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introduction the world is warming very quickly driven by the upward trend in greenhouse gas emissions 1 2 3 rising global temperatures are increasing the incidence and severity of extreme weather events with greater population exposure to flooding across western and central europe 45 ghg emissions are also the major source of poor air quality both with respect to fine particulate matter and other air pollutants released during the combustion of fossil fuels for power generation residential and commercial energy use and transport flooding 67 and air pollution 8 9 10 11 are placing human health at risk in the uk the 12 months up to july 2021 included storms and resultant severe flooding in august november and december 2020 as well as flash floods in january june and july 2021 1213 uk annual monitoring data 14 indicate that 28 of local areas fail to meet the 2005 who guidelines on air quality 9 the more stringent thresholds in the whos updated guidelines are likely to increase this proportion 15 studies of populations exposed to flooding and air pollution have reported participants concerns about climate change and its adverse impacts 16 17 18 however little is known about whether exposure is a predictor of climate change concern and perceptions of its health impacts in the general population a 2018 review of studies of public perceptions of the health impacts of climate change did not report on the studies inclusion of measures of exposure 19 a more recent review 20 found two studies that included uk populations 2122 neither of which investigated exposures as potential factors predicting climate change concern and perceptions of health impacts to address this gap we investigate whether reported exposure to floods and air pollution is associated with greater concern about climate change and more negative perceptions of its health impacts we follow strobe guidelines for reporting observational studies 23 materials and methods data and sample profile the study is based on an online crosssectional survey of 1024 adults aged ≥ 18 conducted via the qualtrics survey platform 24 in july 2021 it was approved by the health sciences research governance committee university of york and informed consent was secured from study participants the survey used quotacontrolled recruitment to match the national uk population for gender age group ethnic group 25 educational attainment where numbers were small response categories were combined to avoid potential priming effects that participation in previous climate change research may have had on responses participants were excluded if they had taken part in a climatechange related survey in the previous year outcome measures climate change concern was measured by the question how concerned if at all are you about climate change 28 with a 4option response all participants were asked this question perceptions of health impacts were measured by the question overall do you think climate change will be good or bad for the health of people in the uk with a 5option response an earlier question asked thinking about peoples health which of these statements best describes your views about the impacts of climate change on peoples health in the uk participants who answered climate change will never have an impact on peoples health in the uk were not asked the pih question exposure measure at the end of the survey participants were asked about exposure to flooding and air pollution in the past 12 months the question avoided terms that may elicit a strong association with climate change for example extreme weather events 29 participants were asked separately if they were aware of these exposures in your local area if they personally experienced them and if a family member or a close friend had experienced them the latter two responses were combined into a single personal exposure category because of small numbers responses for flooding and air pollution were combined due to some correlation of exposures and small numbers in the separate levels of exposure this produced four categories 1not exposed to either flooding or air pollution at local or personal level 2local exposure to oneboth of flooding and air pollution 3personal exposure to oneboth 4local and personal exposure to oneboth analysis bivariate analyses investigated associations between reported exposure and ccc and between reported exposure and pih bivariate associations between exposure and sociodemographic factors and health status were also examined in two regression models multinomial regression was used to assess associations between exposures and ccc and pih using spss version 26 30 the reference groups were respectively not being concerned about climate change and not perceiving the health impacts of climate change as bad the models were built hierarchically with sociodemographic factors and health status added before the exposure measures the backwards stepwise approach was used the threshold for retention was a cutoff of p 01 for inclusion in the final model model testing was performed with goodness of fit r 2 estimates and log likelihood presented for each model along with the percentage correctly predicted results sample profile the majority of participants were concerned about climate change and perceived its impacts on health in the uk to be negative with respect to exposures flooding in their local area andor personally was reported by 36 of participants for air pollution the proportion was 43 bivariate associations between reported exposure and climate change concern and perceived health impacts of climate change as table 2 indicates reported exposure to flooding and air pollution was associated with both ccc and pih among those not concerned about climate change 66 reported no exposure to air pollution andor flooding in their local area personally or among family and friends among those fairly and very concerned about climate change the proportions were 43 and 31 respectively a similar association is evident with respect to pih nearly half of those who did not perceive the health impacts as bad reported no exposure to flooding or air pollution compared with 41 and 29 in the more bad than good and entirely bad groups in the bivariate analyses education was significantly associated with ccc and pih with a higher proportion of those in the highest educational group being very concerned about climate change and perceiving its health effects to be entirely bad other sociodemographic factors were significantly associated with ccc being female being older and living in londonsouthern england region and with pih health status was not significantly associated with either outcome regression analysis climate change concern the regression model assessed the strength of association between reported exposure and ccc it estimated the odds of being fairly concerned or very concerned about climate change compared to not being concerned taking account of sociodemographic factors health status and exposure the effects of exposure are presented in table 3 as table 3 indicates exposure was significantly associated with greater ccc with exposure at local personal or both levels always having a positive association with concern compared to not being concerned about climate change reported exposures in the local area or at a personal level doubled the odds of being fairly concerned reporting both local and personal exposure increased the odds to 335 being female and younger were also associated with a greater likelihood of being fairly concerned living outside londonsouthern england reduced the odds with respect to being very concerned personal exposure was associated with higher odds than local exposure the largest odds were associated with reporting both local and personal exposure being female younger and achieving the highest level of education increased the odds of being very concerned living outside londonsouthern england reduced the odds the model was a good fit with 53 of all cases correctly predicted significant for the goodness of fit test and r 2 indicating that 18 of all variance in the level of climate concern was accounted for in this model perceived impact on health the regression model estimated the contribution of exposure to the odds of perceiving the health impacts of climate change to be negative the reference category included all other responses as above the analysis took account of sociodemographic factors health status and exposure the effects of exposure are presented in table 4 as table 4 indicates local exposure is a significant predictor of perceiving the health impacts of climate change as being more bad than good being female and having a higher level of educational attainment were also associated with a greater likelihood of perceiving the health impacts of climate change as being more bad than good exposure was more strongly associated with perceiving the health impacts as entirely bad compared with those reporting no exposure participants reporting local exposure had an 88 higher likelihood of perceiving climate to be entirely bad for peoples health for those reporting personal exposure the odds were higher and were further elevated for participants reporting both local and personal exposure being female and having a higher level of education was associated with a greater likelihood of perceiving the health impacts of climate change as being more bad than good or entirely bad the model was a good fit with 493 correctly predicted significant for the goodness of fit test and r 2 indicating 98 of all variance in pih was accounted for in this model discussion the study is based on a survey representative of the uk population similar to other social surveys it relies on participantreported data and therefore captures participants perspectives on climate change and health together with their reported exposures to flooding and air pollution over the previous 12 months the proportion of participants reporting flooding to their home in the previous year is in line with a large national probability survey 29 while air pollution can be difficult to detect perceived exposure is associated with measured exposure 31 in line with this finding populationweighted estimates suggest that 28 of local authorities in the uk had pm 25 levels above who guidelines in 2019 the latest year for which data are available 14 in our survey 34 of participants reported air pollutionpoor air quality in their local area some limitations of our survey design should be noted firstly because potential participants were recruited through an online survey agency the study excluded those without access to the internet this means that the views and concerns of some of the uks most vulnerable populations are likely to be underrepresented the large majority of those without internet access face other forms of social disadvantage 3233 however the covid pandemic has restricted alternative methods of data collection and prompted a rapid shift toward online data collection 34 secondly causality cannot be inferred from crosssectional surveys therefore it is possible that heightened ccc and pih resulted in increased awareness of floods and air pollution however as noted above national exposure data are consistent with participantreported exposure to increase robustness we also investigated associations between exposure and ccc and pih using multinomial regression models that were hierarchical in the design and employed a backwards stepwise approach this enabled the inclusion of a wide range of potential predictors and the removal of nonsignificant factors in the final model interactions were not investigated surveys with larger sample sizes may add to the findings presented here thirdly while the sample size was similar to or larger than other uk studies 2122 it prevented more detailed analyses of the patterns and impacts of exposure for example pooling smaller ethnic groups into two heterogeneous groups may have masked important differences in both exposures and outcomes 35 a larger sample size would also have enabled separate investigation of floods and air pollution as predictors fourthly public perceptions of climate change are known to be influenced by events beyond the individuals immediate experience including their exposure to media reporting of climate change events climate change coverage in both the mainstream and social media is episodic peaking at times of scientific and political engagement with climate change 3637 for example when major global reports on climate change are published 3839 and when major global events occur 40 our survey was conducted in a month of limited engagement in climate change in the mainstream and social media we recognize that it is important to repeat the survey at times of heightened media coverage conclusions understanding how the public perceives climate change and its health impacts is essential for climate mitigation and adaptation policies while studies of populations exposed to extreme weather events and to air pollution have pointed to the importance of direct experience in shaping perceptions of climate change and its health impacts little is known about the association between exposure and perceptions in the general population a recent global review 20 located over 50 studies of perceptions of health in the context of climate change in the general population but less than 10 investigated associations with exposure of these none were based in the uk or europe in a representative uk survey of adults we investigated whether reported exposures were related to public concerns and perceptions we examined whether peoples awareness of climate changerelated exposures in their local area and their experience of these exposures either personally or among their family and close friends were associated with climate change concern and perceptions of the health impacts of climate change in the multivariate analyses reported exposure to floods and air pollution was associated with heightened ccc and with more negative pih after controlling for other factors our findings suggest that policies seeking to increase public awareness of climate concern and its health impacts should pay attention to peoples experiences of climaterelated exposures an appreciation of peoples experiences and concerns is increasingly recognised to be essential to securing public support for national and local policies to address climate change and its health impacts 41 42 43 our study provides evidence to support this peoplecentred approach to policymaking data from the study cannot be released informed consent statement informed consent was obtained from all participants involved in the study all participants are anonymous and cannot be identified data availability statement under the privacy notice accompanying the consent form participants were advised that only the project team have access to the data and it will not be shared supplementary materials the following are available online at 103390ijerph19042246s1 table s1participant demographics including gender age group and ethnic group along with reported exposure to floods and air pollution plotted against level of climate change concern and also perceived impact of climate change on health table s2multinomial logistic regression model of reported exposure to floods and air pollution against climate concern table s3multinomial logistic regression model of reported exposure to floods and air pollution against perceived impact of climate change on health author

climate changerelated exposures such as flooding and ambient air pollution place peoples health at risk a representative uk survey of adults investigated associations between reported flooding and air pollution in the participants local area by the participant personally andor by family and close friends and climate change concerns ccc and perceptions of its health impacts pih in regression analyses controlling for sociodemographic factors and health status exposure was associated with greater ccc and more negative pih compared to those with low ccc participants who reported localarea exposure were significantly more likely to be fairly or 207 95 ci 126 340 or very concerned or 340 95 ci 202 571 odds of greater ccc were higher for those reporting personal andor family exposure fairly concerned or 283 95 ci 120 666 very concerned or 411 95 ci 169 1005 and for those reporting both local and personalfamily exposure fairly concerned or 335 95 ci 199 563 very concerned or 617 95 ci 361 1055 for pih local exposure significantly increased the odds of perceiving impacts as more bad than good 186 95 ci 122 282 or entirely bad or 188 95 ci 113 313 our study suggests that public awareness of climaterelated exposures in their local area together with personal exposures and those of significant others are associated with heightened concern about climate change and its health impacts

though the aspirations to create a better sociopolitical system that would satisfy the needs of the majority have been known since ancient times thomas more is the one to whom we are thankful for the creation of the term utopia which often is understood as a nonexisting ideal place the greek meaning of the word is no place but the english homophone derived from greek implies good place mores intention in his masterpiece libellus vere aureus nec minus salutaris quam festivus de optimo reipublicae statu deque nova insula utopia a truly golden little book not less salutary than enjoyable about the best state of a republic and therefore the new island of utopia first printed in 1516 has been to create and introduce a system that would be great for the majority the one in which people could lead a serene and cheerful life free from anxieties however gradually the definition of utopia has developed to a somewhat ambiguous one stating that it is perfect for everyone the cambridge dictionary defines it as a perfect society in which people work well with each other and are happy while the merriam webster dictionary defines it as a place of ideal perfection especially in laws government and social conditions the concept in both cases is unrealistic as so far it has not been possible to find or create a plethora of people whose views of what is perfect and what makes them happy would be the same thus as stated by claeys utopia is not synonymous with perfectionism but represents a guided improvement of human behavior perfectionism is a religious category utopia is not meaning a sociopolitical system that would satisfy everyone is impossible to generate and sustain numerous countries have been promoting ideology aimed at establishing fair strictly stateregulated systems nazi germany the soviet union maoist china and north korea being the most prominent examples these ideologically based aspirations have instead made all of us into deep historical pessimists as though claiming to follow utopian ideals none of these has ever even sought to create a place of ideal perfection for everyone as in all of those a considerable part of the population is slaughtered enslaved or exiled in the process of creating a new system an approach which automatically makes the system imperfect as summarised by duncombe history therefore appears to prove two things one utopias once politically realized are staggering in their brutality and two they are destined to fail at the same time the current situation worldwide affected by constant wars violence corruption increasing income inequality unsustainable use of natural resources starving communities and the pandemic crisis makes us eagerly look for alternatives which in fiction are often represented by dystopias political and social crises of the twentieth century have made the genre of dystopias especially popular as besides reflecting societal fears and concerns it allows to test some popular utopian concepts in a fictional environment and encourages people to view their society with a critical eye sensitizing or predisposing them to political action however while often it is assumed that dystopias are providing a sociopolitical system which is an exact opposite to mores utopia both share several features which considered by more as forming an ideal social structure would seem appalling if applied in practice thus elements of mores utopia like the lack of private property strict daily routine constant supervision uniformed clothing and buildings slavery and limited freedom to travel all often find a place in twentiethand twentyfirstcentury dystopias limiting the freedom of their people and making the system oppressive and unbearable undeniably the term dystopia first used by john stuart mill in 1868 meaning too bad to be practicable directly applies to many aspects of the seemingly ideal system implemented by more thus in utopia while more was attempting to create a complex vision of an apparently ideal society he had created one that was in fact deeply and subtly flawed thus as claeys pointed out mores utopia though it is about perfectibility does not generically portray the perfect society even if its failings often seem swept under the carpet claeys and gordin tilley and prakash stress that contemporary dystopias often have both dystopian and utopian elements but the same also refers to mores utopia or as brilliantly said by gottlieb every dystopian society contains within it seeds of a utopian dream while the concept of dystopia is difficult to conceptualise if it is defined as an inverted negative version of a utopia as dystopian literature is not so much a specific genre as a particular kind of oppositional and critical energy or spirit undeniably it describes a sociopolitical system which as the greek words dus and topos imply suggests the existence of a diseased bad faulty or unfavourable place the year 1516 when mores utopia appeared was characterised by the conquest of the new world simultaneously promising remaking one part of humanity while enslaving another forceful colonisation of territories belonging to indigenous people and establishing a new regime there was considered entirely acceptable by more and the english society at the time the sustainability of a society to a great extent was believed to be based on its economic and military potential and the ability to control and provide for its citizens thus while for modern audiences constant surveillance strict daily routine the necessity to wear uniforms slavery and numerous other norms introduced by more are found unacceptable in renaissance england such a model together with the promised plenty and security would have seemed quite reasonable mores treatment of the elderly must also be viewed in the same light the attitude toward the elderly in mores utopia while generally characterized as positive is one of the concepts that need critical evaluation some of the roles the elderly play are traditional a few may even seem revolutionary while several others would be considered unacceptable by contemporary audiences thus positive and traditional in mores utopia is the role of the elderly as esteemed leaders of the society deserving an honorary place magistrates called syphogrants whose age and experience we do not know sit in the chief and most conspicuous place but next to him sit two of the most ancient members of the community the old men are not only honoured with a particular respect and a place next to the leaders but also are purposefully mixed inbetween younger generations so that the gravity of the old people and the reverence that is due to them might restrain the younger from all indecent words and gestures besides if the young ones behave they receive special treats from the hands of the ancients the old men distribute to the younger any curious meats that happen to be set before them if there is not such an abundance of them that the whole company may be served alike thus more distinctly shows that the elder in utopia are not only honoured but serve as educators in power to reward good behaviour and are better fed than the young ones as adequate nutrition for the young ones does not depend on the treats received from the elderly it may be assumed that this reward system though aimed at retaining stability and respect towards the elderly does not cause stagnation and does not prevent the young ones from developing ideas of their own as such the system introduced by more can be considered a positive feature of the described society traditional is the role of men as the leaders of the society and families and also here the elderly take the upper part the oldest man of every family … is its governor wives serve their husbands and children their parents and always the younger serves the elder at the same time almost revolutionary for medieval england is the role of elderly women if they happen to be widows sometimes the women themselves are made priests though that falls out but seldom nor are any but ancient widows chosen into that order even nowadays the evangelical lutheran church of latvia and many other religious communities all over the world do not allow women to become and serve as priests alas more does not specify why only elderly widows are chosen for the role but the suggestion that women can be made into priests is praiseworthy at the same time the constant use of the pronouns he him and his when speaking about the duties and privileges of the leaders of utopia reminds one of mores preference for patriarchal hierarchy where the possible female priesthood is an exception though typically the elderly in mores