>and potentially isolating route (see also Archer et al. 2016a). The Discourse of Physics as Quintessentially Masculine (and its Supporting Narratives) As well as being symbolically embodied as male, Physics was also presented by many students as a masculine subject and therefore off-putting and/or inaccessible to girls and women. (As Table 2 shows, this discourse was articulated by the 70 young people on 139 occasions in the data.) As Brittney (White, F, social class 3) explains: BI think because it's seen as a masculine subject to do and not really feminine [...] It just doesn't seem very feminine to want to do anything to do with Physics.<unk>There were five distinct narratives supporting this discourse which emerged in response to our question as to whether anything deters women from Physics and Engineering careers: (a) Certain subjects are genderstereotyped as being masculine or feminine (and hence as appropriate for different genders), (b) Men and women are naturally different and drawn to different subjects, (c) Femininity is antithetical to (masculine) manual work, (d) Femininity is superficial, and (e) Cleverness is masculine, and Physics is a clever/difficult subject. Although a few students remarked on the construction of Physics as masculine without attributing a reason for this labelling, some drew on the concept of gender stereotyping to position this as an invalid socially perpetuated association. Others drew on the narrative of men and women as naturally different and drawn to different subjects to explain the dearth of women physicists as due to natural phenomena (an account supporting the monoglossic, binarised construction of gender duality): But I also think that part of it is the way... it's what interests the male brain as opposed to the female brain. For example computer games, you know we have Xbox in the house and my son plays computer games, and my daughter does rarely because she's not interested. And so there's no... it's not anything to do with sexual discrimination or anything or lack of opportunities. I mean she played girly things... sounds terrible... you know female orientated games when she was younger, but she has no interest in playing computer games now. (Joseph, father of Georgie, White, M, social class 1) It was interesting to see which subjects were considered appropriate for each gender here. Supporting previous findings, Bcaring<unk>and Bcreative<unk>subjects and occupations tended to be seen as appropriate for females (Francis 2002), in comparison to the produced Bnatural fit<unk>for males with Physics and Engineering (Archer et al. 2012). For example, Hedgehog (White English, M, social class 4) considers that Byoung women, they're more into like being like midwives and like beauty therapists and that,<unk>and Cristiano (Black Nigerian, M, social class 5) considers young women Bjust have other interests,<unk>which he exemplifies as BProbably healthcare.<unk> dditionally, some respondents perpetuated the longstanding construction of Biology as a'more feminine' science discipline: BWhen I think Physics I think it's more manly and Biology is more feminine<unk>(Carol, White, F, social class 3). Biology could be classed a bit... not saying it's more feminine, but women... or maybe the females would know more about biology, a) with what we all go through... not saying men don't go through it, but you know we learn a bit more about our bodies and why are bodies are doing things from a lot earlier age with like periods and stuff-we get involved a little bit more about biology earlier on. And we could maybe go more i n t o t h e m e d i c a l p r o f e s s i o n o r t h e c a r i n g profession-that side of things. So Biology maybe is a little bit easier or we understand... not understand it more, but we can get involved in it easier. (Sally Ann, mother of LemonOnion, White, F, social class 3) As Sally Ann's response illustrates, often when probed for rationales for these different gender Bdispositions<unk>for different subjects, respondents talked in rather vague terms about different gendered interests in relation to potential subject content in different disciplines. Interestingly, Bcircuits<unk>were mentioned on numerous occasions as an exemplification of an element of Physics that might deter young women' interest, either as reported by young women as a topic they didn't like or as a topic which young men and young women suggested would not appeal to young women. Luna's (British, F, social class 3) response is indicative here: BCos I don't think that electrical circuits really... for a lot of young women might not stand out to them and make them want to do it at A Level... which might be a reason why they don't continue it.<unk> ence, the narratives presented thus far interpolated males and females as different, as well as Physics as more appealing to males, whether due to (spurious) gender socialisation, or to Bnat-ural<unk>inherent differences between males and females which render particular subjects more appropriate to one or the other gender. However, the power hierarchy at the heart of the monoglossic, binarised account of gender produced in the discourse of Physics (and Engineering) as masculine emerged more clearly in the three further, inter-related narratives articulated: Femininity is antithetical to (masculine) manual work; femininity as superficial; and cleverness as masculine (and Physics is a clever subject). As we reported previously, many students, especially young men, denied that there was anything deterring women from Physics, but reversed this view in the case of Engineering. For a few, this was about lack of representation. But for the majority, this was due to the association of Engineering with manual work, and manual work with masculinity: BLike isn't that [Engineering] more manual? So there'd probably be more men in there just for the sake if it being manual labour<unk>(Alan, Mixed, White/Black Caribbean, M, social class 3). What was intriguing, though, was that none of the accounts positioned physiological differences (e.g., physical strength) as underpinning this envisaged deterrent of manual elements for women. Rather, overwhelmingly, respondents positioned the Bproblem<unk>as being feminine avoidance of Bdirt<unk>or mess: BI was going to say they [women] don't really like getting dirty and building stuff<unk>(Football Master, White, M, social class 3); and I don't have a clear idea on that one, but I think people tend to associate Physics, well no not people, I'm not sure about the general view, but I associate Physics with Engineering and I've sort of got a view on Engineering as them building. I see it as a more practical subject with wires and rusty equipment and stuff like that. [...] It's sort of in the same area in my mind as being a mechanic and stuff like that, so it's different to Biology which you can see is a very clean and hygienic subject. (Finch, White, M, social class 2/3) This positioning of femininity as primly Bclean<unk>was integrally connected to constructions of femininity as preoccupied with appearance and grooming: Band for a lot of women-they want to wear nice clothes and jewellery, and they just don't want to wear hard hats<unk>(Naomi, mother of Buddy, White, F, social class 1); BI think that's why a lot more like men are mechanics and things because it's hands on. Women don't want to break their nails do they?<unk>(Louise, White, F, social class 3); and I do think there's still a you know a lot of girls that want to do girl things. [...] you've still got that type of girl that think they should only do girl things and oh well I don't want to do that, because that will be, you know they don't do sport and they don't do Sciences and they don't do Maths and stuff like that, because Booh no what do I want to do that for? I want to go and file my nails and you know do hairdressing and stuff like that.<unk>(Colleen, mother of Caitlin, White, F, social class 2/3) (see also Ghost, Table 2). What these extracts produce, especially via the vivid misogynist trope of the obsession with Bbroken nails<unk>and the mimicking of voices, is a denigration of femininity as superficial. As many feminist researchers have recorded, this construction of femininity remains prevalent in educational environments (Francis et al. 2003, Francis 2010;Walkerdine 1989), and is fundamentally intertwined in turn with discourses that produce femininity as dim, vain, inane, and lacking in substance (Other). The counter side to this construction of femininity is of course the animation of the masculine (Subject) as profound, intelligent, reasoning-in other words, the production of intelligence, or cleverness, as masculine. As Walkerdine (1989) ;Walkerdine 1990) and others have shown, within the gender binary, science and rationality are positioned in association with intelligence and masculinity; the Bcreative arts<unk>and emotionality, with femininity. BHard<unk>science is produced both as difficult and as masculine (Archer et al. 2012;Harding 1982;Walkerdine 1989), just as rationality and intelligence are positioned as masculine in the gender binary (Harding 1982(Harding, 1989)). The narrative of BPhysics as 'clever' and masculine<unk>was reported and/or articulated by some respondents, as an explanation as to why fewer women pursue Physics: BI think young men are just thought of to be the smart gender<unk>(Caitlin, White, F, social class 2/3); Yeah, because there is like some like stereotype things you see that like you can see that oh men are smarter than women, but that's not always true and like if you want to do, become like a scientist or something like that a woman might be like self conscious and think well I can't do that, because I will look kind of stupid in front of men, but that's not always the case. Like women can be smarter than men. (Laura, White, F, social class 2/3); and well like some young women in my year they act stupid. Like I don't think they are stupid, but I think they act it. [...] So they think 'Oh I can't do it, cos I'm stupid'but they're not at all. Mm, why do they do that? Uh... probably because they're sitting near young men. (Hannah, White, F, social class 1) Clearly, in each case these young women are reporting what they see as stereotypes, but Hannah's words especially evoke the ways in which for young women to invest in Bmasculine/clever<unk>subjects, and/or to actively position themselves as clever, involves a negation of the feminine which may be experienced as untenable (Walkerdine 1990) and indeed as an obliteration of the self (Butler 1993;Walkerdine 1990). As we discuss elsewhere (Archer et al. 2016a), such young women also risk being illegible to, and impossibilised by, others as authentic Physics subjects. It is worth highlighting that narratives were far from always consistent in participants' responses, illustrating the jostling, heteroglossic contradiction at play. Perhaps this is unsurprising given the nature of the three key discourses we have identified as operating in discussion of gender and access to Physics: (a) equality of opportunity, (b) continuing gender discrimination in and around Physics, and (c) Physics as quintessentially masculine. Clearly, each of these discourses is in direct tension with the other, hence providing discursive tension and heteroglossic shifts and contradiction within responses when different discourses are drawn upon by respondents to make particular points. --- Discussion The primary contribution of our findings and analysis has been to identify three key discourses operating within young people's and their parents' responses on gender and access to Physics: that of equality of opportunity, that of continuing gender discrimination in and around Physics, and that of Physics as quintessentially masculine. And we have identified how the latter discourse is articulated via five different narratives: (a) Certain subjects are stereotyped as being masculine or feminine (and hence as appropriate for different genders), (b) Men and women are naturally different and drawn to different subjects accordingly, (c) Femininity is antithetical to (masculine) manual work, (d) Femininity as superficial, and (e) Cleverness is masculine and Physics is a clever/difficult subject. We have illustrated the ways in which these three discourses and five narratives emerged in our respondents' talk, and we analysed how they positioned gendered subjects and the disciplines of Physics and Engineering in particular ways. Especially, we have shown how the narratives connected to the Bopportunities as equal,<unk>meritocratic discourse risk positioning women as responsible for their lack of pursuit of Physics and the continued prevalence of the discourse of Physics as quintessentially masculine. This latter finding supports prior research concerning the longstanding association between masculinity and the Physical Sciences (Archer et al. 2012;Cheryan et al. 2011;Gonsalves 2014;Harding 1991;Walkerdine 1990). Our findings show the resilience of this discourse, and how it continues to permeate the talk of young people and parents, subtly precluding the legitimacy of women's presence in the physical sciences. We and other researchers have also illustrated the pervasive association among Science, Bintellect<unk>and masculinity (Harding 1982(Harding, 1991;;Walkerdine 1988Walkerdine, 1990)), and the positioning of Physics, especially as a hard subject (the Bhardest science<unk>), a masculine subject par excellence (Archer et al. 2016a;Gonsalves 2014). This monoglossic construction is supported by the discourse of physics as quintessentially masculine (and the various narratives expressing this discourse), which, as we have shown, speak to, and perpetuate, the monoglossic, dualistic account of gender, with power invested in the masculine elements of the associated binary (see Francis 2012). We have shown that heteroglossia contests and undermines the hegemony of this account, via both the discourse of gender discrimination in and around Physics and via contradictory utterances reflecting the range of different discourses and narratives at play. Nevertheless, we have also shown that the discourse of Physics as quintessentially masculine retains dominance in its reciprocal support for, and perpetuation by, the monoglossic account of gender. In this way, the lack of representation of women in Physics simply becomes further evidence to support the Bnaturalness<unk>of men's domination of Physics. Until these constructions and associations are disrupted, the problem of women's (lack of) access to Physics, and lower uptake of Physics study at post-16, will clearly continue. We have also shown the prevalence of a theme concerning women's (lack of) representation in Physics which was frequently used by respondents to explain women's lower pursuit of Physics, especially by those articulating the discourse of continuing gender discrimination in and around Physics. We have elaborated the apparent effects of this narrative of women's lack of representation in perpetuating the construction of Physics as an inhospitable domain for women. In addition to our discourse analytic approach, our approach was novel in directly asking respondents their views on gender and access to the Physical sciences. Our thematic analysis has shown that young women were more likely than young men to say that women are impeded from accessing Physics and were also more likely to explain this view via an account of gender discrimination and/or social stereotyping. A further finding from our quantitative data supports the existing literature in showing that young women are significantly less likely than are young men to anticipate pursuing the study of Physics after the end of compulsory schooling. --- Limitations and Future Research Directions Although the research presented here offers several contributions to knowledge, a number of limitations need to be addressed. For example, the results presented in the present study relating to our survey data do not escape the limitations of similar self-report measures (e.g., response bias, control of the sample, spurious responses). However, through conducting repeated in-depth interviews alongside the survey, our work covers both the breadth and depth of participants' aspirations and constructions of identity, thus reducing any of these threats to validity. In addition to issues relating to internal validity, several issues regarding the external validity of the research presented in our paper also need to be addressed. Although the results presented can arguably be generalised to secondary school students in England (because our sample was roughly comparable to national figures for Free School Meals eligibility, regional distributions, performance indicators, etc.), wider cultural comparisons need to be made cautiously. Further research replicating these results in other countries would help to build confidence in the generalisability of our findings. Another issue relating to external validity that should be discussed at this point is the choice of students to be included as respondents to the surveys. Although schools were encouraged to invite a spread of top, middle, and bottom sets, or entire cohorts, to participate, it is possible that teachers selfselected certain classes and students (i.e., top set) to be involved. This likely bias is indicated by the relatively high proportion of students from professional backgrounds included in our sample. Testing these points, especially generalisability to contexts outside England, comprise possible areas for future research. Additionally, identification and exploration of the specific discourses and narratives underpinning respondents' discussion of gender and science access provides an important first step in understanding what is necessary to change and confront if access patterns are to alter. However, how this is done, and what strategies might prove most effective in disrupting and challenging these particular narratives, remains unanswered. Hence exploring and trialling such initiatives comprises an important area for future research. --- Practice Implications Our findings have important implications for those engaged with increasing gender equity, especially those working in the fields of education and/or STEM. There are three main points from our findings that we wish to highlight. The first relates to the positioning of inequality as a thing of the past (via the discourse of opportunities as equal). As we have said, it is important not to disparage young people's frequent faith in the attainment of equality of opportunity and meritocracy. Nevertheless, they need to be aware of the overwhelming evidence on continued inequality in relation to the pursuit of Physics, if to reflect on and confront the remaining binary and discriminatory discursive constructions which we have shown to remain prevalent in their talk. One way to approach this may be for those working with young people to use some of the quotes from the data in the present article to provoke discussion (e.g., in classrooms, workshops and/or youth clubs). This approach of analysing and Bdeconstructing<unk>illustrative texts on gender construction in reflective group discussion has been shown to be an effective one in both primary and secondary schools (see Davies 1993;Francis 2000), and it might be productively applied to the topic of gender and science access. Moreover, the frequent use of social science concepts by those young people articulating the Bcontinuing gender discrimination in and around Physics<unk>discourse to reject suggestions that opportunities have been equalised and/or that lack of access is the fault of women, suggests that such concepts provide young people with a helpful arsenal to resist and critique other accounts. Hence concepts such as stereotyping, and even discourse analysis, might be elucidated and applied by educators within these discussions (see Davies 1993). Second, our findings have illustrated the importance of representation, and the negative impact of the lack of women in Physics (both in reality, and as presented in popular media) on perceptions of Physics as a field, and consequently for women's access to it (and likely for other identities excluded from current representation, e.g., Black and/or working class men). The lack of representation of women in Physics triggers and legitimates a range of narratives, including cyclical assumptions that women's inability and/or lack of suitability explains their absence. But additionally, our data shows the visceral concerns at minoritisation and/or isolation for young women-whether for being numerically engulfed or for being stigmatised as B

The present article investigates explanations for gendered trends in Physics and Engineering access, reporting findings from a large-scale study funded by the UK Economic and Social Research Council and drawing primarily on data from interviews with 132 15-16 year-old adolescents and their parents. Survey results in our study and elsewhere show strong gender disparities in anticipated pursuit of Physics after completion of compulsory education. In order to explore the constructions of gender and Physics underlying these trends, we focus on qualitative interview data, applying Foucaultian analysis of discourse to investigate gendered narratives underpinning adolescents' and their parents' articulations. This analysis reveals three key discourses at work on the topic of women's access to Physics: (a) equality of opportunity, (b) continued gender discrimination in and around Physics, and (c) Physics as quintessentially masculine. We additionally identify five distinct narratives supporting the discourse of physics as masculine. These various discourses and narratives are interrogated, and their implications explored. We conclude that it is only by disrupting prevalent constructions of the Physical sciences as a masculine and Bhard^domain will we increase the presence of women in the sector. Working with young people to analyse and deconstruct the discursive assumptions made in relation to gender and Physics, as well as further work to increase accessibility and broaden representation in Physics, may be fruitful ways to challenge these longstanding associations between Physics and masculinity.