utopia are treated with respect and honour a considerably more complicated situation arises if they fall sick and become a burden to themselves and to all about them here discrimination as defined by sally witcher is caused by overprotection or patronizing attitudes in line with dehumanisation when the elderly according to more have really outlived themselves it is suggested that they should choose rather to die since they cannot live but in much misery though the cited passage starts by stressing that this opportunity is offered to the incurably sick suffering pain which would be similar to the modern concept of euthanasia more considers old age which as it carries many diseases along with it … is a disease of itself thus believing in a happy afterlife and being persuaded by priests and magistrates to end their lives they either starve themselves of their own accord or take opium and by that means die without pain though certain persuasion takes place no man is forced on this way of ending his life and they are taken care of still as more stresses a voluntary death … is very honourable so it is evident that moral pressure to end ones life lies quite heavily on those who have become a burden to society whether they like it or not thus discursive discrimination as defined by boréus occurs by arguing for unfavourable treatment of the elderly and forcing them to make an ultimate decision that may go against their own wishes peter stansky suggests that as long as the world is an imperfect place to live we shall have utopians envisioning a world in the future in which all imperfections have been cleansed away and seemingly the land of sameness in lowrys novel the giver first published in 1993 is such a place like in mores utopia the ultimate goal here is to give everyone an opportunity to lead a serene life void of anxieties and to build a system that ensures everyone is satisfied with ones place and role in society to reach such general satisfaction some principles introduced in mores utopia are instituted new ones are added and some liberties are denied common to both utopia and lowrys land of sameness is the leadership role of the elders but in lowrys novel their duties are more specific also in mores work the employment career of all citizens is state regulated but the committee of elders in sameness not only assigns an appropriate job to each child at age twelve thus establishing daily routines they will follow up to old age but also elders are responsible for matching of spouses to accomplish it they spend enormous time and consideration to find an ideal spouse for each adult so that sometimes an adult who applied to receive a spouse waited months or even years before a match was approved and announced similarly in utopia marriage is a stateregulated affair and a special warrant from the prince is necessary to obtain rights to get married in case the young people have run into forbidden embraces before marriage as it is believed that otherwise very few would engage in a state but in utopia at least men and women are allowed to choose ones life partner by themselves in both works mistrust in ones ability to form a healthy marital relationship without interference from officials is demonstrated while only in lowrys the role of providing the necessary guidance is defined as the duty of the old accurate preservation of historical records is another feature common to both lands in utopia their records that contain the history of their town and state are preserved with an exact care and run backwards seventeen hundred and sixty years and are used as a common source of knowledge while the age of historians in mores work is undefined in lowrys this honorary and extremely responsible assignment falls to the chief elder he is the only one with memories of life beyond sameness and though he can deliver his knowledge only to one carefully selected follower is the key source of knowledge and information in an emergency the rest of the society in sameness has reached what francis fukuyama defines as the end of history where any struggle that called forth daring courage imagination and idealism will be replaced by economic calculation the endless solving of technical problems environmental concerns and the satisfaction of sophisticated consumer demands thus while in both works history is used as the source of knowledge the chosen method and its application are strikingly different providing limited access to historical records in lowrys dystopian society and leading to dehumanisation or mankurtism that is the inability of people to recognise themselves their history their kinship and their values in both versions of perfect lands there can also be observed parallels in relation to attitudes towards the sick and elderly similar to mores description of ideal hospitals that are furnished and stored with all things that are convenient for the ease and recovery of the sick and provide tender and watchful care of the sick excellent care of inmates is provided in lowrys dystopian world at the house of the old there is not only occupational therapy but also recreational activities and medications in the house of old and like in mores utopia the old ones are gently taken care of entertained and always given the highest respect but similarly to what david sisk asserts about dystopias in general which even though they may at first appear pleasant they always depict horrible societies the reality is much darker also in the land of sameness the first dissonant accord is brought in by lowry when the narrator learns that there is also punishment for disobedience … for which they use a discipline wand on the old the same as for small children but the idea of a perfect end of life is entirely destroyed when readers learn what happens after the ceremony of release for the old to the knowledge of the community when requiring too much care the elderly are released but what exactly this release means is neither questioned nor explained though they do know that typically release is a form of punishment at the same time citizens believe that the only exception to the rule is in the case of release of the elderly which is a time of celebration for a life well and fully lived according to official ideology for everyone else release means that people are sent elsewhere and never returned to the community and though also after the elderly never return no one questions what exactly release means in their case in the house of the old the ceremony of release takes place in the presence of all the old and the telling of ones life takes place glasses are raised toasts are pronounced an anthem is sung and the old one to be released delivers a lovely goodbye speech neither inhabitants of the house of the old have an idea where exactly the old ones go after the release ceremony nor is it known to the majority of the society except only few whose duties are related to the release ceremony what actually happens with the released elderly in the land of sameness is that after the celebration the old receive a lethal injection such an ending of the life of the elderly highly resonates with mores utopia though there the celebration of ones life takes place after the death when they come from the funeral they discourse of his good life and worthy actions in both cases the old ones condemned to death because they have become a burden to society must meet their fate with pleasure and acceptance in utopia after the funeral people should be able to speak of nothing oftener and with more pleasure than of his serenity at the hour of death but in lowrys world of sameness the old are supposed to meet their death with a look of pure happiness and enter the ceremony being thrilled the key difference is that the old in lowrys dystopia are not aware that they are going to receive a lethal injection immediately after the ceremony while the inhabitants of mores utopia are conscious of their destiny in both cases the increase of the welfare and peace of the society is sought at the expense of the individual rights of the elderly citizens while mores utopia is based on a strict patriarchal hierarchy that gives men power authority and privilege to rule over an entire society in lowrys work the community is ruled by a comparatively impersonal collective called the council of elders with no reference to gender hierarchy while both the protagonist jonas and the key character giver are men most likely this is just a coincidence as the previous givers apprentice was a girl while lowry provides very little information about the members of the council of elders it is stated that the chief elder is elected every ten years and at the moment it is a female but no specific attention is devoted to the issue it is revealed just by the use of the pronoun she when quoting the speech of the character thus contrary to mores utopia the social hierarchy in lowrys the giver is not genderbased there are numerous works portraying how systems that were intended to perfectly serve their citizens turn into mindnumbing dystopias when the theme of death is debated like recent shustermans arc of a scythe series scythe followed by thunderhead the toll and gleanings or earlier ones like among the hidden by margaret peterson haddix watchstar by sargent the talking coffins of cryocity by parenteau and many more the promotion of euthanasia of the elderly however is one of those utopian features that is seldom depicted in fiction thus lowrys the giver is an impressive example of a dystopian novel illustrating a peculiar treatment of the elderly resonating not only with this but with several other practices outlined in mores utopia while the world created by lowry in the giver does not immediately strike the reader as nightmarish eventually this utopia also turns out to be a restrictive system unable to reach the goals it set both utopian and dystopian works make the readers question the essential values of humanity and consider the rights and roles of individuals and society in the promotion of enhanced wellbeing of both though intended as a perfect state satisfying the needs and wishes of the majority of its citizens both mores utopia and lowrys the giver introduced systems and attitudes towards the elderly which would be considered highly unethical and dangerous if implemented in european welfare states

while the first utopias manifested aspirations for a better sociopolitical system dystopias typically reflect societal fears and concerns that are intensified by the twentieth centurys political and social crises that besides other significant turns have caused a rethinking of the role of the elderly in the society while typically the protagonists of dystopias are very young or middleaged they often must interact with the previous generations to achieve their goals thus providing an exciting field for analysis of how these elderlies are depicted in dystopian novels the methodology for comparing the treatment of the elderly in utopia with the treatment of the elderly in lois lowrys the giver involves literary analysis and a comparison of the specific ways in which the elderly in both works are depicted special attention is paid to the specific ways in which they are treated and the roles they are assigned in their respective societies as well as the level of respect and care they are shown especially at the end of their lives the characteristic attitude towards the elderly suggested by more in utopia is masterfully rendered in lowrys twentiethcentury dystopia the giver the study reveals that the treatment of the elderly has often been discriminatory in mores work utopia and is deliberately portrayed as such in lowrys novel

womens life course trajectories have historically been characterized by a particular sequence of demographic events in which the completion of high school and college preceded womens transition into the labor market a marital union and motherhood yet there is evidence which suggests that this typical sequence of demographic events has become less normative as more women are completing secondary and college schooling at later stages of the life course particularly after having children despite evidence of this change theoretical perspectives on the sequencing of schooling and motherhood a prevailing theoretical paradigm for studying the arc of peoples lives is the life course perspective according to this perspective this arc is shaped by the sequencing of social roles and events that people experience over time thus the theory underscores how changes in the traditional sequencing of key life course events of us women represents an important shift that is likely to result in changes in the futures of many families for example there is a small but emerging body of evidence that when mothers without college degrees increase their education their childrens academic skills improve as such changes in mothers trajectories through the secondary and college school systems have the potential to alter the mobility of the next generation of children the theory also draws attention to the contextual factors surrounding this change in womens life course sequence thus it emphasizes the cultural demographic and economic changes occurring during the period when the mothers in this study were raising their families as such it also highlights how shifting circumstances of the time increased the potential for changes in the life courses sequences of women unfortunately our understanding of the changing life course patterns of mothers continuing secondary and college education remains limited by the primacy of other theoretical traditions that generally assume that education precedes fertility and is completed early in the life course for example much of the work on individual or group differences in educational attainment is organized by either the decision making model or status attainment model both frameworks implicitly assume that the pursuit of education stops once one leaves school in a related literature scholars argue that motherhood deters additional educational attainment possibly because parent and student are incompatible statuses or because motherhood dampens ones academic aspirations for the future among studies that do consider the connections between womens life course events the emphasis has been on motherhoods effects on womens future work trajectories how womens education leads them to delay their fertility or how some women select into motherhood as an alternative to academic attainment importantly although the prevailing theoretical and empirical approaches to studying the connections between womens education and fertility generally overlook the potential for womens postchildbearing education they do not preclude them for example there is evidence that while motherhood may dampen some womens academic aspirations for the future it often does not extinguish them although we still do not know how common it is for women to increase their education after having children there is also mounting evidence suggesting that many women now do so evidence pointing to changes in the life course sequencing of womens schooling the first indicator that mothers are increasingly pursing additional education comes from education research on the college going population and offtime enrollment this literature suggests that a growing proportion of students are pursuing higher education out of sequence or after the occurrence of some other life course event typically thought to precede the completion of education such as fulltime work marriage or parenthood in fact one recent study found that enrollment in college following a period of delay has become more common than the normative path through the education system in which students pursue school in a continuous fashion and complete it when they are young research on changes in the characteristics of the college student population also point to a change in the sequencing of schooling and motherhood for many women for example a recent report published by the national center for education statistics based on data from the beginning postsecondary students longitudinal survey found that 19 of first time college students enrolled in 20032004 had dependent children whereas 15 years earlier this figure was 14 among all college students perna and colleagues estimated using data from the national postsecondary student aid study that the total percentage of college students with children in 20032004 was 25 with 71 of them being female more recent estimates based on the same survey administered in 2011 revealed that the percentage of college students with children had slightly increased to over 26 with a similarly large percentage of college students with children being female as for research pointing to an upward trend in mothers pursuit of high school or general equivalency degrees one older study found an upward trend in high school degree completion among lowincome mothers and there are a handful of studies which found that a large percentage of teen mothers that dropped out school returned to complete their degrees taken together these studies provide compelling evidence that there have been changes in the timing of the completion of womens high school and college level educational attainment what scholars need now are estimates of how common it is for women with children to increase their schooling and earn different degrees insight on the timing of their postchildbearing education visàvis the transition to motherhood and knowledge of the characteristics of those who pursue additional schooling state of the literature on womens postchildbearing education given assumptions about the sequencing of schooling and motherhood and established lines of inquiry there is only a very small body of work describing womens postchildbearing schooling and the majority of this work focused on young largely economically disadvantaged women particularly teen parents for example rich and kim examined the postchildbearing patterns and characteristics of teen mothers using data from the nlsy79 they found that 15 years after giving birth 40 of teenage mothers who had dropped out of school increased their education and about 20 of who had completed a high school degree or ged increased their education they also explored demographic differences between teenage mothers who increased their education and those who did not and found few although they only examined a limited set of factors in furstenberg and colleagues study of about 300 urban predominantly minority teen mothers they found similar patterns in mothers postchildbearing education ten years after giving birth 67 of teen mothers who had dropped out of high school had obtained a high school degree 15 years later 30 had earned some college education and 5 had a college degree they also found that rates of additional education were lower for the youngest mothers other noteworthy studies on the topic were limited to a focus on teen mothers attainment of a high school degree two studies have investigated the return to school of women who were not exclusively teen mothers one is a study by bradburn moen and dempstermcclain which drew on a local sample of women born in the 1920s well before many of the changes that were occurring around the time that the nlsy79 women were raising their children had begun the other is a study by macgregor which drew on a urban largely disadvantaged sample mothers in the fragile families and child wellbeing study that at the time of the study had only followed women five years postpartum because perna and colleagues find that more than half of college students with children had children over age 5 this study likely overlooked a substantial proportion of mothers who would later return to school in spite of the limitations of these two previous studies they provide a basis for setting forth some expectations for the current one for example bradburn found that the mean age of return was age 44 in a more contemporary sample where more mothers are unmarried and participating in the labor market i expect women to return to school at younger ages to increase their opportunity for mobility and better support their family bradburn also found that women with families that were welloff financially were more likely to return to school than women reporting average levels of finances which the authors argued reflected the economic costs of returning to school in the contemporary economy i expect this association would be reversed given the growing costs of not returning to school and diminishing financial returns to lower levels of education for similar reasons i expect that mothers without any college schooling will be more likely to return to school than women with some college schooling although consistent with macgregor and research on adults learners more generally i expect a larger share of mothers who return to school to pursue college schooling to pursue 2year over 4year degrees finally based on macgregors findings i anticipate that mothers who are black unmarried and from disadvantaged backgrounds will be more likely to return to school but that mothers with higher cognitive abilities will be more likely to select back into the school system to increase their education summary of study in sum although the life course patterns that once defined contemporary womens lives are shifting we know little about the contours of this shift the extant studies that have examined questions related to womens postchildbearing education have only provided a patchwork of statistics which were derived from nonrepresentative samples of women with children and the general characteristics of mothers who return to school and the timing of these returns remain unknown thus taking advantage of the breadth of the nlsy79 data this study provides for the first time contemporary information on each of these phenomena in a representative sample such descriptive information is vital to pursuing more hypothesis driven research on the ways in which mothers pursuit of additional education affects families and public policies that aim to increase mothers human capital methods data and sample the nlsy79 is a nationally representative cohort study of young americans originally designed to capture their life course experiences it included 6283 women between the ages 14 to 22 when data collection began in 1979 data collection proceeded annually through 1994 then switched to a biennial format although the nlsy79 is a less contemporary data source it captures the experiences of mothers during the 1980s and 90sa unique period characterized by dramatic changes in womens labor force participation and family formation thus it is an important period when the life course trajectories that characterized womens lives in earlier decades were changing the nlsy79 is also the only available source of nationally representative data that prospectively captures womens nearly complete education and fertility histories thereby reducing the problems of left and right censoring or bias in the risk pool additionally it includes rich background data on mothers which allows me to present a portrait of factors that select women back into school compared to women who had similar starting educations at the time they became mothers but did not return to school and allows me to capture an array of timevarying factors such as womens marital status employment situation income that may correlate with mothers fertility timing on one hand and additional degree receipt on the other for the analyses presented here the sample is restricted to the 4925 women who had children this sample includes some women who had become mothers by the start of the first wave of data collection for whom information on postfertility education is unknown these women were retained to avoid biasing the sample by explicitly excluding young mothers because information on their additional education was not missing completely at random multiple imputation techniques could be and were applied to maintain the samples representativeness i used the custom weighting program developed by bureau of labor statistics staff to generate a weight that generalizes my sample to a population of mothers additional exclusions were made using statas subpop to ensure correct estimates of standard errors including 903 women participating in military and poor white oversamples which were dropped fairly early in the study leaving large amounts of missing data and in some analyses subsets of women based on their education at the time of their first birth in some analyses the final sample is also represented in postchildbearing womenyears right censored at 18 maternal education historiesi combine various pieces of information on education with data on the month and year of womens first birth to create several education history measures this information includes highest grade or years of schooling completed whether the mother received a high school degree or ged and date when it was received highest degree ever received month and year the highest degree was received if a college degree was received and what type whether a degree was received since the last interview and whether the woman was currently enrolled in school when pieced together this data provides complete coverage of womens education histories with a few exceptions if a woman earned a college degree after the 1986 interview but attritted by 1988 i cannot account for that degree change also for women who earned college degrees prior to 1988 i can capture the survey wave the degree was earned but do not know the month in such cases month is coded as may if the degree is a college diploma and june if it is a high school degree this assignment has implications for only a small number of cases in which the birth occurred the same year as the degree was earned because i do not know for certain whether the degree came before or after the birth in cases where education was reported inconsistently i recoded the outlying year with the modal report finally i do not know if mothers reenrolled if enrollment did not occur during a survey year combining this information i created several timeinvariant measures the first is a measure of mothers highest degree at the time of first childs birth dummy coded based on four different categories less than high school high school diploma or ged associates degree or bachelors degree the second was an indicator of whether the mother had exited the school system but returned to earn some postchildbearing education the third is a measure of the type of additional education she earned categories were receipt of a high school diploma or ged an associates degree or at least two years of college or a bachelors degree note that these measures are not dummy coded for example a mother could earn a postchildbearing high school degree and associates degree fourth using the same four categories i created a measure of her attainment when her oldest child is age 18 finally i created a measure for whether the mother ever reenrolled in school regardless of whether she went on to earn a degree based on maternal reports of whether she was enrolled in school as of may 1 that survey year in addition i created three timevarying indicators of additional postchildbearing degree the first captured a postchildbearing high school diploma or ged the second captured a postchildbearing associates degree or two years of college the third captured a postchildbearing bachelors degree for these variables the time metric was not survey year but the number of years since becoming a mother for example a woman who first gave birth in 1990 and earned a bachelors degree in 1994 would have a value of 1 on the timevarying measure of postchildbearing bachelors degree for postchildbearing year 4 all years after the observation are censored using the same coding scheme i also created a timevarying measure for whether the mother reenrolled in school that year lastly i created a timevarying measure of highest degree at each postchildbearing woman year dummy coded as less than high school high school diploma or ged associates degree or bachelors degree in creating these measures i counted at least two years of college as a postchildbearing education to allow women who may have earned some type of other credential especially a vocational degreewhich was not an option category for questions about highest college degree and coded as other in earlier questions about type of college degree to be counted i also do not consider education beyond a bachelors degree i make this distinction because in many cases graduate degrees have conventionally been earned at a later stage of the life course particularly after accruing work experience and at older ages timevarying characteristicsto provide a sense of mothers economic and social circumstances and the array of resources that may help or limit womens reentry into school and degree attainment i included measures on various factors that vary over time including mothers occupational sector dummy coded based on us census occupational codes for professional or managerial sales technical or administrative service occupations all others total family income earned the prior year mother reports of family wealth whether the mother was currently employed her marital status number of children in the home number of weeks mother spent out of the labor market in the last year labor force instability and whether she was poor i also accounted for the region these variables were coded using the same womanyear strategy described above timeinvariant variablesusing these timevarying measures i created two timeinvariant variables which correspond to 1 the year the woman became a mother and 2 year she earned a postchildbearing degree i also include timeinvariant measures of the mothers background these include her race nativity whether she lived with a single parent growing up whether her family ever received welfare or public assistance whether either of her parents were foreign born whether she grew up in an urban area the proportion of her school that was poor the number of siblings she grew up with the education of her mother and father and reports of total wealth these factors represent the constellation of sociodemographic factors related to mothers family of origin and thus opportunity for pursuing education via traditional versus less conventional paths such as after the birth of a child lastly i included several timeinvariant variables assessed when women were young that are typical indicators of selection and may positively correlate with their likelihood of returning to school after childbearing these include mothers educational expectations mothers scores on the rosenberg selfesteem scale and mothers cognitive skills based on the armed forces qualification test i also include an indicator for negative selection and delinquency by using selfreports for if she drank alcohol before age 18 analysis plan the analysis has three parts the first is a descriptive study based on a series of bivariate associations specifically crosstabulations of womens education when they became mothers with mothers final levels of education provide a sense of how womens education changed after having children comparisons of the background characteristics of women who earned a postchildbearing degree to women who had the same level of education at the time of first birth but did not earn a postchildbearing degree provide a picture of the characteristics that select some women back into school comparisons among women who increased their education after having children with women with the same highest degree who followed conventional paths through the education system reveal differences in the characteristics of women pursuing these two different life course sequences finally descriptive estimates for the subsample of mothers that earned postchildbearing education which differentiate among women who earned different degrees convey a sense of mothers life circumstances around the time they did so the second part of the study focuses only on mothers that returned to school its aim is to provide a dynamic picture of how mothers likelihood of returning to school earning a degree changes as womens time since becoming a mother increases i do this two ways first i present four histograms where year since becoming a mother is the xaxis separate graphs are presented for any reenrollment and the three categories of postchildbearing degree attainment second graphs of kaplanmeier failure estimates capture the proportion of mothers at each year since the first birth that had returned to school or among those at risk that earned a particular degree graphs for reenrollment associates degreesome college and bachelors degree are stratified by degree at first birth and log rank tests assess whether there is a significant difference in failure rates by starting education these graphs provide a cumulative view of timerelated patterns in mothers additional education the third part of the study is a multivariate analysis where i use discrete event history methods and logistic regression to predict the odds of returning to school or earning a specific degree models 24 were only estimated among women at risk of earning the degree being predicted discrete event history models are appropriate here because time was measured in discrete intervals not continuous units event history models more generally are based on pooled data that allow me to capture a process that occurs at varying points of time for different women and incorporate timeinvariant and timevarying predictors that correspond to the time in which the event occurred time in this case reflects years since becoming a mother right censored at 18 years postfertility to distinguish between periods when women are caring for children and when they are not and the relevance of a degree obtained postchildbearing to childrens or womens lives is different of course women are caregivers for different lengths of time many have multiple births and children do not always leave the home at age 18 but the chosen endpoint must be consistent for all women and thus 18 years postfertility was the most appropriate choice to account for any correlated errors in the repeated measures i employ robust standard errors to deal with missing data i used multiple imputation to impute missing values for all independent variables or covariates although i did not use multiply imputed data to present estimates based on raw frequencies i used stata ice program to impute 20 datasets and the mi estimate suite of commands to analyze multiply imputed data missing data on the dependent variable which is an issue that only applies to the eventhistory models is not imputed but rather is assumed to be independent of the censoring mechanism a key assumption of discrete event history models shared by multiple imputation overall rates of missing data vary missing data on timeinvariant background factors is low rates of missingness on measures of additional maternal education are no greater than 20 timevarying information reached higher levels of missingness due to attrition although the availability of earlier timevarying measures of the same variable for the imputation model provided high quality estimates in such missing data cases moreover estimates based on observed data are remarkably similar to the imputed ones for example results in table 1 and 2 are nearly identical results in table 3 are the same 71 of the time when they were not the same they varied by 1 or 110 of a unit 72 of the time results descriptive statistics table 1 presents crosstabulations of mothers education at the time of first birth with her education 18 years later overall i find that 17 of mothers increased their education to either a high school degreeged associates degree or two years of college education or bachelors degree and one quarter reenrolled in school among mothers who began with less than a high school degree 43 increased their education among mother who began with a high school degree or ged 15 increased their education among mothers who began with an associates degree 13 increased their education to a bachelors degree of the women who did not have a high school degree at first birth 56 earned a high school degreeged 5 completed an associates degree or two years of college and 1 earned a bachelors degree of the women who had high school degreesgeds at first birth and increased their education 11 earned an associates degree or some college and 4 earned a bachelors degree i also report related statistics that focus only on women who earned postchildbearing education in table 2 which reflects the 8 of the total sample who earned a high school degree postchildbearing 9 who completed an associates degree or some college and 3 that earned a bachelors degree within these groups i report estimates of their education at first birth which differ from those in table 1 as some mothers earned multiple degrees i find that out of the 3 of mothers that earned a bachelors degree 28 began with an associates degree 65 had a high school degreeged and 6 had no high school education out of the 9 of mothers who earned an associates degree or some college education 85 began with a high school degree or ged while 15 did not have one mothers who did not have a high school degree at first birth but later increased their education did so on average 651 years after giving birth for women with a high school educationged they completed their education on average 938 years after the transition to motherhood for the associates degree group the mean time to a bachelors degree was 901 years figures 1 and2 provide more detail on the timing of mothers additional education visavis their transition to motherhood figure 1 plots frequencies of years since first birth for reenrollment and different degree types looking at the graph for those who earned a high school degreeged reveals that while mean time to degree was 651 years degree receipt was clustered during the years immediately following first birth after year five the number of mothers earning a high school degreeged declines the pattern also appears for reenrollment alternately for the women who earned at least two years of college or an associates degree there was a slight uptick in completion after year five which continued until about year 14 when it slightly declined there did not appear to be a timing related pattern among women who earned a bachelors degree figure 2 plots kaplanmeier failure estimates which provide a cumulative look at the timing of different types of additional maternal education it allows one to determine the percentage of mothers who had earned a particular type of education at each point in time among those at risk of earning it the plots are stratified by education at first birth for example ten years after becoming a mother more than half of women at risk of earning a high school degree or ged had earned one similarly by year ten the majority of women with an associates degree at first birth who later earn a bachelors degree had done so with a smaller proportional increase between year 10 and 18 yet the majority of women who earned a bachelors degree but started with less than an associates degree did so some time after year 10 log likelihood test statistics suggested that rates of degree completion did vary by starting education the cumulative failure rates of earning an associates degree or two years of college revealed similarly low rates during the first few years for the two groups of women at risk of doing so but then steadily diverge over time with high school graduates returning to school to complete an associates degree or some college at higher rates a log likelihood test also suggested that rates varied by starting education the final set of descriptive statistics in table 3 provides information of the characteristics of women who earned any postchildbearing education around the time they did so to give a sense of the life circumstances of mothers earning additional education for example mothers who earn a high school degreeged were approximately 25 years old on average about half of them had never married or were divorced and 40 were working in service jobs a total of 53 reported being poor and only 25 reported being employed in comparison mothers who earned an associates degree or two years of college were on average about 31 years old typically worked in a technicalsalesadministrative support and were employed at higher rates compared to mothers who earned a high school degreeged they also had more income and wealth had spent less time out of the labor market that year and had more job stability and had higher rates of divorce although they were less likely to have been never married women who earned a bachelors degree on average were about 33 years old the modal occupation was managerial or professional only ¼ were divorced or single and over half were employed unsurprisingly they had more income and wealth than other mothers and were less likely to report being poor but their rates of job stability were about the same as women who had earned an associates degree or some college and they spent more weeks out of the labor market than them bivariate associations the next estimates provide two sets of comparisons table 4 compares the background characteristics of women with the same starting levels of education who did not earn additional education to those who did table 5 looks at women whose highest education was the same and compare between those who earned that degree before the transition to motherhood with those who completed it afterward the results of table 4 reveal few significant differences in the characteristics of women who returned to school compared to similar women who did not for mothers who started without a high school degree the only differentiating characteristics were mothers race if the family of origin received welfare and number of siblings for mothers who had a high school degreeged at first birth a smaller proportion of minorities earned postchildbearing education than did not within this group women that earned additional education were also more likely to have grown up with a single mother to have been never married at time of first birth and were a younger age at first birth yet their parents had more education for women starting out with an associates degree there were few notable differences except by parents education and age at first birth turning to table 5 i find far more differences between women who earned a degree postchildbearing from those who earned the same degree before motherhood among those whose highest degree was a high school diplomaged women who earned it postmotherhood were more likely to be a minority have lived in a home where a foreign language was spoken the mother was single the family received welfare and there were more children they also went to high schools with a greater proportion of poor students and their parents had less education they were also younger at age of first birth more likely to have been unmarried or experienced poverty and were less likely to be employed among mothers whose highest degree was an associates degree or some college i find the same factors are significantly different across groups and the patterns follow the same direction with two exceptions there was no difference by raceethnicity or foreign language for women whose highest degree was a bachelors degree raceethnicity is statistically significant between groups as are the other characteristics previously noted multivariate analyses in the final analyses i use eventhistory methods to predict the odds of reenrollment or earning different levels of education postchildbearing by an extensive set of timeinvariant and timevarying factors which were assessed during the same wave as mothers education model 1 of table 6 predicts reenrollment among mother who did not have a bachelors degree at the time of first birth i find that the odds black and hispanic women reenrolled was 54 and 37 greater than for whites increased odds of reenrollment was also associated with growing up with a single mother afqt score poverty job instability and having divorced or never married versus married being employed was associated with decreased odds of enrollment as was each unit increase in mothers age or number of children among women at risk of earning a high school degree or ged the results in model 2 reveal that being black was associated with a 33 decrease in the odds of earning such a degree as was growing up in an urban area mothers afqt score current poverty prior labor force instability and early expectations of earning a 4year degree were associated with increased odds of returning to school to earn a high school diplomaged in model 3 i find that being black is again associated with an increased odds of earning an associates degree or some college as is each unit increase in mothers afqt score or weeks out of the labor market poverty job instability being employed and divorced vs married early alcohol use is associated with a 13 decreased odds as is each unit increase in age at first birth and employment in all occupation categories compared to professional and managerial model 4 focused on women at risk of earning a bachelors degree and revealed only a few significant predictors among them having some college was associated with an increased odds of earning a bachelors as was each unit increase in afqt score a unit increase in mothers age at first birth was associated with a 6 decrease in the odds of returning to school to earn a bachelors degree compared to women in professional or managerial occupations mothers in all other categories were at decreased odds of returning to school to earn a bachelors degree discussion the life course trajectories of us women have grown increasingly varied as a nontrivial proportion of women now complete their schooling after the transition to motherhood this historic change in womens lives has not gone unnoticed by scholars and policy makers for example a small emerging literature examines the returns to postchildbearing education for mothers and children there is also growing policy interest in two generation interventions that encourage womens postchildbearing educational attainment as a way of improving the lives of both mothers and children as such it is surprising we know so little about this trend and the population of women driving it this study represents a step in learning more about this life course phenomenon using data from a cohort of women who were raising children during a time of tremendous change in the work schooling and family experiences of women and thus shifts in the structures organizing womens life courses first population based estimates described which education groups of women were most likely to return to school and what their typical postchildbearing attainment looked like for example i found that 28 of mothers who earned a bachelors degree began with an associates degree but 65 had a high school degree or ged only 5 lacked a high school degree thus while it appears that many mothers who earned fouryears degrees began their pursuit of additional education with less education than we might anticipate such numbers also highlight how two generation approaches aimed at helping disadvantaged mothers complete a college degree may have a harder time reaching the subset of mothers for whom such programs would have the biggest impact those without high school degrees at the same time over 40 of high school drop outs increased their educationa number on par with studies on high school drop outs in general thus these results suggest that young mothers with children may be no less likely to return to school than those who dropped out for other reasons broadly the array of figures provided in this study provide much needed information for policy makers who currently lack basic statistics by which to assess the potential for programs which support mothers additional schooling or researchers studying topics related to this phenomenon this study also explored the timing of mothers schooling visàvis the transition to motherhood for all three educational outcomes the average time to completion occurred when the first child had entered formal schooling moreover five years after giving birth less than 13 of mothers who returned to school to earn an associates degree some college or a bachelors degree had done so after this time the rate of increase was gradual not sharp which is a pattern that contrasts with the findings of bradburn and colleagues these findings move the current research which is has focused on women with young children in a new direction they also suggest we need to better understand cohort based changes in the timing of womens postfertility schooling heterogeneity in the timing of mothers return to school and the impact on families wellbeing given such timing differences from a social policy perspective it suggests that social policies need to be designed that support women with older children as well as younger children furthermore this study provided information on the background characteristics of mothers who earned additional schooling revealing that mothers who returned to school to earn an academic credential were more disadvantaged in a number of ways compared to women who completed the same credential before having children although this pattern is not surprising the fact that this particular pattern of life course sequencing is driven by less advantaged segments of women suggests that increased education may represent an adaptive strategy for those women who face the greatest challenges to mobility particularly during a time when the crescendo of calls to tie welfare to work was growing louder conversely it also informs studies on whether the returns to education may be less for women who achieve it at later stages of the life course for policy these insights underscore how many women from disadvantaged backgrounds not only desire to pursue additional schooling as reported elsewhere but actually do and as such future work and family policy should be careful not to create barriers that reverse this trend alternately i also found that women who returned to school compared to those that did not but had similar educations at the time of first birth were not as select in their background characteristics as one might assumea pattern also noted by rich and kim this finding suggests we likely need new data including qualitative data to yield better insights into how mothers who return to school differ from mothers of similar educational backgrounds that do not such information is essential to crafting policies that better target the factors that help or hinder mothers pursuit of additional education moreover while such studies may not be able to achieve representativeness they could draw on the information presented here to provide a portrait of mothers lives around the time they earned their additional education this information is a necessary update