those young people articulating the Bcontinuing gender discrimination in and around Physics<unk>discourse to reject suggestions that opportunities have been equalised and/or that lack of access is the fault of women, suggests that such concepts provide young people with a helpful arsenal to resist and critique other accounts. Hence concepts such as stereotyping, and even discourse analysis, might be elucidated and applied by educators within these discussions (see Davies 1993). Second, our findings have illustrated the importance of representation, and the negative impact of the lack of women in Physics (both in reality, and as presented in popular media) on perceptions of Physics as a field, and consequently for women's access to it (and likely for other identities excluded from current representation, e.g., Black and/or working class men). The lack of representation of women in Physics triggers and legitimates a range of narratives, including cyclical assumptions that women's inability and/or lack of suitability explains their absence. But additionally, our data shows the visceral concerns at minoritisation and/or isolation for young women-whether for being numerically engulfed or for being stigmatised as Bweird.<unk>These concerns are not unreasonable, especially when accompanied with a ready store of cautionary tales of discrimination and humiliation that women have endured in entering the Physics and/or engineering fields. Hence we need to continue work to ensure that women are represented in the Physical sciences: in higher study, in careers, and in educational and media vehicles and materials. Many Physics and STEM associations and Societies are increasingly paying conscious attention to equity in visual representations of the subject. However, it would appear from our findings that these are not yet having sufficient traction or disruptive impact on continued wider representations. Educators and activists continue to have an important role in encouraging media, employers, and educational institutions to recruit and present women in Physics. We need to encourage organisations to take a determined approach to ensuring the appointment and representation of women in key positions and to campaign to persuade the media to adopt a more socially responsible attitude to representation. Findings from Seymour and Hewitt (1997) and others also remind us that recruitment alone is not sufficient: Women and other Bnon-traditional<unk>STEM students and employees need also to be retained. Campaigns encouraging employers to ensure a supportive environment for women in STEM are productive in this regard, and those of us working in universities may be well-placed to encourage some of the less individualistic pedagogies which Seymour and Hewitt (1997) advocate to retain women and minority ethnic students. (These latter might also help to deconstruct associations between Physical sciences and masculinity.) This leads to the third issue we wish to highlight: The construction of Physics as a Bhard<unk>subject (and thus, as masculine). Some notable exemplar organisations have already acknowledged and embraced this agenda. For example, the UK's Institute of Physics is leading the way in its attention to gender and its recent agenda to present Physics as an accessible and welcoming subject, rather than a hard one. Drawing on such exemplars, those working with young people in teaching or activist capacities are well-placed to alert young people to the daily relevance of science, as we are demanding accessible and illustrative learning materials that engage rather than deter students. We can also challenge the myth that science is Bhard<unk>and difficult, whenever raised by students, colleagues, by our institutional practices or in the media. Only by disrupting the symbolic hegemony which perpetuates the Physical sciences as a masculine and Bhard<unk>domain will we increase the presence of women in the sector. --- Conclusion International research has shown the social and economic benefits of widening participation in STEM. Representation of women has been shown to be especially problematic in the Physical sciences. Having shown that our wider cohort study's findings support prior research evidence that young women are less likely than are young men to pursue Physics, the present paper explored respondents' explanations for such patterns. We have drawn on interviews that asked students and parents directly about gender and access to Physics to identify the various discourses and narratives at play in respondents' talk. These discourses and narratives are frequently contradictory, and a discourse of continuing gender discrimination in the Physical sciences was used by some respondents to contest discourses that position the underrepresentation of women in Physics as Bnatural<unk>and/or their own fault. However, these latter discourses were very powerful, respectively evoking opportunities as equal or of Physics as quintessentially masculine to produce women as deficient. It is argued that we need to find ways to work with young people to unpack these discourses in order to reflect critically on the status quo. Presentations of STEM as Bhard<unk>and difficult need to be challenged to encourage identification and participation from non-traditional STEM students, and diversity of representation in the Physical sciences needs to be taken seriously to the same end. In these ways we may support greater equality of access to the Physical science, benefitting individuals and society. Open Access This article is distributed under the terms of the Creative Comm ons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

The present article investigates explanations for gendered trends in Physics and Engineering access, reporting findings from a large-scale study funded by the UK Economic and Social Research Council and drawing primarily on data from interviews with 132 15-16 year-old adolescents and their parents. Survey results in our study and elsewhere show strong gender disparities in anticipated pursuit of Physics after completion of compulsory education. In order to explore the constructions of gender and Physics underlying these trends, we focus on qualitative interview data, applying Foucaultian analysis of discourse to investigate gendered narratives underpinning adolescents' and their parents' articulations. This analysis reveals three key discourses at work on the topic of women's access to Physics: (a) equality of opportunity, (b) continued gender discrimination in and around Physics, and (c) Physics as quintessentially masculine. We additionally identify five distinct narratives supporting the discourse of physics as masculine. These various discourses and narratives are interrogated, and their implications explored. We conclude that it is only by disrupting prevalent constructions of the Physical sciences as a masculine and Bhard^domain will we increase the presence of women in the sector. Working with young people to analyse and deconstruct the discursive assumptions made in relation to gender and Physics, as well as further work to increase accessibility and broaden representation in Physics, may be fruitful ways to challenge these longstanding associations between Physics and masculinity.

GILES Over the last 35 years, the study of intergroup communication has appeared in an array of edited books (e.g., Gudykunst, 1986;Giles & Maass, 2016) and journal special issues (e.g., Clément, 1996;Giles & Gardikiotis, 2018), and been bolstered further by a Handbook (Giles, 2012a) and a two-volume Encyclopedia (Giles & Harwood, 2018). Furthermore, there have been many other overviews, introductions, or critiques of this academic arena that, in and of themselves, demonstrate its burgeoning spirit (e.g., Abeyta & Giles, 2017;Gallois et al., 2018;Keblusek et al., 2017;Kienzle & Soliz, 2017;Maass et al., 2014;Raki<unk> & Maass, 2019). Within and across these outlets, the field is very eclectic, and this is manifest in a rich variety of ways, including the following: • Disciplines and orientations, including ethnographic (Carbaugh et al., 2012), evolutionary (Reid et al., 2010), neuroscientific (Clément et al., 2016), and sociolinguistic (Stubbe, 2012) perspectives as well as the exploration of bridges between them (see, e.g., Krauss & Pardo, 2006). • Methods, with an eclectic array of quantitative and qualitative procedures within each (see, e.g., Augoustinos & Goodman, 2018;Gallois et al., 2021). • Social groups, from the well-trodden classic ones of between-nations/ cultures, -ethnicities, -generations, and -genders (see, e.g., Giles & Harwood, 2018) as well as many others, including encounters between gangs (Goldman et al., 2014), sports teams (Giles & Stohl, 2016), and religious (Morgan et al., 2020), political (Nau, 2016), and military groupings (Wilson & Chernichky, 2016). • Communicative features, as manifest in choices concerning, for example, languages, accents, vocabulary, syntax, and metaphor (e.g., Cervone et al., 2021), nonverbal behaviors in terms of personal space, smiling, and eye contact (Dovidio & Gluszek, 2012), culturally-unique architecture and written histories (Giles, 2012b), dress style & appearance (Keblusek & Giles, 2018), music (Harwood, 2017), and dance (Pines & Giles, 2018). • Research paradigms, including but far from limited to language attitudes (e.g., Dragojevic et al., 2021), linguistic biases (e.g., Maass, 1999), bilingualism (Al-Hoorie et al., 2021), language, identity, and power (e.g., Wakslak et al., 2014), media portrayals and effects (e.g., Hartmann & Tanis, 2013), intergroup contact and communication, group labeling (e.g., Fasoli et al., 2015), language and stereotyping (e.g., Lyons & Kashima, 2003), and hate speech (e.g., Waltman & Haas, 2011). • Applied and social domains, such as the family (e.g., Harwood et al., 2017), health care and medical specialties (e.g., Watson et al., 2012), educational groups of students and teachers (Nussbaum et al., 2012), organizations and institutions (e.g., Suzuki, 1998) such as law enforcement agencies and the court (Watson & Soliz, 2019, see also Giles et al., 2021), and the media (e.g., Ortiz & Harwood, 2007;Tukachinsky et al., 2015). --- TOWARD INTEGRATING SOCIAL PSYCHOLOGICAL AND COMMUNICATIVE PARAMETERS OF INTERGROUP RELATIONS Our focus in this special issue is on the social psychological underpinnings of intergroup communication which, as evident herein, reflects much of the diversity of the foregoing. Again, there is no monolithic approach even within this perspective, as a wide variety of theories have been invoked in the broader field of intergroup relations (see Brown & Gaertner, 2008;Gaertner & Dovidio, 2000;Jost & Major, 2001;Taylor & Moghaddam, 1994). This is evident, arguably to a lesser extent, in the distinct area of intergroup communication, with its main foci -even hegemony -being social identity and social categorization theories (for a critique of this orientation and the need to broaden it, see Taylor et al., 2010;the uncertainty-identity theory, Belavadi et al., this issue). Relatedly, other intergroup models have played lasting and distinctive roles including, but not restricted to, anxiety uncertainty-management (e.g., Gudykunst, 2005), communication accommodation (e.g., Palomares et al., 2016), vitality (e.g., Clément & Norton, 2021), communication theory of identity (e.g., Jung & Hecht, 2004), identity negotiation (e.g., Ting-Toomey, 2005), intergroup contact (Paolini et al., 2021) theories as well as the linguistic category model (e.g., Maass et al., 1989). --- The Collection Readers are encouraged to consult Harwood and Gim's (this issue) splendid conceptual model (or map) overviewing the contributions to this special issue that also suggests innovative ways of their being mutually interlocking in future works. In this prologue, selective features of the (admittedly quantitativelyskewed) papers that follow are introduced. This is accomplished by recourse to two issues. First, by depicting variable features of what constitutes an intergroup scenario in each article and, second, moving second to their cumulative contribution to extending the current principles of intergroup communication. --- Inter-Individual versus Intergroup Interactions Related to the first issue, it is important to highlight an early distinction proposed by Tajfel and Turner (1979) when introducing their social identity theory (for reviews and critiques, see Demirden, 2021;Reicher et al., 2010) between social interactions that are -at their extremes -interindividual versus intergroup. The former was originally termed thusly to distinguish it from socalled interpersonal communication which can actually be intergroup in nature (see Dragojevic & Giles, 2014). As the distinction implies, interindividual communication is shaped primarily by the individual characteristics (their personal identities) of the people involved -their unique personalities and temperaments -such as when spouses respond in a sensitive and caring manner, accommodating each other's unique concerns. In contrast, intergroup communication is considered as such when people's perceptions of (and stereotypes about) their own and others' group affiliations (their social identities) are situationally salient (see Palomares et al., 2016). It is important to underscore that once people categorize others as members of a contrastive outgroup, they depersonalize their mental representations of such people by viewing them as an embodiment of a salient group prototype rather than as idiosyncratic individuals (Hogg & Reid, 2006; see also Lee, 2006). Moreover, just as people categorize others, they can also categorize themselves (see Fasoli et al., this issue). In this way, self-categorization has the same depersonalizing effect on self-perception so that people internalize an ingroup prototype and begin to think, feel, and behave in collectively normative ways (Turner et al., 1987). Indeed, people can construe not only whether they themselves are prototypical members of their own group, but also the prototypicality of outgroup members and their messages (see Gaffney et al., this issue). In other words, both personal and social identities can have a differentially powerful impacts on how people communicate. For instance, when a police officer stops a vehicle, the driver's behavior toward the officer can be heavily influenced by the officer's status, appearance, and as an authority figure, not the officer's novel personal identity. Converging to another's attributes as a prototypical member of an outgroup is called group identity-based accommodation (Soliz et al., 2019; see also Bernhold & Giles, 2020, 2021). This distinction is important, as whereas individuals' communication practices can be driven by group identities being salient in an interaction, many people are unaware as to the extent their social category memberships dictate the verbal and nonverbal features they enact. For instance, Tajfel estimated in (admittedly undocumented) everyday casual conversations with some scholars that 70% of interpersonal interactions are actually intergroup in nature. Although the above is introduced conceptually in almost dichotomous terms, it is not nearly as straightforward, as both identities can be operating simultaneously (referred to as high interpersonal plus high intergroup situations, see Giles and Hewstone, 1982). Interestingly also, Gangi and Soliz, 2016 (p. 40) argued, almost paradoxically, that "communicatively recognizing and affirming differences in multi-ethnic-racial families can actually decrease group salience and increase relational closeness." Given the notion of intersectionality (see, e.g., Crenshaw, 1990;Harwood & Gim, this issue) and the fact that we belong to a range of social groups, the importance of conceding others' multiple identities can be communicatively important (see Belavadi et al., and Fasoli, this issue) as well as others co-present (Gaffney et al., this issue). For instance, in one study, Bernhold and Giles (2021) found that relational closeness remained consistently high when older adults perceived that their romantic partners engaged in high levels of accommodation based on their partner's third-most important group. These findings suggest that romantic partners who "dig deeper" into their loved one's lives by learning about their perhaps less obvious and less important groups, and accommodating accordingly, can enhance relational well-being. Whatever the intrigue surrounding these complexities (see Giles & Walther, 2022), this backdrop is significant for understanding the articles that follow, in that they relate to communicative practices when situations are intergroup in character. In Table 1 below, and control experimental conditions notwithstanding (see Collins et al., this issue) where participants may well see the situational task as more inter-individual, the different ways in which studies in this special issue are constituted in intergroup terms are outlined. The Table also reflects the variety of social groupings, nationalities, and media platforms depicted in this volume. Furthermore, the valued and infrequent attention in intergroup communication studies to macro-societal issues and contexts, such as national crises (see Belavadi et al., and Kioumi et al.) and other social dramas notwithstanding, the above intergroup features therein are, necessarily, just an academic tip-of-the-iceberg of how ingroup-outgroup situations unfold in real life. Nonetheless, Table 1 also shows how the group identities of participants are only one piece of the intergroup puzzle in the context of the sequence and flow of events unfold in real time (see Collins et al., this issue). --- Refining Principles of Intergroup Communication A decade ago, and with the intent of elucidating major communicative dimensions that underlie the different ways that people's social identities can be expressed, questioned, and reinforced, Giles (2012) introduced a set of fundamental Principles of Intergroup Communication alongside Hogg and Giles (2012; see also Abeyta & Giles, 2017). These are articulated below