to the study by bradburn et al which found that the mean age of mothers returning to school was 44 and that returning mothers were more economically advantaged i found that poverty was a common feature among women with children that increased their education the multivariate models also revealed a pattern associated of economic and demographic factors connected to disadvantage although mothers were also more likely to increase their education if they had higher academic ability and personal aspirations labor force attachment professional job experience and were younger too other factors such as mothers marital status were not associated with increased odds of earning additional education although it was associated with reenrollment this finding suggests that unmarried mothers with children in school may face more barriers to pursuing a degree than married womena finding which could be further examined in future research as well in spite of such contributions the study also had limitations first a study of this kind must rely on available sources of data to date the nlsy79 is the only one up to the task it is also based on a cohort of women born in the early to mid1960s given much of the trend in postsecondary enrollment among adults with dependents seems to have occurred in the last decade and likely driven by women born a few decades later more contemporary data is desirable we will have to wait some time to examine this possibility once more recent cohorts of women for whom there is similarly extensive longitudinal data available like the nlsy97 have completed both their schooling and fertility this study however sets the stage for future comparative analyses using the nlsy97 data another limitation of the data is that while it is considered nationally representative its representativeness of certain subpopulations especially hispanic women has decreased over time this problem has been documented elsewhere and is shared by other nationally representative data collections that began decades ago next there was missing data largely due to attrition i used multiple imputation techniques but the results of imputed analyses in a descriptive study of this kind may elicit more skepticism results based on the observed and imputed values were remarkably similar however next i cannot capture all nonfour year postsecondary credentials as well as other studies do perhaps due to the specific questioning in the nlsy79 i therefore consider academic gains reflected in two years of college but it would be preferable to know whether a degree or certificate was earned and what type i also do not distinguish between high school degrees or geds to prevent the results from being overwhelmingly nuanced but this grouping is also often made when categorizing education the timevarying measures were also assessed at the same time as mothers education these measures are intended to reflect the life circumstances of mothers around the time they earned their degree but it is possible that in some cases they reflect the degree earned although i cannot eliminate this potential source of error in these measures it is likely to introduce less error in measurement than using data often taken two years earlier from the previous wave next although i included a rich array of timevarying and timeinvariant factors i may have not accounted for the full range of factors associated with mothers selection back into school or different types of schooling although the associations presented in this study are descriptive and not intended to convey causal connections accounting for such factors could alter the patterns of associations reported in this study it also remains possible that the association between these factors may vary at different stages of womens life course a possibility that should also be investigated in future research lastly measures of enrollment are based on enrollment during the current survey year and therefore does not capture some mothers reenrollment especially after 1994 when data collection became biennial in sum more research is needed to illuminate the various reasons for this new life course trajectory the impact of returning to school and earning postchildbearing education on mothers and children and changes and continuities in this trend across time such research is essential to understanding a how key element of peoples lives their education is obtained and shapes other dimensions of the life course in contemporary times yet such studies also would be incomplete without drawing on the information presented here this study therefore provides the necessary foundation for these pursuits and a spring board for future investigations on a timely topic by describing a key change in the life course patterns of contemporary us women during a time when womens lives were undergoing tremendous change by doing so the study also lays the foundation for future investigations that explore this changing life course pattern in a more contemporary cohort of womenfor example mothers raising children during the post welfare reform era when opportunities for lowincome mothers to pursue additional education were restricted and tuition increased precipitously yet access to loans to support the pursuit of additional schooling and educationrelated wage gaps increased as well frequencies of additional educationreenrollment by years since first birth notes frequencies correspond to years since the mother first gave birth or correspondigly the age of the oldest child reenrollment and associates degreesome college estimated among women without bachelors degrees at time of first birth associates degreesome college estimated among women with a high school degree or less at first birth high schoolged estimated among women without a high school degree or equivalency at first birth kaplanmeier failure estimates for additional education presented for education type and additional education stratified by education at first childs birth notes ticks on y axis presented in increments of 25 for high school ticks in increments of 05 for associates degreesome college and bachelors degree and 10 for any reenrollment reenrollment and associates degreesome college estimated among women without bachelors degrees at time of first birth associates degreesome college estimated among women with a high school degree or less at first birth high schoolged estimated among women without a high school degree or equivalency at first birth 1 some estimates based on subsample of women who had less than a bachelors degree at the time of their first childs birth postmotherhood education was not calculated for women who had bachelors degrees at the time of first birth 2 estimates based on weighted sample 2 raw ns do not add to 4925 because it excludes women for whom information on their education at their time of first birth was missing estimates of percentages however are based on imputed data and thus the full analytical sample of 4925 women notes 1 estimates calculated for the subsample of nlsy79 women who obtained additional education after becoming a mother 2 presented background characteristics represent a selection of the timeinvariant covariates used in the multivariate models

a mounting body of evidence suggests that the life course sequence that once defined contemporary us womens lives is changing as an increasing number of women now complete their education after the transition to motherhood despite such evidence we know little about this changing pattern of life course events for many us women the aim of this study therefore is to produce populationbased estimates that describe the prevalence of mothers school reentry and secondary and college degree attainment the timing of womens postchildbearing education visàvis their transition into motherhood and the characteristics of mothers who pursue additional schooling to do so the study draws on data from a nationally representative cohort of us women participating in the national longitudinal survey of youth n4925 and descriptive and event history techniques findings suggest that a substantial proportion of mothers 17 completed additional education after the transition to motherhood especially mothers who had the lowest levels of education at their time of first birth high school dropouts 43 these mothers who overwhelmingly earned high school degreesgeds were most likely to do so within five years of giving birth while mothers pursuing higher levels were more likely to do so when children were older mothers who pursued schooling after the transition to motherhood were remarkably more disadvantaged than women who followed the traditional sequencing of life course events compared to women who had the same education upon being mothers they were also younger more often poor and had greater job instability but higher cognitive test scores

background vaccination programmes have been shown to reduce health inequality worldwide 1 however despite national immunisation programmes in europe some groups remain incompletely or unvaccinated with underserved minorities and certain religiousideological groups repeatedly being involved in outbreaks of vaccine preventable diseases 2 as an example in 2004 a rubella outbreak occurred within an undervaccinated religious community in the netherlands 3 which spread to canada 45 and led to cases of congenital rubella syndrome 46 these outbreaks in undervaccinated groups sometimes cause spill over disease in the general population as occurred during two measles outbreaks one occurred in germany in 2008 from the anthroposophic community to the general population who had vaccination coverage below the world health organisation recommended level 7 the second one in the netherlands in 19992000 started among unvaccinated members of orthodox protestant reformed churches and spread to children of vaccinating parents but whose children were susceptible as they were still too young to be vaccinated 89 between may 2013 and february 2014 another measles outbreak was ongoing in the netherlands among the same religious community with 2700 reported cases 10 the world health organization regional office for europe has set several goals for elimination of endemic measles and rubella in europe 11 however achieving this goal and improving vpd vaccination coverage in general remains difficult as long as clusters of large undervaccinated groups still exist in various countries in addition in case of a major vaccine preventable outbreak like the 2009 influenza a pandemic these groups are likely to refuse any new vaccination which may be advised by the governmentpublic health authorities therefore they can form a susceptible pool of individuals at increased risk to acquire the vpd and can act as a focus for and multiplier of the infectious agent with subsequent spread to the general population for communicable disease control it is especially the social clustering of nonvaccinated individuals that increases outbreak risk clustering of nonvaccinated individuals is found in various groups in europe most of these uvgs are labelled as hardtoreach however not all groups are hardtoreach and each group has its specific reasons and even individuals with in a group may differ for which specific approaches are needed and not general ones knowledge on the specific reasons for low vaccination uptake among the various uvgs might facilitate communication based on their needs the strategic advisory group of experts on immunization has defined determinants of vaccine hesitancy worldwide both for general populations andor groups they divided the determinants into three categories 1 contextual influences 2 individual and group influences and 3 vaccinevaccination specific issues costs 12 in this study we focus on the specific determinants of vaccination uptake in undervaccinated groups which can also include determinants of poor availability while the only intervention to increase vaccination uptake addressed in this study is on communication we do recognize that communication might not be the only intervention needed and that other interventions such as changes in the delivery strategy of vaccines might have high impact but nevertheless in all cases communication is essential this study is part of one of the work packages of the eufunded project effective communication in outbreak management development of an evidencebased tool for europe which started in 2011 the aim of our contribution to the project is to identify vantage points for communication strategies and present suggestions for communication with uvgs that can be used effectively by health professionals and agencies throughout europe in case of an epidemic or pandemic of a vpd to that purpose the focus in this paper is on how to identify the uvgs in europe and the description of factors for poor uptake of vaccination in order to know with whom and how to communicate we performed two systematic reviews as to our knowledge this has not been done before the objective of the first review was how to identify uvgs in europe and to describe the uvgs and of the second to describe beliefs attitudes and reasons of nonvaccination of these uvgs identified by the first review and a comparison of the factors among the uvgs methods protocol and registration no review protocol exists and the review has not been registered eligibility criteria for the first systematic review to identify uvgs we used the following case definition we defined a uvg as a group of persons note the general population might also have had historically low vaccination uptake such as was the case for mmr in the uk due to a suggested link between autism and the mmr vaccine however in this study the focus is on uvgs and not on the general population furthermore we did not include people living together in closed settings as prisons or nursing homes because although there might be low vaccination coverage reported in some of these settings they are not identified as a group which is culturally close andor do not share the same belief system in addition there also are some groups who are refusers or hardtoreach but are not easily identifiable for example the middleclass worried who read something on the internet may be only a loosely definable group but they may still be significant we also did not include these groups in order to find out how to identify uvgs in the literature terms were used that describe a group that shares the same beliefs andor who lives in socially closeknit communities furthermore we restricted the search to terms such as vaccination and immunisation and did not search for health in general of which vaccination may be part of both qualitative and quantitative studies were included english published articles were selected between 1950 and may 2013 information sources studies were identified by searching electronic databases scanning references lists of articles and if relevant findings about factors for nonvaccination of uvgs were found in the fulltext articles from the first review these articles were selected for the second search however fulltext articles from the first review were only used in the case that no articles about factors for nonvaccination were found for that uvg this search was applied to medline embase and psycinfo the last search was run on may 2013 for both systematic reviews we selected with the assistance of a librarian a specific search term combination based on mesh and free text terms search the two search strategies are briefly described below for the first strategy the search term combination was based on the list of european countries and a list of vpds and any of the search terms outbreak epidemic or low vaccination coverage and any of the search terms community minority ethnic group or subgroup for the second strategy the search term combination included the list of european countries a list of vpds and a list of the names of uvgs found in the first literature review and any of the search terms ethnic groups minority groups religion anthroposophic or complementary therapies and any of the search terms attitude belief argument treatment refusal patient acceptance of health care health knowledge attitude practice decision making patient compliance ideology or objection tables 1 and2 present the full electronic search strategy for the medline database study selection two reviewers independently selected the relevant articles according to the case definition of a uvg and search terms firstly the selection was based on title and abstract for papers identified in medline and only on title for papers identified in the two other databases the final selection was done on fullpaper in case of discrepancy a third reviewer was asked to review articles all the reviewers discussed the findings and consensus was reached data collection process a data extraction sheet was developed by the first author where title manuscript publication year name of uvg short description of uvg which country or countries in europe they live which vpds have been circulating based on what it was clear that it was a uvg vaccination coverage which beliefs attitudes and reasons for nonvaccination were described the form was not piloted and extractions were not completed in duplicate syntheses of results for the first review we provided a short description of each uvg such as the population size and in which countries members of the uvg live and their main characteristics in addition other information such as about outbreaks that have occurred in that population and estimations of the vaccination coverage were provided for the second review we first described beliefs attitudes and reasons for nonvaccination among each uvg found in the literature secondly we counted the number of times a certain factor was mentioned in the articles found for each uvg note if a factor was reported in two articles it does not have to mean that the factor was twice more important than when a factor was reported in only one article if it was a qualitative study we took each factor mentioned in that study once into results identification of the undervaccinated groups in europe the first literature search resulted in 606 articles these were screened based on abstract andor title and 58 of them were subsequently screened based on fulltext article of them 48 were selected and included in the review thirteen articles were found in the index references of 34 selected articles and 1 came from the second literature search consequently 48 articles were selected we identified five uvgs orthodox protestants anthroposophists roma irish travellers and orthodox jewish communities below we briefly describe the five uvgs practically all articles were published after 1990 four describe vaccination coverage among orthodox protestants irish travellers or orthodox jewish children the remaining articles were outbreak reports describing mainly outbreaks occurring between 2004 and 2012 including 35 articles describing measles outbreaks orthodox protestant communities orthodox protestants live in closeknit communities within dutch society with their own church political party primary and secondary schools the population size is estimated at 250000 ie 15 of the dutch population 1314 and almost 75 of them live in an area stretching from the southwest to the northeast of the netherlands also called bible belt different op denominations vary in their interpretation of the bible the overall vaccination coverage among ops is estimated to be at least 60 but it varies from below 25 to more than 85 depending on the op denomination 13 in another study identified by the literature review comparing the percentage of 2 yearolds who completed diphtheria tetanus pertussis polio vaccination the mean vaccination coverage was estimated to be 935 in municipalities with one or more op denominations which was significantly lower than in municipalities without op denominations 14 in the netherlands from 1950 until may 2013 different outbreaks are described in the literature within this community such as poliomyelitis in 1978 15 and 19921993 16 and mumps 1718 measles 89 and rubella 356 outbreaks between 1999 and 2009 anthroposophists anthroposophy is a spiritual movement founded at the beginning of the twentieth century by rudolf steiner an austrian philosopher social reformer architect and esotericist anthroposophists applied his theory to different settings such as education medicine architecture and agriculture the anthroposophical society has its international centre at the goetheanum in switzerland they have developed schools anthroposophical health care centres and centres for people with learning disabilities 219 anthroposophists live in various countries over the world and in almost all european countries the number of individuals sharing anthroposophical beliefs is unknown no articles were identified about the vaccination coverage among this group they experienced outbreaks of measles in united kingdom in 1997 19 in austria 20 21 22 germany 72223 norway 22 and measles and mumps outbreaks in the netherlands 1824 between 2008 and 2010 roma roma constitute a transnational ethnic community composed of various groups living predominantly in central and southeastern europe 2 the size of the roma population within the european union is estimated to be in the range of 68 million people 225 the actual figure might be even higher given that there is no agreed upon definition of who is roma 25 a part of the community is highly mobile and some people who selfidentify as roma are reluctant to disclose their ethnicity during census for fear of stigmatization 2 roma have been historically marginalized 2 and still face significant discrimination nowadays 2526 their health indicators are significantly worse than those of the general population 2 the poor economic conditions and improper housing 27 create favourable circumstances for the spread of communicable diseases the roma community usually has low vaccination coverage 25 since 2006 several measles outbreaks occurred within their communities in italy 2829 germany 30 31 32 greece 3334 romania 35 croatia 36 serbia 37 poland 26 bulgaria 27 ireland 38 and spain 39 40 41 irish travellers irish travellers are also called travelling community or gypsytravellers and are recognised as an ethnic minority group in the united kingdom and ireland all of whom were or are nomadic 242 today although nomadism is an important part of their culture and history the term is more accurately a descriptor of ethnic identity distinct beliefs and culture rather than a description of actual daily activities 242 their number is difficult to estimate and reports vary widely 2 many are reluctant to disclose their ethnic identity due to fears of prejudice and mistrust of authority they often have poor access to education and employment in the sphere ofregarding health care the marginalisation and their travelling way of life has historically resulted in poor access to servicesincluding immunisation 2 the irish traveller community usually has low vaccination coverage 2 42 43 44 45 46 outbreaks of measles in irish traveller communities are well recognised in the european region particularly in the uk a measles outbreak associated with a gathering of irish travellers in 2007 in england was subsequently linked to a measles outbreak in norway among nomadic irish travellers from england 42 43 44 45 another measles outbreak occurred in ireland in 2009 among this community which was also reported among the roma community and spread to the general population in 2010 38 orthodox jewish communities the orthodox jewish community shares religious observance and cultural practices they are usually living closely within their own community have large families with a high proportion of young children and often have considerable household crowding 247 in europe there are significant oj communities in london and salford in the uk and in antwerp in belgium 4748 no articles were identified about the overall vaccination coverage among this group in a 19911992 study in north east london 49 the vaccination coverage was 79 for measles mumps rubella among oj children similar to the coverage in the general population two measles outbreaks happened within this community in 20072008 in belgium 5051 and england 5152 these outbreaks were epidemiologically linked and spread to israel 53 many of these children were incompletely immunised 50 description of ideologies beliefs or attitudes towards vaccination among the identified uvgs the second literature search resulted in 406 articles this resulted in 21 articles that were screened based on fulltext article and 13 were subsequently selected and included in the review one about orthodox protestants four about roma three about irish travellers and 1 about both groups two about anthroposophists and two about orthodox jewish communities despite that no english language articles were found specifically addressing beliefs attitudes and reasons towards vaccination as a main topic among irish travellers and roma communities eight articles were found in the first literature search which also briefly described factors for nonvaccination that lead to the corresponding outbreak in these two communities in total 13 articles were included in the second literature search the list of factors regarding vaccination for each uvg is presented in table 3 and below the factors are briefly explained per uvg orthodox protestant communities one dutch study among orthodox protestant parents 54 used indepth and semistructured interviews with 27 