and have been refined and elaborated into six principles in accord with the articles in this special issue. More specifically, they now appeal to ingroup members' self-perceptions of their own communicative practices and others' perceived stigmatization (see Fasoli et al., this issue), social networks and social media (Kioumi et al., this et al., this issue), certain forms of positive messages from outgroup members (Moscatelli, this issue), intergroup identity-uncertainty (Belavadi, this issue), and the co-presence of others in intergroup arguments (Gaffney et al., this issue). Their presentation here provides, especially for the novice to intergroup communication, a complementary backdrop to the preceding interindividualintergroup discussion for digesting and interpreting the subsequent articles that appear in this special issue: I: Language and other diverse modes of communication (e.g., nonverbal and appearance) can serve as markers of-and sometimes criteria for-the multiple categories to which group members belong and with which they are perceived by self and others, sometimes stereotypically, to affiliate. II: Outgroup rhetorical positions and messages -even morality praisecan be biasedly-interpreted by ingroup members, often fostering within them anxieties and uncertainties, and even harmful psychochemical reactions. III: Groups' messages about their intergroup histories and demographics, along with other ingroup communicative practices, can signify distinctive cultures (in terms of normative routines, values, and world views) that coexist with comparative others from whom they can differentiate, even denigrate and stigmatize, and beyond that, dehumanize, particularly under conditions of perceived social threat. IV: The communicative practices and boundaries that differentiate social groups are malleable, and when they evolve or change to better meet prevailing social identity needs, can be responsible for reconstituting the dynamics of the intergroup setting at hand. V: Group members will strive, and sometimes be strategically encouraged, to acquire the communicative practices of dominant outgroups who can, ironically in reactance, move linguistically away from such identity-threatening tactics. Such intergroup dynamics of a dialectic tension (or "accommodative chase") can be prolonged, and oftentimes ultimately abandoned, because of their deleterious effect on the former maintaining a positive social identity. VI: Through the expression of intergroup norms in their social networks and social media platforms, individuals control and negotiate normativity in everyday life, enabling them to recognize any ingroup deviancies that can lead to publically discrediting and marginalizing offenders. Consequently, group leaders who more prototypically manifest the values and communicative practices of the ingroup emerge and/or are elected over influential others. --- Conclusion By means of this content-diverse special issue, we have sought to promote further the value of current and future work on intergroup communication and we are indebted to this journal's editors for their patience and generous assistance in allowing us this exciting opportunity. The guest co-editors are also grateful to the authors of the seven papers in this special issue for their due forbearance and willingness to accommodate our feedback in a professional and collegial fashion. Hopefully, this prologue will provide a modest step in provoking theoretical advances in unpacking when, how, and why situations are deemed intergroup by social actors who may be positioning themselves with other ongoing societal and legal changes (while also being shaped by them) and, finally, how these interlocking dynamics can be transformed through interventions and social policies to be optimally positive. --- Conflict of Interest Disclosure The Author reports no conflicts of interest. --- Research Ethics Statement Not applicable.

This prologue to a special issue on social psychological processes and intergroup communication begins by outlining the constituents of the field of intergroup communication. This includes many of the major publications, disciplines and orientations involved, the methods, social groups, and communicative features studied together with selected research paradigms, applied and social domains, and theories featured. The empirical articles that follow are discussed with respect to two fundamental issues. The first refers to a seminal distinction manifest in social identity theory, namely, how social interactions can be distinguished, conceptually and operationally, as either interindividual or intergroup. Consequently, the articles are discussed in terms how they are variably manifest as intergroup encounters. The second issue relates to past principles of intergroup communication that are articulated, refined, and elaborated further by recourse, in the main, to the emergent concepts in this special issue.

Introduction Domestic wireless networks have become a mundane feature of a great many homes, routinely established by Internet Service Providers as part of the set up of broadband connections. Household activities are increasingly carried out through the network via multiple networked devices that populate the home. Media is increasingly consumed through the network; family communications are supported by it; everyday life is coordinated through it. A burgeoning range of activities are now predicated on and managed through the home network [5]. Despite the broad uptake of network systems in the home, there has been little effort on the part of industry providers to shape networking technology around user characteristics. Home networks consequently embody network management tools developed for enterprise that are "too complex for home users" [19]. Researchers have sought to reduce this complexity by (re)shaping network management around the distinctive characteristics of home users. For example, Yang et als Eden system (ibid.) * This is the authors' version of the accepted manuscript. The final publication is available at Springer via http://dx.doi.org/10.1007/s00779-014-0771-6 exploits a spatial metaphor to support network management, and Chetty et al. [4] developed Home Watcher to surface bandwidth usage and enable direct user control. We wish to consider a topic which is implicit in these kinds of systems: network policy or the use of 'rules' to regulate and govern the home network. Network policies are an integral part of existing network infrastructures but they are also social and implicated in attempts to reshape network management for the home. The design of Eden and the 'internet restriction badge', for example, clearly implicates policy considerations, as does the 'etiquette' that emerged around the Home Watcher deployment. Curiously, however, neither study treats the topic of network policies or rules explicitly or in any depth. This paper presents our experiences in shaping domestic policy interfaces and explicates the tension between user orientations to and understandings of 'network rules' and the enterprise orientations and understandings embedded in current home networking infrastructure. We briefly consider the nature of policy systems from an enterprise perspective, and the tools that have emerged to allow a range of prospective network policies to be written and subsequently enacted by the network [20]. We then report on the results from a range of ethnographic studies of the ways in which network rules are established retrospectively within domestic networks as an ongoing feature of the moral ordering of domestic life. We highlight the emergent and contingent nature of network rules and the extent to which users interpret and negotiate their occasioned use in a domestic context. We address the inherent tension between the prospective enterprise view of network rules and the retrospective domestic view through two technology probes [11] that exploit services provided by our modified domestic router [12]. The probes provide two different kinds of interfaces for effecting network policy: one, the Comic Strip interface, which enables users to write network rules; and the other the Control Panel interface, which affords a means of network governance that "more closely mimics how households manage access and sharing with social relations and rules" [4]. The probes share strong similarities with the functionality provided by Eden insofar as they enable membership management, access control, network monitoring, and QoS policy. However, they reach out beyond the lab to understand network governance 'in the wild'. In this respect, the findings reported complement and extend those of Chetty et al. [4], moving beyond the politics of identity, representation and power to elaborate the underlying moral order that drives day-to-day governance of the home network. We report on the deployment of network control and policy system interfaces, highlighting the ways in which household members exploited these to support network governance. Our results suggest that, in a domestic context, the rules of the network are understood to be inseparable from the rules of the house -that the rules governing one are directly implicated in the rules governing the other. The challenge, then, is one of understanding how the rules of the home might be articulated and used to define the rules of the network. --- The technical character of rules Rules or policies are a key feature of network systems. Indeed, the separation between policy and mechanism is widely used in distributed computer systems as a technique for simplifying complex problems into generic, widely applicable mechanisms and specific, contextdependent policies. Examples of mechanisms might include the weighted fair queuing discipline for providing quality-of-service in core routers; the BGP routing protocol through which the Internet is made into a connected network of networks; or the WPA2 standard for securely associating a device with an 802.11 Wi-Fi network. These mechanisms are deliberately neutral in how they might be used. Policy, on the other hand, focuses on encoding how the network is intended to be used. Examples include deciding that real-time audio traffic should be protected from interference by web browsing traffic; that the Sprint network should be preferred to AT&T's; or that your brother's laptop should be allowed to connect to your home network, but your neighbour's should not. Policies can be complex and multi-faceted, and depend on all kinds of features within and without the network. Distinguishing policy in this way permits the re-purposing of underlying software mechanisms without having to recode them. Policies can be static, specified in advance and remaining in place until someone determines that the policy implementation needs modification; or adaptive, changing automatically in response to use and environmental features. Policies can be distinguished in a range of ways, e.g., by the roles to which they refer, the layer to which they apply, or the type of policy expressed. This has driven the development of a broad range of languages to express policy [20]. Specification of network policy in particular is closely related to the broader network configuration problem, where network devices (routers, firewalls, etc.) must all be configured consistently, both with each other and with the wider constraints of the network owner/manager. Configuration of this nature is complex, and misconfiguration leads to many, often globally visible, problems. As a result tools have been built that statically analyse network-wide configuration against a high-level policy specification [8]. All such policy specification is prospective, performed in advance of deployment, e.g., packets for a particular destination should be dropped; traffic matching a particular pattern should receive a particular quality-ofservice. Creating such specifications requires a high level of expertise: general understanding of the technology involved and the environment into which it is deployed, specific understanding of the problems to be dealt with and the aims of the deployment, and an ability to express the policy specification in the chosen tool. This places it clearly within a professional work context: experts carry out specification, observing and refining implementation. As a result, it is professionally managed enterprise networks to which such tools are applied. These are largescale, geographically distributed, and often strive for homogeneity as a pragmatic way of reducing complexity. None of these features apply to the home network. Home networks are typically far smaller in scale (tens of devices, not thousands or more), exist within a restricted physical context, and are resolutely heterogeneous with new devices being continuously added in an ad hoc manner (from mobiles and games consoles to TVs, bathroom scales, etc.). Network policies typically emphasise generic cases, foregrounding network traffic and device characteristics, with users being dealt with in terms of broad classes rather than particular individuals. Commercial products for managing home networks, such as Cisco Connect Cloud, continue to reflect this perspective even though they provide more usable interfaces. Our orientation to policy seeks to move away from a technical orientation to the network towards consideration of the ordinary activities that network use is embedded in and shaped by in the home. Networks are an unremarkable feature of many homes and their management is now one of the domestic chores involved in running the household [16]. Household members have come to orient to the network as a mundane feature of everyday life and manage it as part and parcel of the ongoing social organisation of their ordinary domestic affairs [5]. The challenge here is one of understanding how this might be reflected in network policies -i.e., of understanding how we might exploit the rules ordering domestic life to govern the home network. --- The social character of rules Seen from a sociological perspective rules have been construed of as foundational to social organisation and order: through rules our individual behaviour is regulated and social order is created, maintained and reproduced. As Hilbert [9] puts it, "the idea that rules stabilise behaviour or that behavioural stability requires rules is a common-sense assumption of our time. As Rawls [14] points out, it is also wrong because "rules cannot tell you how to follow them... that would entail an infinite regress." In short, one set of rules begets another and so on ad infinitum. Rules cannot provide for social order then -they are not sufficient in and of themselves -and can instead be seen as an articulation of an underlying moral order that creates, maintains, reproduces and adapts rules and which gives them their force [6]. While it is tempting to view the moral order as being instantiated and reinforced through rules, which in turn produce the social order through their operation, infinite regress prohibits any such reduction. The analytic separation between social order and moral order is also fallacious: the moral order is the social order, the two are equivalent, one and the same (ibid.). "When individuals confront moral reality, they are confronting society; society and morality are one and the same... Morality is not simply an extrasocietal phenomenon attached to society that makes it run smoothly... Absence of morality is absence of society..." [9] This means that if we want to understand rules and their role in the production of social order, we need to attend to the moral reasoning that articulates rules and which reflexively produces the social order in their articulation. D. Lawrence Wieder provides an exemplary case in his seminal ethnographic study of the convict code in a halfway house [18]. While it is possible to render this code as a set of rules ordering resident behaviour (don't snitch, do not trust staff, show loyalty to other residents, etc.), residents could not recite the rule set. Rather, in practice, "the code" was locally employed by residents and staff to make sense of whatever was happening, and to make whatever was happening accountable to one another. As Wieder (ibid.) put it, "hearing the code and employing it as a 'guide to perception' gave behaviours of residents a specific and stable sense." The upshot of this is that rules should not be treated as prescribing order but as devices invoked to account for order. Rules gain their sense from within the particular contexts in which they operate, and they operate to make the social order accountable to those who inhabit the settings in which they are manifest in, as well as to inquiring ethnographers. If we want to understand the sociality of rules then, we need to understand their accountable character and this will involve explicating the moral order that shapes the accountable use of rules in particular contexts. It is towards understanding the accountable character of rule use in the home and how this shapes network governance that we now turn. --- Understanding network rules in the home Our study of network rules in the home is part of a series of ongoing ethnographic studies of home networks initiated in 2009 and continuing to this day. The studies involve 24 households of enormously varied character, from families with younger and older children to single and shared occupancy households and from blue-collar to white collar and professional backgrounds. The studies are conducted through fieldwork [13] and involve informal interviews and direct observation with any and all household members (including children) who are willing to talk to us (and not all are). Fieldwork sessions are typically of 2 to 3 hours in duration, recorded on video and subsequently transcribed, and are conducted intermittently (every 3 to 6 months) and according to members availability and convenience to elaborate particular issues emerging from ongoing analysis. In effect, the households provide us with a social network that we can contingently 'dip into' as occasion demands and 'drill down' into particular issues that interest us, as well as pool to draw on for deployments. One of the issues that interested us for design reasons was the topic of network rules. For other issues that have been treated during the course of these studies see, for example, [3,5,8,15]. The results of our studies of network rules, including re-examination of the materials that sparked our interest in the topic [10], are outlined below. --- Network rules are about people In the following examples we see that household members have a specific orientation to 'just who?' is using the network and that use is bound up with quite definite expectations about appropriate conduct. Father: Ellie has some boundaries imposed upon her -the new regime is for the laptop to go outside the bedroom door at 9 o'clock. Fieldworker: What happens if she breaks those rules? Mother: We take it off her. The worst punishment is to take the laptop away from her. Fieldworker: Has that happened? Father: Yes, yes... The rule is a recently re-imposed one. We had a conversation about the quantity of usage and the isolating effect of being online. It's very addictive. It's much more fun than being with your mouldy old parents. She's a 14 year old girl so whether she has a laptop in her room or not she would choose to spend a good deal of her time in her own space; really typical for a 14 year old. She's had her laptop for 2 years and before that had access to another machine but she wouldn't use it in her room. There were rules initially -we've let go a lot of those and possibly become too lax, hence the kind of reopening of a conversation. No doubt a familiar conversation to a great many parents of teenagers, but the above vignette extends way beyond this to index the unexplicated ways in which members' orientation to 'just who?' is using the network, and all that is implicated in that question, shape and govern its use. 'Just who?' is a subtle and nuanced matter. It may implicate moral concerns with good parenting and it may implicate a host of other moral concerns at work in the home. Here we see someone who runs his export business from home expressing concerns regarding the use of the network by his son, who works part of the time as a DJ: With my activities -I mean if I only call off emails it doesn't take a lot unless I have large attachments -but I think Danny has no real concept of being economical in what he does... If I don't use much data at the time then fine... I don't really have any large requirements on film or music downloads. Danny's requirements are far larger than mine, but I don't want his to be so large that my relatively small data requirement becomes slow. Another participant who also ran a business from his home put the basic concern here more bluntly: I see myself as using the Internet to bring in income, so I can justify that pretty well everything that I do takes priority. In both of these examples one might see the potential grounding of rules in accountable claims regarding whose use of the network should take precedence. However, in the first example you can also see that it's subtler than that. The householder in question has no problem with his son hogging the network if he's not using "much data at the time." So the reasoning here is also bound up with just what particular people are doing at particular times, something that is intrinsically contingent. The infinite regress implicated in rule following means that it is simply not possible for formal rules to cover all contingencies. The distinction between a formal position and contingency extends to how household members' reason