families the aim of this study was to gain insight into how op parents decide for or against vaccinating their children four different groups emerged from this study traditionally nonvaccinating deliberately nonvaccinating traditionally vaccinating and deliberately vaccinating parents the main argument for those who refuse vaccination was the necessity to rely on divine providence if god sends an illness to somebody or an outbreak on earth he has a reason to do so one must not oppose gods will and should trust in god on the contrary those who actively choose to vaccinate their child consider that vaccination is a gift from god some members were concerned about vaccine safety and sideeffects and some did not consider some paediatric illnesses as serious diseases such as measles and mumps anthroposophists two studies are related to anthroposophists one study 55 was performed in the netherlands and used focusgroup methodology among parents who visited an anthroposophical child welfare centre another study 56 was performed in the uk and sent postal questionnaires to measles cases from a predominantly unimmunised anthroposophical community in gloucestershire parents with an anthroposophical view believed that with a healthy life a good nutrition and a safe environment the immune system of children would be stronger and better able to fight against infectious diseases and therefore vaccination is not needed some carefully weighed the perceived severity of and susceptibility to the infection in making their vaccination decision 55 some parents believed that paediatric illnesses are necessary and a part of the development of the child some parents had doubts about the safety the sideeffects the effectiveness and the components of the vaccine 5556 most of the parents preferred monovalent vaccines instead of combination vaccines in order to have more freedom of choice and flexibility to adapt the schedule in the dutch study while they mostly trusted health care providers some did not trust the information provided by the public health authorities all parents mentioned the need to have more information about the risk of vaccinating the components of the vaccine and more transparency from the public health authorities 55 some vpd are not severe 1 some vpd are helpful for childs development 2 1 perceived nonsusceptibility to vpd 1 perceived safetyeffectiveness of vaccine perceived unsafety of the vaccine 1 1 2 1 perceived noneffectiveness of the vaccine 2 beliefs about vaccine 1 1 flexibility freedom adapting vaccination schedule to the child 1 combined vaccines should be monovalent 1 knowledge need for more information or lack of information 1 1 2 1 low awareness of vaccination as a preventive measure 1 social networks 1 ideas about prevention anthroposophic 2 complementary medicine being unavailable 1 religious beliefs 1 1 social structural aspects socioeconomic and cultural differences 4 3 improvement in access and facilities for their children 1 poor access to health care centres roma no article in the sample elaborates on roma attitudes and beliefs regarding vaccination there is no evidence that roma parents object on ideological grounds to having their children immunized their misconceptions about vaccination are by no means different from those encountered in the general population 2 for a variety of reasons many members of the community have difficulties in accessing healthcare services 225 the explanations advanced by the authors for the low vaccination uptake among roma include the high spatial mobility of some members of this ethnic community 2527 which makes them difficult to reach by vaccination programmes precarious socioeconomic conditions 22629 and exposure to stigmatization marginalization and discrimination 22526 low level of formal education 26 low awareness of vaccination as a preventive measure 26 and cultural differences from the general population 26 irish travellers from the second literature review also no english language article was found referring to attitudes beliefs and reasons regarding vaccination within the irish travellers community however some reasons for low vaccination coverage were reported during measles outbreaks in several countries in europe 242 in the 2007 measles outbreak among irish travellers in london with links to a norwegian measles outbreak the norwegian authorities reported that the irish traveller community responded favourably to interventions with many nonvaccinated contacts being given mmr vaccine 44 suggesting that the community is not averse to vaccination in general similar misconceptions about vaccination are present among irish travellers compared to the general population 2 additionally muscat et al 2 suggested that the low vaccination coverage among this community is explained by poor access to health care because of population mobility other identified barriers to healthcare accessincluding access to immunisation services for irish travellers include inequalities in registration with family doctors illiteracy and lack of services that are culturally sensitive and respond to the needs of traveller communities 24246 orthodox jewish communities two studies using semistructured interviews or administered questionnaires were conducted in northeast london among orthodox jewish families both aimed to identify reasons for low uptake of immunisation 5057 in the study from cuninghame in 19911992 49 parents deemed immunisation important and that measles could be a serious illness the main reason for missing immunisation was parental decisions to delay immunisation usually mmr some had concerns about sideeffects of the vaccine contrary to these findings in the study from henderson conducted in 2003 57 some mothers believed that bcg vaccination was unnecessary because they were living separately from the general population and consequently were not exposed some others had doubts about the measles mumps rubella or diphtheria polio tetanus vaccination despite their lack of exposure to a broader social network ideas spread by media reached them and therefore they felt anxiety about vaccination they were afraid of adverse effects from mmr and whooping cough vaccinations and to have foreign substances associated with illness being injected into their child religious arguments were also reported they trust in god and if god wants to give a disease the child will get it both articles identified barriers to accessing health care vaccinations including restricted practice opening time lengthy waiting times and the difficulty to rearrange appointments discussion public health authorities in the european region face challenges with outbreaks among uvgs and equally in efforts to meet the requirements set by the who for eliminating measles and rubella in the near future elimination can only be obtained through high vaccination coverage in the respective countries as long as pockets of low vaccination coverage remain in many european countries outbreaks of vpds will continue to occur and elimination will be infeasible as long as there are uvgs these pockets of low vaccination coverage may occur through clustering once exemption begins to take hold in a particular community 58 besides outbreaks will occur within these groups they can also act as a source for further transmission to the general population increasing vaccination uptake in these groups starts with talking with the groups and develop together with them appropriate communication we found several common beliefs related to nonvaccination in these groups that could help to find policy vantage points for communication with these groups looking at outbreaks and low vaccination coverage studies among groups and communities we identified five uvgs throughout europe that represent a significant number of people orthodox protestants in the netherlands 1314 anthroposophists mostly in austria germany and bordering countries roma mainly in central and southeastern europe 225 irish travellers in the united kingdom and republic of ireland 2 and jewish orthodox in the united kingdom and belgium 4748 all five uvgs experienced measles outbreaks measles is highly contagious and requires at least 95 vaccination coverage to maintain herd immunity 59 which could explain the higher number of measles outbreaks that were described compared to rubella and mumps outbreaks in the context of low vaccination coverage large vpd outbreaks will continue to occur in these groups with the risk of spreading disease to vulnerable individuals in the general population as has been seen in several previous measles outbreaks 8 from the factorsoriented literature search we conclude that there is as yet little published englishlanguage literature specifically addressing beliefs attitudes and reasons regarding nonvaccination among these groups as we only found five articles these five articles were based on empirical research using both qualitative and quantitative study designs one among orthodox protestant parents two among anthroposophists and two among orthodox jewish parents we have not identified research published in the english international literature aiming to study mainly beliefs attitudes and reasons regarding nonvaccination among the roma and the irish travellers communities however some reasons for nonvaccination were described in the eight additional articles selected from the first literature search a variety of beliefs and objections to vaccination were reported among each group not all members have the same beliefs also called withingroup heterogeneity on the other hand some similar beliefs were shared between different groups also called betweengroup homogeneity the most frequently mentioned shared reasons for not vaccinating their children are the perceived nonseverity of the disease the perceived unsafety of the vaccine and the need for more information or the lack of information about for example risks of vaccination apart from these common factors for nonvaccination each uvg has its own specific factors low vaccination coverage for certain diseases among the anthroposophists could be explained by their specific philosophy of a healthy lifestyle for orthodox protestant firm trust in divine providence seems to be the most important reason for not being vaccinated this religious factor is incidentally also found among the orthodox jewish communities although jewish scholars have rejected arguments that medical interventions interfere with divine providence 60 whereas low vaccination coverage among anthroposophist orthodox protestants and orthodox jewish communities may be explained by their beliefs our findings from the literature suggest that low vaccination coverage among roma and the irish travellers communities is predominantly explained by poor access to health care services due to mobility as the objective of our contribution to the eu project mentioned in the introduction was to find vantage points for communication tactics with uvgs in case of an epidemic we searched for factors regarding nonvaccination of these groups with regard to epidemics no literature has been found on uvgs in the framework of pandemics also not with regard to the influenza a pandemic in 2009 we did find literature on factors for nonvaccination against pandemic influenza a among the general population as the general vaccination uptake during the 2009 pandemic was low in various countries 61 strikingly most of the factors for nonacceptance among uvgs of regular universal childhood vaccines were similar to those among the general population in various countries during the a pandemic 6263 as well as for routine universal vaccinations 46 64 65 66 67 68 69 70 71 72 the same factors were also found on many antivaccination websites 73 74 75 76 opposing routine universal vaccination new forms of reluctance to vaccinate seem to emerge in the general population identified as people following an alternative dietary system and among so called critical citizens 7778 another phenomenon are the freeriders in a highly vaccinated population one can avoid vaccine adverse events by nonvaccination while being protected by the vaccinated contacts 79 if freeriding takes hold in a social network new undervaccinated pockets may arise as these new opponents are not organised as a group as defined in this article we did not include them in the literature review however we are aware that these likeminded groups that are not geographically clustered might gain importance in the near future as the number of followers seems to be growing it is therefore important to start engaging with these likeminded groups that are not geographically clustered as soon as possible by listening to their arguments and try to mitigate vaccine refusals in our opinion two shared beliefs for nonvaccination also found in the general population are amenable for influencing vaccination decisions by targeted communication tactics that are discussed later on perceived nonseverity of the disease and its possible complications and vaccine unsafety the factors for nonvaccination for irish travellers and roma communities are different and seem to be related mostly to access to health care and therefore also other interventions than communication are needed an important limitation of these two literature reviews is that we limited the search to english language peerreviewed literature a lot of knowledge is actually available in the grey literature and in the countries where the uvgs live as it is the case in the netherlands for orthodox protestants and in portugal for roma 80 however this information is not available in the open english language scientific literature another limitation is that we restricted the search to vaccination and immunisation in mesh and title andor abstract vaccination is part of the process of health in general and beliefs and attitudes are closely linked therefore we did not include articles explaining beliefs and attitudes regarding vaccination in the broad framework of health for example healthrelated beliefs for roma and irish travelers communities are well described in many articles 81 82 83 84 but the relation to vaccination seems to be less important as access to health care is the dominant factor in these groups previous work in the uk suggests that indiscriminate populationbased interventions that aim to improve overall uptake of vaccination are unlikely to reduce socialbased inequalities in uptake 85 there needs to be recognition of the differences between population groups that different approaches are essential to meet the needs of these groups and that a specific effort has to be made to reach groups with barriers to vaccination in routine vaccination programmes 8586 we have found that important beliefs for nonvaccination are shared by many groups as well as by the general population we therefore argue that in developing communication strategies for specific uvgs and the general public partly the same arguments may be used however to reach uvgs it is important to cooperate with these groups and to adapt the information to their specific needs if used in a trustworthy and reliable context uvgs can use the information also from other members in their group who do vaccinate for deciding on vaccination several technical reports and tools were developed by ecdc and who for health care professionals and public health institutes to increase vaccination uptake and suggest communications activities such as educating people about risks of vaccinating and not vaccinating addressing misconceptions promote positive health outcomes and partnering with health care workers as they are believed to be a trusted source these tools target especially mmr 8788 andor the general population 89 a study by horne et al 2015 90 with commentaries by betsch et al 2015 91 and horne et al 2015 92 have shown that highlighting objective information about the consequences of not vaccinating and countering vaccination myths can positively impact the intention to vaccination of people who are doubting however on the other hand nyhan et al 2014 93 showed that attempts to increase concerns about communicable diseases or correct false claims about vaccines may be in some cases counterproductive it is therefore important to carefully test vaccination messages in a specific group governments and public health authorities might have to take a different stand regarding uvgs firstly they could act as sentinel population for early detection of transmission of vpd as the large number of susceptibles increases the chance of disease detection if transmission occurs secondly they might also be used as well as sentinel for beliefsattitudes and reasons for nonvaccination in the general population as some of them might take over similar ideas about vaccination therefore efforts to communicate with these groups should start as soon as possible in all eucountries the epitheton hardtoreach should be abandoned as not all groups are hardtoreach and each group has its specific reasons and even individuals with in a group may differ for which specific approaches are needed and not general ones better that each country determines its own uvgs with their own beliefs and starts to develop trustful relationships conclusions within each uvg identified there are a variety of health beliefs and objections to vaccination in addition similar factors are shared by several of these groups communication strategies regarding these similar factors such as educating people about the risks associated with being vaccinated versus not being vaccinated addressing their concerns and countering vaccination myths present among members of a specific uvg through a trusted source can establish a reliable relationship with these groups and increase their vaccination uptake furthermore other interventions such as improving access to health care could certainly increase vaccination uptake in roma and irish travellers abbreviations mesh medical subject headings oj orthodox jewish op orthodox protestants sage strategic advisory group of experts uvg undervaccinated groups vpd vaccine preventable diseases who world health organisation wp work package not applicable authors contributions fk jd mc rr and js helped with the study design nf and lm independently selected the relevant articles nf identified the undervaccinated groups and searched for their beliefs attitudes and reasons of nonvaccination hr ih mw and ak helped with analysing data about respectively orthodox protestant communities anthroposophists roma and irish travellers and orthodox jewish communities es and jf helped with interpreting the results for defining communication strategies nf wrote the first version of the manuscript all authors contributed to the draft of the final manuscript their remarks were discussed and processed into the final version that was finally approved by all authors 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 author details 1 centre for infectious diseases control national institute for public health and the environment bilthoven the netherlands 2 municipal health service amsterdam amsterdam the netherlands 3 laboratoire danthropologie sociale centre national de la recherche scientifique paris france 4 centre for research in anthropology universidade do minho braga portugal 5 department of public health at xian jiaotongliverpool university suzhou china 6 leiden university medical centre leiden the netherlands 7 amsterdam institute for social science research university of amsterdam amsterdam the netherlands 8 the childrens institute university of cape town cape town south africa 9 strategic social marketing liphook uk 10 brighton university business school brighton uk 11 amsterdam school of communication research university of amsterdam amsterdam the netherlands 12 department of public health health service executive st finbarrs hospital cork republic of ireland 13 centre for infectious diseases leiden university medical centre leiden the netherlands 14

background despite effective national immunisation programmes in europe some groups remain incompletely or unvaccinated undervaccinated with underserved minorities and certain religiousideological groups repeatedly being involved in outbreaks of vaccine preventable diseases vpd gaining insight into factors regarding acceptance of vaccination of undervaccinated groups uvgs might give opportunities to communicate with them in a trusty and reliable manner that respects their belief system and that maybe increase vaccination uptake we aimed to identify and describe uvgs in europe and to describe beliefs attitudes and reasons for nonvaccination in the identified uvgs methods we defined a uvg as a group of persons who share the same beliefs andor live in socially closeknit communities in europe and who havehad historically low vaccination coverage andor experienced outbreaks of vpds since 1950 we searched medline embase and psycinfo databases using specific search term combinations for the first systematic review studies that described a group in europe with an outbreak or low vaccination coverage for a vpd were selected and for the second systematic review studies that described possible factors that are associated with nonvaccination in these groups were selectedwe selected 48 articles out of 606 and 13 articles out of 406 from the first and second search respectively five uvgs were identified in the literature orthodox protestant communities anthroposophists roma irish travellers and orthodox jewish communities the main reported factors regarding vaccination were perceived nonseverity of traditional childhood diseases fear of vaccine sideeffects and need for more information about for example risk of vaccination conclusions within each uvg identified there are a variety of health beliefs and objections to vaccination in addition similar factors are shared by several of these groups communication strategies regarding these similar factors such as educating people about the risks associated with being vaccinated versus not being vaccinated addressing their concerns and countering vaccination myths present among members of a specific uvg through a trusted source can establish a reliable relationship with these groups and increase their vaccination uptake furthermore other interventions such as improving access to health care could certainly increase vaccination uptake in roma and irish travellers