about other people on the network as both categories of people and living breathing individuals they actually know. This is particularly pronounced when we consider the reasoning implicated in giving external parties access to the network. One participant put it as follows: You don't want it so your next-door neighbours could be able to get on for free onto the network. Nonetheless, time and again throughout all of our studies we saw exceptions routinely being made for people who were actually known by the participants, and with a variety of entirely cogent situated accounts: Our next-door neighbour is an old lady. Her daughter works at the university as well and she's in poor health so her daughter comes round a lot. I've given them access to the network as well so she can check her email and do a bit of work while she's here. I've no idea how often they access, I've just given them the key. It's invisible. I know it's not heavy -it doesn't impact. If the usage did get heavy I would put a new password on it and block them out. But as I can't see it it's not an issue... One of my friends came to visit with an iPhone and I have given them the password and that has been OK. I am not sure what sort of connection they have and they tend to manage that. Most people never ask for the password although I would be happy to give it to them... I keep thinking about having one of these apps that would let me have an open guest network but I have never explored them much more than that. Rules that encompass groups of people as certain kinds of identifiable categories might at first sight be seen to be a useful basis for defining policies. However, the question of 'just who?' is subject to a potentially endless series of refinements based upon moral matters to do with being a good host or good neighbour which implicate specific people with specific requirements that are difficult to predefine. The rules that shape network use -who is allowed on to it, when, for how long, and even what they do on it -are themselves shaped by a host of situationally contingent moral concerns revolving around the individuals that use the network and what it is appropriate for them to be doing at any particular time. --- Network rules are socially situated While oriented to by individuals rules are, nevertheless, socially situated. They are shaped by intersubjective relationships and concerns about being good parents, good hosts, good neighbours, etc. Rules are embedded in lively social arrangements and the lively character of these arrangements has consequences for how it is that we might think of specifying formal rules too. In a domestic context rules are rarely written down, instead being largely accomplished and brought to bear by means of talk and conversation. The following vignette elaborates the point: Fieldworker: Do you have any rules in terms of using the network? Thanh: Like in the evening, do not download too much. You can download but not too much. Giang: If someone is downloading you are just gonna shout "Who is downloading?" Fieldworker: Is it mostly when you play games that you want to make sure there is no downloading happening at the same time? Thanh: Sure! Giang: Even Skype is off. Thanh: When we play everyone turn off their download automatically, there is no problem. The problem is when sometimes people want to download a movie and others are not aware and it is slow. Giang: Sometimes it is not too slow but sometimes it is really, really slow. Fieldworker: Are there any usage rules in terms of your visitors and guests? Giang: They can Skype, they can surf the web, they do whatever they want but I don't think they download. Thanh: They don't download. Fieldworker: What if someone was doing that, what would you do? Giang: If it would slow it down, we'll tell them no. Thanh: We tell them to stop. The interaction that occurs during such events doesn't necessarily lead to the direct articulation of a rule. What it does do is make visible to members what kinds of activities others might call them to account for. This is usually enough to establish the grounds for telling people to stop doing things in the future, without having to expressly point to the presence of a rule. Even when there is an express rule in place, members place moral value on the'social touch', on making rules accountable, which impacts the devolution of formal rules to automatic systems: The problem for me with that is -if I say to Emma, "I don't want you going on the net after nine o'clock because that's when I want you to go to bed" -I could set it up that her computer just locks her out at nine o'clock, but there's a whole load of things about whether as a mother I should actually be going to her and speaking to her... Rules are not simply about enforcing conduct then. They are embedded in social relationships and situated in dialogue between relevant parties to a rule's use. What matters is not the rule as such but what the rule is intended to bring about within and as a constitutive feature of the ongoing social organisation of domestic life: Father: Some period of time is negotiated for doing homework and we know that they haven't, so I go on the history and you know, "oh look for the whole time you said you were doing homework there's all this Facebook activity!" That tends to be the most part, there doesn't tend to be any kind of looking through history for anything more dubious. Olivia: Mum has this thing -no computer for 2 hours while we're doing homework unless you need it. Fieldworker: Are the rules followed? Olivia: Sometimes (laughs). Fieldworker: What happens if they're not? Olivia: Mum's basically said "shut it down". Mum will just sneak up behind us (laughs) but we never get in that much trouble for mum to take away our phones or whatever. As this vignette makes visible, blind obedience to the rule is not the point -the homework rule is occasionally ignored and it is known by Olivia's parents that it is occasionally ignored. The issue is not one of following the rule per se but of complying with the "negotiated" order, which results in homework being routinely accomplished. Clearly the rule does not enforce that. What provides for it is the ongoing negotiation between relevant parties to the rule's use. The vignette suggests that making residents aware of particular activity may be of greater value than automating formal rules, thereby providing resources to support the lively social arrangements and ongoing negotiation that rule use is embedded in. --- Network rules are open to interpretation and negotiation The socially situated and negotiated character of rules means that rules are open to interpretation and also to renegotiation. The contingencies of social life make it impossible to pre-specify the exact circumstances of a rule's application. Consequently, members find themselves labouring under a 'gambit of compliance' [2] and thus seeking to 'honour the spirit of the rule' [21] i.e., respecting what the rule is intended to bring about rather than respecting the rule per se. The upshot of this interpretive work is that the actions carried out on any particular occasion might seem to stand in direct contradiction to formal articulations. Receiving guests and visitors provides a perspicuous example. In one of the households we studied both of the adults routinely worked at home as well as in their offices and their work activities on the network were typically oriented to as taking precedence. However, the moral order of the household also encompassed notions of having guests and being a good host when guests were present. This could lead to occasioned revisions of the general rule that 'work takes precedence': One thing that I try to do is to schedule my work around them... if they are watching TV on their machine or using Skype I tend to back off from the network for a while and let them do that... It is tempting to see such events as exceptions to the rule but the moral order drives the continuous interpretation and application of rules in the face of contingencies: Fieldworker: Are there other rules in the house? I know you've mentioned an evening meal no device use. Mother: Yeah, nobody is allowed to use -generally -there's the occasional -but generally, nobody uses mobile phones. Father: Not unless you're taking a phone call, no (laughs). Mother: You see that's where it becomes unclear. If you're on the phone and then dinner's served then it's difficult to put the phone down and to start to eat. Father: So you're saying it's alright for you to be on the phone (laughs) but no-one else. Mother: Yeah, but on the whole we don't have devices at the table. We don't allow it. Even in cases where we might expect rules to be rigidly applied, we find in practice that they are open to interpretation and renegotiation. We found in our studies, for example, that some parents try to pre-specify rules of Internet access for their children through systems such as NetNanny. What we uncovered, however, was a much more nuanced use of such rules with their application being regularly subject to renegotiation upon the pleading of their case by children: As the kids got more into the Internet we kind of thought "yeah, we're not entirely sure what they're going to find, what they're going to browse" so we thought we'd install NetNanny. It's hard to be systematic about which sites you want to block and which ones you don't. It does take active control. So basically you've got a couple of options: you could go into the sites that NetNanny recommends by default, but it turns out that doesn't satisfy the kids. There are some things they want to look at that we are happy for them to look at that aren't on the list, so you can then either maintain the list of allowed and blocked sites yourself but you'd have to update that fairly regularly with a fair bit of discussion about each one or you end up saying "never mind all that, we'll log you in as 'grown up' mode." For us updating the list doesn't happen because it feels like just a bit too much hassle to do it. So when they log on, NetNanny will be set to kid mode and then if they want to look at something else they'll come to me and there'll be a bit of whingeing and they'll say "we hate Net Nanny, wurr-wurr-wurr" and then we'll decide whether to unblock it temporarily. Thus, even in situations where rules are formally specified, their use is subject to ongoing revision. --- Network rules are retrospective When rules are formally specified in domestic life, not only are they rarely written down, being articulated in interaction and conversation, they are also and essentially retrospective in character. Rare exceptions to the written rule demonstrate the point: During the night's about the only time I'm ever certain of getting anything downloaded 'cause at any point in the day someone can answer the phone and kill it. If I have something