background coronavirus disease 2019 is an illness caused by a novel pathogen that has been named severe acute respiratory syndrome coronavirus 2 1 as of early april 2020 over 14 million covid19 cases and 80000 deaths have been reported in over 100 countries and regions worldwide after the first cluster of cases was reported in wuhan china 2 the world health organization declared the situation as pandemic on 11 march 2020 3 patients with covid19 can present a wide spectrum of symptoms and severity ranging from no fever or abnormality on lung radiology results to multiple complications 1 humantohuman transmission has been confirmed by numerous studies 45 a cluster of cases in hospital and family settings 1 suggests that the disease can be easily spread between people who have close contact with each other including workrelated settings in early march 2020 the media reported an outbreak of covid19 in a company meeting in massachusetts us with 70 out of the first 92 covid19 cases in massachusetts being linked to employees of this company by 10 march 2020 6 this case demonstrated how severe the consequences of an outbreak in the workplace can be therefore more attention should be paid to the guidelines and measures provided at the workplace to prevent the disease to respond to the evolving pandemic multiple types of interventions and policies have been implemented by governments in various countries and regions including school and workplace closures cancelling public events and public transport public information campaigns and restrictions and control of internal movement and international travel as summarized by a database established by the university of oxford 7 among these policies the closure of certain workplaces compulsory and recommended workfromhome policies and flexible work hours were announced by several governments for the purpose of social distancing multiple health organizations and authorities also published their own guidelines for employers and employees to prevent covid19 spread in the workplace the who suggested a set of guidelines for employers to prepare and respond to covid19 in their workplace 8 which included advice for maintaining good personal hand hygiene maintaining social distancing in the workplace through suggestions such as holding online meetings instead of facetoface ones and precautions for workrelated travel online resources from the who and the international labor organization have also been synthesized and provided by the european agency for safety and health at work 9 most of them focus on preventing infection in healthcare facilities for health workers and public emergency workers which is essential for maintaining the capacity and efficiency of the health system however the information and resources provided for nonhealth and ordinary workplaces have been limited even though some of these occupations involve exposure to crowds longer working hours and lower income it was reported in 2019 that the median monthly salary for craft workers machine operators elementary workers and salesservice workers in hong kong ranged from hk 12900 to hk 21900 while it was hk 28100 for managers professionals and associate professionals moreover the median number of weekly working hours was 480 h for manual laborers while it was 406 h for other occupations 10 in early april the euosha published guidance to assist employers providing advice to staff for adequate prevention 11 the centre for disease control and prevention in the us also developed guidelines for nonhealth settings helping individuals to identify risks and isolate sick employees promoting social distancing and hand and environment hygiene and encouraging employers to provide health education for employees 12 thus the focus on covid19 prevention in nonhealth workplaces hasincreased however a considerable part of the contents of the aforementioned policies guidelines and instructions aims to promote prevention in the workplace by altering and improving the personal protection behaviours of employees such as hand and environment hygiene and social distancing the macrolevel guidelines published by governments and health authorities might not catch the attention of or be easily accessed by ordinary employed individuals more importantly the unequal availability of workplace guidelines and measures for covid19 prevention across occupations should be emphasized previous studies have revealed that individuals living in more deprived areas are more vulnerable to community outbreaks of covid19 as well as more easily affected by responses to pandemic 1314 inequalities in housing condition may also contribute to inequalities in incidences of covid19 15 however the inequality across occupations has received less attention in the literature of covid19 despite inequalities in mortality in different occupations have been found in the 1918 influenza pandemic and many chronic illnesses 15 there are only a few studies focusing on this issue among the working population a us national survey during 20142017 indicated that there were racialethnic differences in occupations at high risks of covid19 severe illness 16 another usbased study found that hispanic or nonwhite workers in wholesales manufacturing transportation accommodation and food services were facing greater workassociated infection of covid19 than those working in professional finance public administration and entertainment occupations 17 these studies highlighted the disparities of covid19 infection risks across occupation groups but neither of them indicated its relationship with their workplace guidelines considering all these it is necessary to investigate the inequality of relevant workplace guidelines and measures across occupations covid19 prevention in the workplace is also crucial among high density population areas like hk a city with 745 million residents a labour force of 398 million and 387 million employed persons in 2018 including employers employees selfemployers and unpaid family workers 18 the consequences could be severe if precautions were not taken seriously by employers and employees only one local study has been published on the degree of stress and views towards workplace supportive policies and protective equipment supply among employees 19 to our knowledge evidence on the relationship between the implementation of workplace guidelines and its relationship with protection behaviours for preventing covid19 spread at the corporate level is scarce thus this study aimed to examine the relationship between workplace guidelines and measures and employees protection behaviours for covid19 prevention and whether behavioural responses differ according to the nature of their occupations we hypothesized that the availability of workplace guidelines and measures and its associations with personal protection behaviours are different across occupations methods a crosssectional selfadministered questionnaire survey of employees was conducted using an online platform from 17 to 27 february 2020 in hk during the survey period daily covid19 confirmed cases were lower than 10 20 but the cumulative cases had increased to 93 by the end of february in hk study sample and data collection this study focused on the employed population of hk which comprises 354 million individuals 18 we considered nine occupation groups as defined by the government 1 managers and administrators 2 professionals 3 associate professionals 4 clerical support workers 5 service and sales workers 6 craft and related workers 7 plant and machine operators and assemblers 8 elementary occupations and 9 farm workers animal husbandry workers and fishermen and other unidentifiable occupations for this study hk residents aged 18 years or above employed or selfemployed working either on a fulltime or parttime basis and able to understand chinese were eligible an electronic device was also needed by survey participants for accessing the internet and completing the online questionnaire which was feasible because of wide possession of webaccessible mobile devices among workingage individuals 21 students housewives and those who were retired were excluded as they did not work in a workplace the participants were recruited using the convenience sampling method the questionnaire was distributed on an online platform to the target population through email and multiple social networking platform as it is considered to be a safer way for both research staff and participants to avoid contact in person while conducting the survey and reduce the risk of covid19 infection the questionnaire was available as a google form and selfadministered an information sheet about the study aims data collection procedure and participants right was included at the beginning of the survey followed by an electronic consent form the data collected through the questionnaire were stored in an online drive and passwordprotected the people who received the link for the online survey were encouraged to forward the survey links to others instruments and measures the questionnaire was developed based on the who guidelines for covid19 prevention in the workplace 8 and the validated instrument in a related study on health behaviour practice during ebola epidemics 22 was used to inform identification and categorization of relevant personal protection behaviours for analysis as its instrument synthesized the findings and instruments from multiple relevant studies under a similar context to the early stage of covid19 epidemics when our study was done this study focused on two major aspects of the survey as follows 1 availability of workplace guidelines and measures for preventing covid19 and 2 frequency of personal protection behaviours in the past 7 days for the protection behaviours a total of eight items under four categories were assessed 1 hand hygiene 2 face mask 3 household hygiene and 4 social distancing demographic and occupation information were also collected a fourpoint likert scale was applied to measure the frequency of personal protection behaviours of the respondents regarding the availability of workplace guidelines and measures respondents provided a binary response available or not available statistical analysis data processing and analyses were conducted using stata 140 the demographic and occupational characteristics of survey participants were described and reported a twoway cross tabulation analysis was performed to assess the association of occupation group with frequency of personal protective behaviours and availability of workplace guidelines respectively using chisquare or fishers exact test to identify differences in behaviour frequency and availability of guidelines between different occupation groups following this ordinal logistic regressions for different personal protection behaviours were conducted for all survey participants and for participants in different occupation groups separately which can be specified as ln pr y mi jj x à á 1pr y mi jj x à á¼ α m j þ x h k¼1 β mk x ki þ ε mi j ¼ 1 2 … j1ð1þ where the frequency of behaviour m with j categories of responses of individual i was the dependent variable and the independent variables x k included availability of workplace guidelines and measures occupations age gender marital status living arrangement education attainment and work status in order to determine the associations between workplace policy and personal protection behaviours and examine the differences in these associations according to occupation as the study sample had a disproportionate distribution of occupation compared with the entire working population in hk 18 a sensitivity analysis was conducted using the sample with the adjusted occupation distribution to explore whether the findings from the regression analysis were affected by this disproportion the adjustment was made by giving different weightings to participants with different occupations based on the relative occupation distribution of the working population in hk the same multiple ordinal logistic regression models applied in original sample were conducted again with the weighted sample for the comparison analysis results demographics a total of 1196 participants completed the online survey of these 148 reported being retired or currently unemployed or did not provide their occupation thus the responses from 1048 participants were deemed valid for subsequent analysis among the 1048 participants 68 were female regarding age 207 were 1829 years 280 3039 years 329 4049 years 156 5059 years and 28 60 years and over over half of the participants were married or cohabited and only 6 were living alone around 75 had attained undergraduate education at university or above the majority of participants worked on a fulltime basis with regards to occupation 42 were professionals 24 associated professionals 17 managers or administrators and 10 clerical support workers our study sample comprised fewer participants from worker groups and more from professional groups according to statistics on the labour force and employed population in hk 18 for the analysis the four occupation groups of 1 servicesalescraft workers 2 plantmachine operators and assemblers 3 elementary workers and 4 farm workers animal husbandry workers and fishermen and unidentifiable occupations were grouped as manual labourers who comprised around 6 of the study sample compared with the local working population 18 this study sample did not have a substantial difference in age and gender distribution but the occupation distribution was disproportionate there were more professionals and less manual labourers than in the general working population personal protection behaviours for prevention of covid19 in table 2 compliance with the four behavioural categories comprising eight personal protective behaviours was evaluated regarding hand hygiene of the 1048 survey participants 771 reported always washing hands before meals and 975 reported always washing hands after using the toilet but only 564 always used alcoholbased hand rub when outside regarding face mask use 954 always wore a face mask when outside as for household hygiene behaviours only 199 and 165 always put disinfectant into toilets and drainpipes respectively regarding social distancing behaviours 512 reported they always avoided leaving their home and 632 always avoided contact with their neighbours compliance with personal protection behaviours by sociodemographic and occupation groups in table 1 personal protection behaviours differed between sociodemographic subgroups in terms of age gender living arrangement marital status educational level and work status participants aged below 50 years tended to wash hands more frequently after using the toilet while those under 30 years old washed hands less frequently before meals females were more likely to always perform protection behaviours especially using alcohol hand rub avoiding leaving home and avoiding contacting neighbours the cohabiting participants showed a lower frequency of several behaviours than their single married divorced and widowed counterparts namely handwashing before meals wearing mask and avoiding contact with neighbours while those who were single divorced or widowed reported a lower frequency of avoiding leaving home as for living arrangements there was a clear pattern that participants living alone were less likely to perform protective behaviours than those living with others in addition there were no significant differences according to education attainment or work status for most of behaviours except that those who finished higher secondary school reported lower frequency of using disinfectant in toilets and fulltime employees were less likely to always avoid contact with neighbours in table 2 personal protection behaviour patterns in different occupations were mostly alike except for manual laborers who reported a slightly lower frequency of such behaviours in the twoway cross tabulation analysis of occupation and frequency of behaviours a significant difference between occupations was only found for putting disinfectant into toilets with 240 of managers and administrators and 242 of associate professionals always performing this behaviour and only 154 of manual laborers always doing so for handwashing approximately 78 of the combined professionals always washed hands before meals and around 98 of them always washed hands after using the toilet while manual labourers reported slightly lower frequencies for these two behaviours however these differences were not significant around 908 of manual labourers wore a face mask while at least 94 individuals from the combined professionals always did so as for social distancing there was a lower proportion of manual labourers who always avoided contact with their neighbours in comparison with combined professionals however these differences were not statistically significant inequality in workplace guideline and its relationship with personal protection behaviours as shown in tables 2 899 of participants reported that relevant guidelines and measures were available in their workplace while fewer manual laborers reported such availability the association between personal protection behaviours and availability of workplace guidelines and measures was examined after adjustment for covariates individuals with available guidelines and measures in their workplace tended to report higher frequency of handwashing before meals the association between workplace policy availability and personal protection behaviours was found to be significant for managers and administrators as well as manual labourers with adjustment for covariates while no significant association was found for other occupations among managers and administrators the availability of workplace guidelines was found to be associated with handwashing before meals wearing a face mask avoiding leaving home and avoiding contact with neighbours among manual laborers the availability of guidelines was associated with handwashing before meals using alcoholbased hand rub for disinfection avoiding leaving home and avoiding contact with neighbours although a significant association was found the standard errors were relatively large and 95 cis were also wide because of a relatively small sample size for a few behaviours and occupational groups thus the interpretation of point estimates of adjusted ors should take this into consideration sensitivity analysis relationship between personal protection behaviours and workplace guidelines in a weighted sample in the weighted sample there were 121 manager and administrators 82 professionals 216 associate professionals 134 clerical support workers and 493 manual discussion during the current covid19 pandemic few studies so far have looked at personal protection behaviours and their relationship with the availability of workplace policy related to covid19 prevention in considering workplace policy availability during the covid19 pandemic this study revealed that manual laborers had a significantly lower availability of workplace policy and relatively lower compliance of selected personal protection behaviours than those with other occupations this inequality should receive greater attentions by government employers and employees in further prevention practice for personal protection behaviours most employees performed hand hygiene and wore face masks and over half of them showed high compliance with social distancing maintaining household hygiene was measured as frequency of using disinfection for toilets and drainpipes which comes from the experience of the2003 severe acute respiratory syndrome outbreaks in hk where the virus was likely to be transmitted through sanitary plumbing systems 2324 however these behaviours were found to be performed by fewer participants in this study which might be related to the fact that no cases of covid19 infection have been confirmed to occur through buildings plumbing systems locally at the time of the present survey another possible reason for the low compliance with household hygiene might be related to the difficulty in accessing detergents in the supermarket or online 25 our findings also indicated that individuals living alone showed a lower frequency of protection behaviours which highlights the importance of social support from the family in promoting prevention at the individual level as those living alone might have lower the accessibility to relevant information awareness and concern about performing such behaviours because of a lack of reminders from other sources in light of this governments and local communities should be able to approach these individuals to promote communitylevel health education and information dissemination this study found that not only employees with different occupations showed differences in personal protection behaviours but workplace policy availability was also a factor related to such behaviours the employees with access to guidelines and measures for the prevention of covid19 showed a higher frequencies of protection behaviours especially hand hygiene wearing a face mask and social distancing this indicated that publishing guidelines and implementing prevention measures in the workplace is associated with greater compliance of the personal protection behaviours of employees regarding the relationship between workplace policy availability and personal protection behaviours only managersadministrators and manual labourers who had access to guidelines and measures in their workplace were more likely to perform adequate protection behaviours on one hand managers and administrators might be the persons who have the authority to make decisions about providing such guidelines and measures in their workplace therefore their own frequency of protection behaviours could reflect their knowledge awareness and attitude regarding the prevention of covid19 and this might consequently affect the availability of guidelines and measures in their workplace on the other hand the lower adoption and compliance of a few personal protection behaviours among manual labourers including hand hygiene and social distancing was possibly related to inadequate workplace policies this association was not significant for behaviours related to household hygiene implying that the workplace policies may not improve the compliance of personal protection behaviours that are typically performed at home even though they were associated with other precautions during their work and daily life as mentioned earlier most manual laborers come from lower socioeconomic backgrounds and experience worse working conditions such as longer working hours and heavier working load than other occupational groups this could hinder their access to adequate knowledge and awareness of the need for such protection behaviours 26 the nature of their work also requires them to make contact with other individuals especially for those working in sales and service provision so it could be difficult for them to keep social distance from the crowds if no special work arrangements are put in place for them 2728 moreover a supplementary analysis revealed that the information transparency on covid19 infection among coworkers was much lower among manual labourers without workplace policies for covid19 prevention thus this finding suggests that workplace guidelines and measures may serve as an important way to communicate relevant information to manual laborers to increase their awareness and attention and encourage them to comply with the health behaviours additionally it could also be difficult for these workers to obtain hand disinfectants and face masks due to the shortage of supplies and inflated prices for manual labourers available workplace policies for covid19 prevention were also associated with greater accessibility to adequate personal protection equipment and products that were provided by their employers which could increase their compliance with health behaviours meanwhile other occupations such as professionals might have more knowledge and information about covid19 and its prevention thus workplace policy availability did not have a significant association with their behaviours our findings which suggest that it is important to promote the prevention of covid19 at the individual level by improving workplace guidelines and measures can be used to inform formulation of workplace policies and interventions to prevent spread of covid19 individual and organizational level policies for workplace preventions should primarily target to the managers and administrators and manual labourers based on the study results on one hand improvements are needed for employers as well as managers and administrators to enhance the availability of guidelines moreover there should be instructions or templates to develop guidelines and measures provided by health authorities as a reference for administrators to follow and develop their own version adequate training for infection control can be made available to employees to improve their awareness and hygiene practice based on experiences from outbreaks and epidemics of other diseases 2229 on the other hand among the different occupations more efforts are required to provide workplace prevention guidelines and measures for manual labourers including service workerssalescraft workers plantmachine operators and assemblers and elementary workers as their reported availability of such guidelines was lower and some of them such as servicesales workers are exposed to a higher risk than others because of having more frequent contact with other individuals according to the results guidelines which acts as a reminder or encouragement to the manual labourers should be provided to increase their awareness of hand hygiene and social distancing restrictions moreover availability and transparency of covid19 related information could also increase the mutual understanding between employer and employee it therefore enhances the compliance of their health behaviours this finding is supported by a china study that identified exposure to covid19 information was associated with higher compliance of wearing masks and hand sanitizing among factory workers 30 the effectiveness of specific guidelines and measures for them to improve their personal protection behaviours can be further examined in future studies previous research showed the governments played an important role in promoting workplace policies for covid19 prevention thus a swift and coordinated policy at regional and national level with a strong multilateral leadership is required mainland china extended public holidays and issued a mandatory workfromhome policy for inessential positions in late january and early february 2020 31 the government of japan and singapore have encouraged employees to take leave if they have symptoms and promoted teleworking and staggered office hours 7 singapore closed all the workplaces for nonessential services in april 2020 32 the hk government has also implemented workfromhome arrangements for government employees since february and urged the private sector to make flexible work arrangements for employees in late march 2020 33 although the workplace policies of the infection control had at least moderate effects in reducing covid19 attacks 34 by reducing the frequencies of contacts and ensuring social distancing it may not be applicable for all the manual labourers it is because most of the manual labourers cannot work from home due to the nature of their work and they could easily lose their jobs due to workplace closure and covid19 related transportation restrictions 3536 besides the workplace closure and workfromhome policies during the pandemic a wider range of workplace policies suggested to be decide to employees in order to avoid lack of protection due to shortage of the equipment adequate ppe for covid19 prevention should be made available by the employers at workplace with the support of governments including hand sanitizer and face masks singapore government acts as an example that the employers should ensure there are sufficient masks for employees 37 mandatory mask wearing at workplace can be considered where people are close to each other in working areas mainland china 38 and singapore were the few countries launching the related policy since early 2020 37 employees also demand the related instructions on how to properly maintain hygiene and wear a face mask 19 this information could help improve the adequacy and effectiveness of their protection behaviours these measures that are universally available to all workplaces are expected to improve the equalities of accessibility of materials information and workplace