downloading, you can get up to just about any point in it and then if someone answers the phone I've lost the whole download. I have to start again from the beginning. If I hear the phone ring it depends on the state of the download. If it's over 50% then it's already been running for quite a while and I'd prefer people didn't answer the phone, so I'll ask them not to. But if it's still only up to about 20% I don't bother. I also have a post-it-note by the telephone. Sometimes if I remember I try to stop people picking up the phone by physically sticking it on the phone. It reads "Do not answer. Download in progress." Such inscriptions are not 'keep off the grass' notices, however, intended to express a general over-arching rule, but rather notices that have been placed where they are to remind people not to do specific things that have been done in the past which have produced negative results. The rule, while clearly oriented to future events, is based on retrospective experience that breaches the social order and which household members seek to avoid in the future. Rules are shaped retrospectively rather than prospectively. Rule specification is almost always a consequence of some kind of breach, rather than something that members sit down and actively consider in advance. More than this, the terms upon which members are called to account with respect to rules rarely relate to 'good technical practice', but instead to how their actions might impact upon the social organisation of the home and its moral order. In the following example we see, for example, a general appeal being made to the availability of online access for all members of the household when it is undermined by the uploading of videos to YouTube by one of it's members: Chloe: We have had big rows about Tim stealing the Internet -Emma said to him "You've stolen the internet!" -'cause he's uploading to YouTube and the whole thing just like grinds to a halt for everybody else. We have had to say, "You put it on overnight Tim when nobody else needs it." Tim: Yeah, so normally I just upload overnight. And that's it. Normally what I do is if the video files are under 50 megabytes I upload it because it only takes 5 or 10 minutes, but normally if it's bigger than that I do it overnight. The specification of the upload rule is the outcome of retrospective experience that impacts upon the social order and the moral concerns that shape it. It is designed to regulate an individual's conduct for the benefit of all household members, though it is not adhered to as a blanket policy, but rather one that can be applied in a nuanced way in relation to matters such as file size and the likely impact this will have on others' access to and use of the network. Rules may also be imposed in light of retrospective experience to sanction individuals and enforce the moral order. In another example from the same household we saw rules being implemented to actively punish "bad" behaviour by one of the household members as well as to limit the possibility of it happening again: She's on MSN but she's on a ban at the moment. She got into a scrap with a girl online which was a bit unhelpful. She is using the Internet again but she's not allowed to go on MSN. She was getting involved in some cyber bullying and I had a concern that she was actually doing it, and I think she was about eleven or twelve at the time and just wasn't mature enough to walk away from it. So I stopped it because I thought she was actually the perpetrator. I just wanted to cut her off from that and stop it because I didn't want another child being hurt by her. In discussions with householders about the remit of possible future deployments it became quickly apparent that they are perfectly well aware of the retrospective character of rule specification and use and were keen that systems be able to accommodate this: One of my things has always been thinking about blocking access to certain things or certain types of things, and one of the problems is that it's a very difficult thing to do that in a nuanced way. It's like when is bad language gratuitous and when is it not. So if we said we don't want them to access websites where they use the F word there might well be things that are lost by that... So you'd have to do it by website and say things like "Oh Sam you're not allowed to go to bloodandgore.com", so it would be reactive rather than proactive... In short, rules are not specified in advance of their use but contingently to maintain the moral order of domestic life. They may be invoked for a wide variety of purposes but they are not pre-configured. Rather, they emerge and are applied in the ongoing production of social order. Their application is subject to contingency, interpretation and revision. They are socially defined and situated in relation to specific activities. They are member-centric, oriented in their application to specific individuals, and include specifications of temporal order. --- Supporting network rules Our study of network rules were conducted as part of a broader project that seeks to redefine domestic network infrastructure by reinventing the home router [12]. Network policy is an integral feature of home router design and our studies were both shaped by and in turn shaped our understanding of the topic. While informed by a particular 'value position' then, one that put emphasis on the need to reinvent network policy as part and parcel of the effort to re-engineer the home router around user characteristics, our studies were not drawn on to specify requirements for systems development. Rather, they sensitised the design team to the social nature of network governance and the moral ordering of network rules. The design team responded to the issues raised by our studies by deploying interfaces to probe [11] the topic of network rules and to understand the potential to develop mechanisms that respect the social character of network governance. Thus, and for example, the interfaces developed to probe this topic enable parental control (much as Eden does) and surface network behaviour (much as Home Watcher does), but with the explicit goal of exploring the moral imperatives and social practices that shape and drive network use in the home and thereby enabling users to express their own 'value positions'. Our home router monitors and controls networkconnected devices without requiring the installation of additional software on these devices. It also provides a distinct control API that lets us develop user interfaces to control traffic and devices on the network. These routers have been deployed within 5 of the homes participating in our ongoing studies for extended periods of time (between 3 and 6 months to date) and their use also studied through fieldwork. The period of deployment is required to transcend the novelty effect and allow sufficient time for the router to become an unremarkable feature of domestic life [17]. Two particular interfaces emerged as a response to our ethnographic studies of rules and were also released as part of the router deployment: the Comic Strip and Control Panel interfaces. --- The comic strip interface Drawing on the insights provided by the ethnographic studies we explored approaches to policy or rules that moved away from the traditional views of devices and traffic inherent in networking systems. We wished to foreground household members and their activities in the articulation of policies. Our main policy interface exploits the underlying mechanism in our infrastructure but focuses on users' reactions to network activities rather than the traffic on the network. Our vocabulary is deliberately not one of bandwidth and types of traffic or of the attribution of priority to control consumption. Rather our focus is on what people are doing on the network, who should be aware of this and what the potential consequences of these activities might be. Our interface takes the form of simple comic strips that convey what the network should do under particular circumstances. The aesthetic of the interface is chosen to be playful rather than overly task driven in an attempt to make policy specification and change a 'low overhead', 'easy-to-implement' activity [1]. Actions are specified in response to a range of factors, including time and date, bandwidth, device connection, and access to particular domains. Actions can be applied to specific devices, users or services (currently identified by their DNS name). Actions can range from simple recording of network state as collected by the router, to notification of individual's actions by some means (e.g., SMS, telephone, email), to direct control over a device's connectivity to the network or to particular services. Figure 1 depicts a simple notification policy, where mum is to be notified whenever dad is using a particular device to access the network. This form of notification policy focuses on prompting the social interactions and negotiations that shape network use. --- The control panel interface The policy comic strip was complemented in our deployments by a control panel that displayed the status of devices on the network. This control panel interface allowed devices to be added and removed from the network using a simple drag and drop gesture. For example, Figure 2 shows the control panel when a machine requests connection. The requesting machine appears in the central display panel. Any user with access to the display may then choose to drag any device to the right. Doing so invokes the web API on the router to mark the device (identified by MAC address) as 'permitted', granting it an IP address and enabling its traffic to be routed. Similarly, by dragging a device icon to the 'not allowed' region users can disconnect devices from the network. Connected machines' icons vary in size with the proportion of the bandwidth they are using and are highlighted when connection issues arise. --- Home network rules-in-use The control panel and policy system were deployed in 5 homes

We draw on ethnographic studies to understand the collaborative nature of network policies or rules in domestic settings. We outline the technical nature of network policy in enterprise domains and how this contrasts with the social or collaborative nature of rules in everyday life. We then consider the deployment of network control and policy system interfaces in domestic settings, highlighting the ways in which household members collaboratively exploited these to support network governance. Our results suggest that an important feature of network policy in domestic contexts is that rules about network activity are shaped by and answerable to the moral reasoning that governs domestic life. This reframes our understanding of how rules are oriented to and used in the home and has significant implications for the design of home network policy systems.