guidelines for covid19 preventions across occupations in addition more attentions should be paid to vulnerable working population some individuals had concerns about salary penalties for absence due to influenza or covid19 19 this kind of concern may reduce employees willingness to comply with suggestions such as staying at home and keeping social distance if they experience symptoms especially for employees with lower income which would consequently expose their colleagues and general public to a higher risk therefore paid sick leave medical benefits andor insurance for compensating the income loss due to covid19 infection can be provided to financially vulnerable workers especially for essential workers who need to stay in work position during the pandemics 39 limitation first the survey adopted a convenience sampling method which is not a parametric sampling method and there was no sampling frame the sample collected might not represent the working population in hk well indeed the study sample comprised more professionals and managers administrators and fewer manual laborers compared with the occupational distribution of the employed population in hk this is probably because the online questionnaire for participants were distributed through the social networking platforms of the research team and the institution in the first place whose primary audiences are professionals therefore there might have been selection bias due to the recruitment method on one hand those who participated into this survey might have greater concerns over the epidemicpandemic situation and therefore they might have greater awareness and compliance with personal protection behaviour than those who did not participate the compliance level of some personal protection behaviours in the general working population might not be as high as what was found in this study sample such as mask wearing or handwashing on the other hand the relationship between workplace policy and employees personal protection behaviours could be different according to their occupation to minimize the influence of the disproportionate occupation distribution in our sample for the regression findings two additional analysis were performed the first of these was performed in different occupations separately to reflect the differences between occupations to ensure that this results would not be affected by distribution of occupations the second additional analysis was a sensitivity analysis using a sample adjusted by occupations which means participants of different occupations were weighted to have an accurate occupation distribution of the working population in hk the extra findings showed that the disproportionate occupation distribution did not have a substantial influence on the primary finding of this study nevertheless more robust sampling recruitment and data collection methods should be adopted in future studies second the number of participants in some occupational groups and with certain experience of workplace policy availability was relatively small which led to larger standard errors of adjusted or estimates or nonconvergence of statistical models therefore the estimates of the regression models were reported and interpreted along with their confidence intervals which reflect their standard errors third when needed and sometimes could be similar in describing the frequencies of the behaviours when needed was used to indicate that individuals would perform the behaviours only when they believed it necessary while sometimes was used to indicate that the individuals would comply with the behaviours from time to time in addition the type and contents of workplace guidelines and measures were not specified in the survey therefore conclusions on whether a specific measure or workplace policy may be associated with personal protection behaviours need to be drawn in future studies conclusion the covid19 pandemic not only affects the global health but also transforms into an economic and labour market shock protecting workers and their families from the infectious disease outbreak needs to be a top priority this study provided evidence on current flaws in workplace policy availability regarding covid19 prevention and its inequality across occupations as well as its association with personal protection behaviours attention is needed from multiple parties including employers employees and governments to increase awareness about the importance of workplace guidelines and measures in preventing covid19 spread at individual and community levels especially for manual labourers given that adequate workplace policy was associated with greater frequencies of employees behaviours for preventing covid19 spread the workplace policies should include not only workplace closure and workfromhome arrangements but also a wider range of responses and guidelines to ensure accessibility to infection control materials and information for essential workers who have to attend to their workplace and financially vulnerable workers cannot afford to be absence of work the workplace policy may also serve as a way to disseminate information for health promotion and education regarding covid19 therefore more efforts and resources need to be invested in this area by public health authorities further studies are also needed in different regions and countries for a thorough evaluation of workplace policies competing interests the authors declared that they have no competing interests

background the evolving pandemic of coronavirus disease 2019 has become a severe threat to public health and the workplace presents high risks in terms of spreading the disease few studies have focused on the relationship between workplace policy and individual behaviours this study aimed to identify inequalities of workplace policy across occupation groups examine the relationship of workplace guidelines and measures with employees behaviours regarding covid19 prevention methods a crosssectional online survey using a structured questionnaire was conducted to gather employees access to workplace guidelines and measures as well as their personal protection behaviours statistical associations between these two factors in different occupations were examined using multiple ordinal logistic regressions results a total of 1048 valid responses across five occupational groups were analysed manual labourers reported lower availability of workplace guidelines and measures 769 vs 899 for all p 0003 employees with available workplace guidelines and measures had higher compliance of hand hygiene wearing masks and social distancing and this association was more significant among managersadministrators and manual labourers

introduction femi osofisans works demonstrate and give support to the view that political and social commentary is the epicenter of contemporary nigerian drama olu obafemi sees osofisan as a dialectical materialist who consciously rejects idealism fraught with tragic recommendation that are fatalistic deterministic and passive for the society osofisans dramatic oeuvre equally draws inspiration from traditional culture but he uses devices of oral literature and songs as insignia of his alienation technique he uses his plays as platform for exploring social issues the world that osofisan present in his plays is a real world which according to olu obafemi and ahmed yerima are consistently involved in a process of change and manifestly observable from the conflict of struggle with oppressive hegemony in society osofisans plays are permeated with dialectic and didactic elements he is a playwright with an eye for the problems of his society muyiwa awodiya says osofisans dramatic works reply to the disillusionment of the masses arising from their disappointment at the insensitivity of the rulers to their plights after the euphoria of independence stinking corruption injustice and oppression greed selfishness and drift of political leadership that led to coups and countercoups the horror of the civil war the postcivil war lawlessness and indiscipline of the military government and the mismanagement of nigerias economy by our prodigal governments since the oil boom days of the seventies through the eighties to the present osofisan has remained defiant in deploring his art to elicit the consciousness of his audiences for he believes in the collective action of the people which is capable of engendering a new social order promise nyatuame and madinatu bello say that osofisans plays address themselves to david essi iconic symbols in femi osofisans once upon four robbers tropical journal of arts and humanities volume 4 number 2 2022 characters who he imbues with more assertive voices in their quest for progress and development interestingly osofisan denies his audience what tejumola olaniyan describes as the expected pleasurable magic of art in which dreams come true normality prevails and the scale of justice is balanced osofisan always want his audience to leave the theatre with a goaded mind osofian in his words says i want an ending which tells them that the theatre doesnt solve anything… because it is a fictional world the problem has to be solved in the society… but it wont be solved if we simply dont discuss it we must discuss the thing and work towards solution he is a playwright who jolts his audience out of dormancy and provoked to think with uncommon sense which according to olaniyan is … a thorough analysis and assessment of situations in order to arrive at the way the situation should be not how it is perceived by society a provocation of the audience to a critical reexamination of their social circumstances femi osofisan is a theatre alchemist who in spite of being a leftist of the theatre demands a theatre where the audience is both responsive and flexible engendering an intercourse involving the performance the message and the audience in the end there is an entanglement of the audience message and performance in a pleasurable harmonious bonding andrew onokerhoraye says that osofisans theatre …reflects both his sympathy for human suffering and his outrage at human absurdity alternating between moods of wistful pathos and flashes of ironic humour which disqualify his play from being mere slices of life as a playwright who possesses a deep humanity osofisan brings drama to a higher realization of its human role of compassion subsequently edde iji refers to femi osofisans style as post brechtian direction which is a directorial style characterized by a theatre that calls attention to itself and deconstructs itself in order to refocus the audiences attention on social issues and values iji caps osofisans theatre with a perusal that elicit plaudits as follows thus it can be argued that despite the fall of the berlin walls visàvis the putative death of practicable communism the ideals of marxistsocialist ideology that tend to enrich brechts and osofisans pedagogy of the oppressed or theatre as a tribunal to redress human relations flaws remain very valid this synthesis suggests that osofisan has a complete feeling for theatre as a craft and cultural tool as he continues in his quest for the ideals of the total theatre aesthetics in which theatrical embellishment and endowment are used to the fullest he always has the feeling and conviction that the coming together of the audience and players is one of the few opportunities in our society for a debate in live terms hear him … i write primarily for an african audience… because of the way our audiences respond to songs they like… so that the audiences begin to sing with me they begin to learn in the african theatre is a festive experience which everyone must share in a communal experience brought about by music song dance costume and makeup the performers and the audience are engrossed in this experience giving no room for audience aloofness and glacial disposition osofisans deployment of songs and dance rituals ceremonies myth rhetoric history and oral tradition as resonating dramatic condiments is an efficient method of reaching out and arresting the audience mentally and emotively as tracie chima utohezeajugh observes the effect of the union of drama music and dance is the resurgence of a participatory theatre which readily appeals to the african psyche through story telling techniques and other dramatic forms osofisan is able to elicit responses from his audiences and mobilize them to participate actively and imbibe the lessons contained in his works to osofisan there are few things more marvelous than an audience which is actually being lit by a theatrical experience using the words of peter hall it is on this template that we examine and interpret the iconic symbols in osofisans once upon four robbers synopsis once upon four robbers this play is the story of four hardened criminals major alhaja angola and hassan whose leader has just been executed publicly while alhaja is in grief over her late husband the other robbers ruminate on their present condition as well as reminisce on their past robbery escapades aafa the narrator appears on the scene as an islamic imam cum a babalawonative doctor aafa reprimands the robbers for indulging in criminal activities the robbers say it is hunger that has driven them into crime since there are only menial and demeaning jobs offering pittance available aafa offers to help the robbers to get rich he gives them a dance inducing charm he however tells the robbers there is a caveat first they should never rob the poor second they should only rob public places and finally they should never take human life no shedding of blood aafa equally tells the robbers that they can only use the charm to rob three times and thereafter it becomes impotent the robbers after acquiring the charm attack the village market robbing the market women and soldiers on guard at the market later major doublecross the rest of the gang collecting the loot for himself major is shot by the soldiers who appear on the scene led by sergeant while major is taken away as prisoner sergeant keeps the recovered loot to himself alhaja appears later disguised as a corn seller and succeeds amorously in convincing the soldiers that major is innocent the soldiers abandon the execution platform they are building promising to set major free as major is brought in for execution followed by the saboteursoldiers all in chains alhaja comes on stage with the other robbers stopping the execution while the crowd yearns for blood aafa as narrator comes on stage to stop proceedings asking for the audiences opinions if the robbers should be shot or not iconic symbols in once upon four robbers the play has a single set depicting a market square centre stage while at the centre stage right there is a platform and a stake constructed on top of the platform for the david essi iconic symbols in femi osofisans once upon four robbers tropical journal of arts and humanities volume 4 number 2 2022 execution of armed robbers the stake is symbolic and thus represents retributive justice as the bible aptly puts it the wages of sin is death the stake is symbolic of the punishment for the misdemeanor of the robbers conversely the platform and stake is equally a symbol of oppression and human degradation the platform and stake is an indictment on the government because the rich and powerful politicians and the military junta who have stolen the commonwealth of nigerians are never shot at the stake as a result the platform and stake is a reminder of the failure of the government as well as a sad commentary on the societya society that slaughters its own hassan asks hassan after his death yours mine after our death …the hammering of the boards together for the stateapproved slaughter what will be left the platform and stake graphically symbolizes the cavalier disposition of those in authority femi fatoba refers to the platform and stake as using terror to fight terror the yorubas refer to this as stemming a curse with a curse kafepe wepewhich means setting two negative forces against each otherlike the proverbial two wrongs which dont make a right most worrisome is the fact that it is only the poor and vulnerable that are shot at the stake it clearly shows us how deep the society has sunk in morass finally the platform and stake is a graphic symbol of a hobbesian state of nature where life is nasty brutish lawless and short the market square is a symbol of a place of commercial enterprise as well as a place of survival of the fittest the market is symbolic of the african world view of death there is a yoruba adage which says aye ioja orun nile which when literally translated means the world is only a market heaven indeed is home the armed robbers in the course of their dialogue always refer to the market as a place where their journey terminates angola in anger tells hassan and alhaja that major deserves the death of a traitor and makes reference to the market angola we shall be here when they bring him tossed up theyll walk him up that platform and shoot him hell get the death all traitors deserve in a common market among the smell of stale meat and rotten vegetables in yoruba cosmogeny the market is a place where people of all spheres of existence come to buy and sell tunji azeez says that it is believed in some circle that the dead even come at night to banter and haggle in the market thus the market possesses a sort of spiritual power which can make or mar a person for instance it is believed that any mad person who gets to the market can never be cured as all eyes have seen him or her in that state of madness tunji azzez also holds that the market is important symbolically and socioeconomically and that women dominate this powerful space ropo sekoni opines thus the location of the market in the centre of yoruba towns…constitute… a sanitization of the centrality of the market trading and exciting to the social dynamics of life referring to the market mama alice says mama alice the market is our sanctuary the market space is a predominantly female space azeez is of the opinion that men are mere visitors to this metasemiotic sphere sckoni goes further to throw more light into the symbolic nature of the market thus market life is laden with risks and uncertainty not amenable to rational control and scientific predictions because it is fundamentally saturated with divine irrationality its disorderliness is an aspect of ambivalence the bar beach this is the terminal place for armed robbers hassan tells angola that their leaders death has left them vulnerable as there is no hiding place for them he says hassan all we have left is the bar beach and then six feet in the ground hassan angered by majors betrayal tells him hassan youre doomed major one day well come gunning for you to which major replies major ill be waiting at the bar beach angola tells hassan and alhaja that major the traitor will meet his inevitable end in a most despicable way he says angola… in a common market among the smell of stale meat and rotten vegetables he wont even make the bar beach interestingly also angola replies aafas advice to the robbers to look for decent jobs or else they would be arrested and executed for armed robbery angola right aafa so the journey ends at the bar beach… from the foregoing it is obvious that the bar beach is symbolic of the execution ground for armed robbers during the military era in nigeria bar beach in lagos was dreaded as it is seen as the execution arena for armed robbers back then in nigeria the bar beach was notorious and symbolic as the slaughter ground for armed robbers mat bead and a small kettle these items are the paraphernalia of a muslim faithful they stand for purity and piety martial music military camouflages and boots these are symbolic of oppression and repression phalic symbol in the play sharp tooth is a phallic symbol as this dialogue attests ogogoro bottle the soldiers are the ones seen here drinking the native gin this obviously delineate their financial and social status they clearly belong to the lower rung of the military cadre and more so they are a bunch of disgruntled soldiers who are desirous of a better life as this dialogue attest david essi iconic symbols in femi osofisans once upon four robbers tropical journal of arts and humanities volume 4 number 2 2022 soldier 1 yes miracles as long as there are underdogs like me and you to make them happy ah i am tired soldier 3 some of us are born to take orders you fool so shut up soldier 1 not me i am going to be officer you watch soldier 3 and you complain about miracles do you think its the number of crawcraw on your body that they count for promotion characters the characters in the play are all symbolic they are symbolically analyzed viz leader of the robbery gang the leader of the gang is executed at the very beginning of the play his execution has a great impact on the play as his ideas underline the actions of the robbers the robbers had so much faith in him as he had raised the robbers as an army of warriors to stand up and fight for justice however the leaders death throws the other robbers in confusion the leader made his disciples believe the whole army could not defeat him but unfortunately he was eliminated by the decree it is rather unfortunate that the robbers attempt to rescue the leader ended in a disaster which claims many lives in the process the leaders death created a leadership vacuum that was difficult to fill the leaders death renders the gang of robbers as sheep without shepherd major major was born and bred in the slum and was trained by the late leader to fight for justice although he is a hard faced criminal he so much desires a good and decent life it is this desire to live a good life that goaded him to betray his comrades this indeed attests to human greed the death of their leader created a vacuum which major would have stepped into but his naivety and greed disqualifies him this makes angola to tell alhaja and hassan that major no longer belong to the gang but on the other side of the streetthe government forces however majors bravery is shown as he is tied to the stake he predicts a change in the sociopolitical order for he says major but tomorrow that law will change the poor will seize and twist its neck the starving will smash the gates of the supermarkets the homeless will no longer yield in fear to your bulldozers and your children yes your dainty little children will be here where i stand now on the firing block alhaja alhaja like yoruba women do not see her role as foisted on her by her generic and psychological makeup as inferior to that of her male counterparts alhaja sees the roles of male and female as complimentary as the wife of the leader she has seen so much violence which makes her streetwise alhaja is undoubtedly a symbol of a consistent persistent and pushful character after the death of her husband she asserts herself as the pivot of the gang since nature abhors vacuum alhaja galvanizes members of the robbery gang for the rescue of major in alhaja osofisan has subtly shown his disposition to gender equity for according to osofisan this is why so many articulate young women through my stage each defiantly refusing to be silenced… david essi iconic symbols in femi osofisans once upon four robbers tropical journal of arts and humanities volume 4 number 2 2022 angola angola is stubborn forceful and actively courageous he is very eager to avenge the execution of their leader angola is very angry with major for betraying the gangs that he refuses to take part in rescuing him angola insists that major is a monster who should be disfellowshipped and marooned angola maintains that if their leader was alive he would have personally eliminated major for his act of betrayal angola angrily tells alhaja angola and our leader would have been the first to disinherit him to have him wiped out angola is a character foil of major hassan it is most interesting that hassan is sergeants younger brother hassan became a robber much early in life because of his awareness that his early life had been founded on layers of lies and lashes from parents priest and teachers he desires a backlash of those lies and lashes on the criminal society because he is frustrated by the current socioeconomic malaise hassan passionately believes in the bonding of the robbery gang in order to overcome any eventuality hassan wants to get even with the society for blowing the bubbles out of his dreams he says it is unacceptable for him to be a slave in his own fatherland hassan could be referred to as a patient moderate and thoughtful character hassans respect and love for the life of major a comrade makes him ready to forfeit their last chance of getting rich by using the charm to attempt rescuing major hassan tells sergeant his brother that he is on the side of the government forces the oppressors and morbid killers of the defenseless he says hassan…you run with the hunters i with the rabbit aafa he is the narrator of the dramatic happenings in the play he emerged first as a muslim carrying a mat bead and a kettle for ablution this shows that he is a muslim imam aafa tells the robbers that if they steal only from the rich there will be no hiding place for them since it is the rich that makes the law train the lawyers build the law courts and own the firings squad aafa transforms into a babalawo and make charms for the robbers aafa is familiar with human greed and that is why he discloses to each member of the gang a part of the formula s in order to engender the efficacy of the charm if only they come together and each one of them recite his own portion of the formula aafa could be referred to as the conscience of a society steep in morass he is also the arbiter of the dramatic event aafa is a dedicated committed humane and reasonable character sergeant sergeant is the elder brother of hassan his name is ahmed the market women call him baba mayo he is in charge of the execution of robbers he is also in charge of the soldiers on guard at the market sergeant is a symbol of an oppressor he has developed a potbelly which is symbolic of his corrupt and extortionist demeanour sergeants opportunistic urge comes to fore when he arranges to share the loot of the robbers after his verdict that the robbers ran away with the money it is ironic that sergeant does not actually belong to the mainstream oppressive and repressive class he remains on the fringe of the oppressive and repressive authority this is because sergeant belong to the lower rung of the society and as such he too suffers david essi iconic symbols in femi osofisans once upon four robbers tropical journal of arts and humanities volume 4 number 2 2022 deprivation and neglect he is no better than an armed robber himself sergeant panders to a thieving inclination the other soldiers they are archetypes of the nigerian soldier for they are barely educated and do whatever they are told they complain about corruption in government but can do nothing about it their jerky movements makes them look like robots this is the major reason the late afro beat king fela anikulopa kuti call nigerian soldiers zoombie ironically these soldiers equally suffer deprivation since they like sergeant belong to the lower rung of the military the soldiers too are morally deficient and are worse than the armed robbers they are a bunch of depraved soldiers on the prowl the market women the market women in their song song of the market expresses their opinion of this life as a market in which it is a survival of the fittest these women see the market as their sanctuary interestingly these women are determined and courageous azeez says that anyone who claims that african women are voiceless this play is enough to correct such impression furthermore the market women and alhaja are loud and courageous hence azeez opines thus this is contradistinguished from the european conception of women as a mere domestic docile gullible penisenvying gender the market women are flamboyant shrewd and heartless symbolic biblical allusions quite notable in the play is the prevalence of symbolic biblical allusions which raise very intriguing questions in part two major in the course of betraying his comrades says major there was a messiah once and one was enough for all the centuries one great monumental mistake and nobody since has been in any hurry to repeat it the nails and blood the crown of thorns all is a charade… inferred from majors speech above is the reference to a messiah whose death for mankind seems to be a monumental mistake because christians have learnt nothing from it major equally refers to nails blood and a crown of thornsthese are all symbolic allusions to the suffering and death of jesus christ on the cross which osofisan uses his actors voice to say its all a charadebecause of the hypocrisy of religion another example is in part three when angola refuses to take part in majors rescue he tells alhaja angola the lost sheep eh dont tell me i know the parable angola refers here to the parable of the lost sheep in which jesus says thus how think ye if a man an hundred sheep and one of them be gone astray doth he not leave the ninety and nine and goeth into the mountains and seeketh that which is gone astray… in contrast angola does not agree that major is a lost sheep that deserves bringing back into the fold angola seems to be saying here that majors act of betrayal david essi iconic symbols in femi osofisans once upon four robbers tropical journal of arts and humanities volume 4 number 2 2022 renders him unfit to belong to the fold and as such should be ostracized permanently conclusion it is evident that femi osofisan deliberately uses symbols in once upon four robbers and his other plays to unfurl his themes of injustice oppression and stressing the need for nigeria for example to have better leaders he repeatedly reflects on the ills of the society drawing our attention to the way some people are stupendously affluent while the bottom millions wallow in abject penury thus osofisans dramatic oeuvre obviously demonstrate and lend support to the view that social and political commentary is the prime preoccupation of his craft finally osofisans plays are replete with symbols and other essential elements of african communal aesthetics which makes his plays enjoy maximum production patronage in nigerian theatres and beyond works cited awodiya m the drama of femi osofisan a critical perspective ibadan kraft books azeez t

femi osofisan is a committed playwright who believes fervently in emphasizing the social responsibility of the playwright he has sought in several ways to make the theatre reflect the problems of the nigerian society and to make his plays a platform for exploring these social issues his plays are replete with symbols which explore these social ills in nigeria examples abound in once upon four robbers yungba yungba and the dance contest aringindin and the night watchmen many colours make the thunder king red is the freedom road etc this paper seeks to examine interpret the iconic symbols in once upon four robbers and how these symbols reflect the very concrete and biting sociopolitical statements the paper submits therefore that osofisan deliberately employ symbols in once upon four robbers to show the society for what it is and for the audience readers to have a fuller comprehension of his dramaturgy

introduction in the past two decades subsaharan africa has experienced significant increases in contraceptive knowledge and prevalence the five east african countriesburundi kenya rwanda united republic of tanzania and ugandawitnessed unprecedented progress in reproductive maternal newborn and child health for example contraceptive prevalence rates have over the years increased significantly in rwanda from 212 in 1992 to 516 in 2011 1 and in kenya from 327 in 1993 to 58 in 2014 2 in uganda maternal mortality reduced from 604 to 310100 000 live births in the period between 2000 and 2013 owing to the accelerated millennium development goals framework 3 similarly burundi recorded notable declines in infant and underfive mortality from 1101000 in 1990 to 861000 in 2011 strengths and limitations of this study ▪ a major strength of this study is the use of nationally representative samples in five east african countries to study the influence of womens birth history on their contraceptive use ▪ the study has affirmed the importance of considering womens birth histories in the promotion of contraceptive use in the east african region ▪ the study did not control for an important variable relating to decisionmaking on contraceptive use as there were many missing cases ▪ like any crosssectional study interpretations are limited to associations rather than causal relationships of the determinants of contraceptive use and from 1831000 in 1990 to 1391000 in 2011 respectively 4 in tanzania facilitybased deliveries increased from 44 in 1999 to 51 in 2010 5 6 despite this overall progress evidence suggests that the east african community region is still grappling with major gaps in access and quality in rmnch services 7 even though contraceptive knowledge is nearly universal in the region and contraceptive prevalence has increased in the past two decades the unmet need for contraception remains high in all the countries whereas proven strategies to reduce unplanned pregnancy such as increasing access to and correct use of effective contraception and contraceptive counselling exist on average only 46 of all sexually active women who would want to use contraceptives in east africa in 2012 could access them 8 9 research has documented an association between contraceptive use and unplanned pregnancy in some settings 10 11 12 13 poor use of shortterm hormonal contraceptive methods are known to be responsible for a high proportion of unintended pregnancies 11 other predictors of unplanned childbearing are residence ethnicity marital status low maternal education and maternal age 12 moreover a history of an unplanned pregnancy predicts the future occurrence of another unplanned pregnancy 14 however research on the links between the maternal history of an unplanned pregnancy and current use of contraception in east africa is limited 15 16 17 most of the evidence is based on studies from western contexts 15 16 matteson et al 15 demonstrated that a past experience of an unplanned pregnancy did not predict overall contraceptive use among young women aged 1425 years in the usa in contrast a recent study conducted in the urban slums of kenya indicated that women whose last pregnancy was unintended were more likely to be using a modern method of contraception compared to their counterparts whose last pregnancy was intended 17 the study found marked variations among these groups of women driven by their socioeconomic status unintended pregnancy was not associated with subsequent contraceptive use among poor women unlike among wealthier women however the generalisation of this studys findings to other settings in kenya or in the region is limited given that the study was done among urban poor women additionally the small sample size of the study limited the understanding of the issues to the urban setting these limitations should be addressed if the linkages between unplanned pregnancy and current or future use of contraception among the general population in the east african region and other regions with similar context are to be better understood this paper attempts to address this gap by using nationally representative samples to examine the relationship between pregnancy history and subsequent use of contraception among women aged 1549 years in the five east african partner states context in 2013 the eac consisting of burundi kenya rwanda tanzania and uganda was home to approximately 1435 million residents with an annual population growth rate of 29 18 in the same period the regional average maternal mortality rate stood at 469100 000 live births infant mortality was 621000 live births and child mortality at 981000 live births these data considered in the light of the high total fertility rate of 52 and a generally high hiv prevalence among partner states point to gaps in the knowledge and use of reproductive health information especially gaps in access to and proper use of contraception this is particularly so given that evidence points to the benefits of contraception such as reduced infant maternal and child mortality and preventionreduction of unwanted pregnancies that often lead to unsafe abortion 19 20 21 this context together with the fact that the eac partner states are increasingly cooperating in health through collaborative determination of health priorities and implementation of common policies strategies plans and investments makes the region a unique context for investigating issues of unintended pregnancy and contraceptive use among women of reproductive age methods data sources the study used data from the most recent demographic and health surveys in burundi kenya tanzania rwanda and uganda dhs are a series of nationally representative data collected by the respective countries and cover the areas of demography health and family planning the surveys are implemented by the respective countries governments in collaboration with development partners and with technical assistance from icf international the data sets are freely available to the public on application to measure dhs and require no further ethical clearance at the time of our analysis and writeup kenya had released preliminary dhs results for 2014 but the data had not been released dhs use a household questionnaire to enlist all members and visitors who spent the previous night in the selected households to capture basic demographic data such as age sex education and relationship to the head of the household the household questionnaire also collects information on household characteristics such as source of drinking water type of toilet facility and the type of material used for house construction the rationale for data collection on all members and visitors in the household is to identify women and men eligible for the individual interview the womans questionnaire captures the respondents background characteristics birth history and childhood mortality knowledge and use of fp methods fertility preferences antenatal delivery and postnatal care breastfeeding and infant feeding practices vaccinations and childhood illnesses marriage and sexual activity it also gathers data on a womans work and her husbands background characteristics her awareness and behaviour regarding acquired immune deficiency syndrome and other sexually transmitted infections in addition to adult mortality including maternal mortality knowledge of tuberculosis and genderbased violence the mans questionnaire collects information similar to that in the womans questionnaire except for questions on reproductive history and maternal and child health the surveys utilise a twostage sampling strategyclusters are first selected from the most recent population census sample frame and later and households are systematically selected from the clusters participants eligible for interview include all women of ages 1549 years and men of ages 1554 years who are either permanent residents of the selected household or are visitors who spent a night in the household before the survey to facilitate data collection at household and individual levels the surveys use model questionnaires developed by the measure dhs programme developed specifically for households women and men these questionnaires undergo slight modifications at country level to reflect demographic and health issues relevant to respective countries detailed information about sampling strategies and data collection can be found in the dhs reports for respective countries 14 6 samples used in this study are presented in table 2 and refer to women of ages 1549 years who were not pregnant during the survey had sex intercourse at least once in the month preceding the survey and had at least one birth variables contraceptive use which was the dependent variable was coded zero if the woman used a modern contraceptive method and one if she used a nonmodern method or did not use any method during the most recent sexual encounter the main independent variable was pregnancy history whereby the last pregnancy was categorised as wanted mistimed or unwanted in this analysis wanted pregnancies refer to pregnancies that were planned at conception or reported to have happened at the right time or later than desired mistimed pregnancies are those that occurred earlier than desired while unwanted pregnancies are pregnancies that were reported to have occurred when no children or no more children were desired other independent variables were grouped into three categories individual household and community individual variables included maternal age womans desire for more children and maternal parity household variables included maternal educational attainment household quintile of wealth religion media exposure at least once in a week through radio television or newspapermagazine and womans decisionmaking on her healthcare finally community variables consisted of a womans place of residence region and whether a woman had been visited by a fp worker in the past few months analysis all statistical analyses were conducted using ibm spss statistics v22 to account for the multistage sampling strategy adopted by dhs in the respective country surveys the study used the spss complex samples module to incorporate sample weights primary sampling unit and sample domain in all the analyses 22 logistic regression was used to first determine the raw effects of maternal pregnancy history in predicting contraceptive use among sexually active women in the second stage other individual level variables were included in the regression model to determine the gross effects of maternal pregnancy history in predicting contraceptive use table 5 shows the gross effects of maternal pregnancy history in predicting contraceptive use taking into account variables at the individual and household levels the last stage of the analysis shows the net effects of pregnancy history in predicting contraceptive use taking into account variables at a womans individual household and community level results descriptive statistics table 2 summarises sample characteristics of the five east african countries across the region women in burundi had the lowest prevalence in the use of modern contraceptive methods with the majority either using folkloric traditional or no contraceptive method during their most recent sexual encounter rwanda had the highest prevalence of modern contraceptive use in relation to pregnancy history unwanted pregnancies were highest in kenya while mistimed pregnancies were highest in uganda of the sampled populations the majority of women across the five countries were aged between 20 and 29 years resided in rural areas and had attained primary education logistic regression results table 3 shows unadjusted associations between contraceptive use and maternal pregnancy history of the five east african countries results indicate that maternal pregnancy history was a significant predictor of contraceptive use among sexually active women in uganda tanzania rwanda and burundi but not in kenya results of adjusted regression models are shown in tables 46 adjusting for other individual household and community variables maternal pregnancy history persisted as a significant predictor of contraceptive use in uganda rwanda and burundi and becomes significant in kenya women who had a mistimed pregnancy history were less likely to use a nonmodern contraceptive method or none at all during their most recent sexual encounter as compared to those who had a wanted pregnancy history in kenya rwanda and burundi in uganda women who had experienced either a mistimed or unwanted pregnancy were less likely to use a nonmodern contraceptive method or none at all during their most recent sexual encounter at the individual level a womans desire for more children persisted across all the five countries even after controlling for household and community variables women who desired more children had higher odds of using a nonmodern contraceptive method or none at all as compared to those who did not want more children in all countries and the ors were quite similar maternal parity persisted only in kenya and rwanda after introduction of community level variables an increase in the number of births was associated with an increase in the probability of using nononmodern contraceptive method maternal age was a significant predictor of contraceptive use at the individual level of the analysis but faded when household and community level variables were controlled for at a household level wealth was a consistent predictor of contraceptive use across all the five member states of the east african region taking into account other variables at the three levels of analysis compared to their counterparts in the richest wealth quartile women belonging to the poorest wealth quintile were twice as likely to use a nonmodern contraceptive method or none at all in uganda kenya and tanzania the ors were lower in burundi and rwanda maternal educational attainment persisted as a predictor of contraceptive use in uganda tanzania and rwanda after introduction of community level variables in uganda and rwanda women with no education were almost three times more likely to use a nonmodern contraceptive method or none at all than those who had attained higher education however the case was different in tanzania where women who had no education were less likely to use a nonmodern contraceptive method or none at all during their most recent sexual encounter other household variables that persisted as predictors of contraceptive use after adjusting for community variables were womens access to fp information through radio and religion having not heard about fp through radio was associated with higher odds of using a nonmodern contraceptive method or none at all in kenya tanzania and rwanda not being christian or muslim was associated with higher odds of using a nonmodern contraceptive method or none at all in kenya while the contrast was true in burundi where it was associated with less likelihood of using nononmodern contraceptive turning to community level variables significant incountry regional differences were observed in kenya tanzania rwanda and burundi after adjusting for other variables at the individual household and community levels in kenya women residing in the north eastern region were three times more likely to engage in sex using either no contraceptive or a nonmodern contraceptive as compared to those residing discussion this paper explored the relationship between womens pregnancy history and current use of contraceptives among women of reproductive age in the eac region several control variables were included to examine the effect of pregnancy history on contraceptive use the results indicate that women who had a mistimed pregnancy in their past were more likely to use a modern contraceptive method during their most recent sexual encounter in kenya rwanda burundi and uganda this finding suggests that womens decision to adopt a modern contraceptive method was significantly influenced by their past birth histories and that those who had mistimed pregnancies were more keen to avoid future pregnancy similar relationships have been reported in the few studies that have investigated the relationship between a womans pregnancy history and her contraceptive use patterns 16 17 of significance to this finding is the study conducted in the urban slums of kenya whereby unintended pregnancy history served as a wakeup call and led to increased use of modern contraceptive methods 17 other individual factors significantly associated with modern contraceptive use in our analysis were a womans desire for more children and maternal parity as expected a woman who desired more children was less likely to use a modern contraceptive method than other women in all the east african countries studied an increase in parity was also associated with a lack of modern contraceptive use in kenya and rwanda this is significant given the fact that women who have more children are likely to have unplanned pregnancies as a result of not using a modern contraceptive in these two countries these two results speak to the core of the high fertility rates noted in several east african countries 18 importantly it points to the major gaps in the use of contraception such as low access to fp services that could empower individuals to make informed choices with regard to use of contraception 14 6 the influence of household factors on contraceptive use is evidenced by the significance of household wealth maternal education and media exposure through radio wealth education and access to information inequalities were noted for women in the poorest household wealth quintile women with no education and those who could not access information through radio were more likely not to use modern contraceptive methods this finding is in tandem with findings elsewhere that have documented the importance of socioeconomic status in influencing contraceptive use 23 24 and therefore cannot be underestimated poverty lack of education and limited access to information are associated with higher fertility rates it has been suggested that the effect of wealth education and access to fp information on contraceptive use patterns could be through female autonomy and economic development 25 26 socioeconomically empowered women are likely to afford modern contraceptive methods make independent decisions on matters affecting their health and most importantly take advantage of the existing health services as evidenced in several studies 27 28 29 30 31 controlling for individual household and other community factors this study noted substantial withincountry differences in relation to contraceptive use apart from uganda other countries showed greater heterogeneity in their regions for example in tanzania sexually active women in zanzibar lake and western regions were over 10 times more likely to use nonmodern contraceptives compared to women sampled in the southern region these significant differences within countries in the use of contraceptives could be a reflection of existing regional disparities in economic development cultural orientation and may in part mirror inherent inequalities in the provision of healthrelated services across regions strengths and limitations a significant strength of this study is the use of nationally representative samples to study the influence of womens birth history on their contraceptive use in five east african countries we also grouped possible predictor variables into distinct levels of analysis to study individual household and community factors capable of influencing womens decision in contraceptive use a major limitation of this study is the failure to control for an important variable relating to decisionmaking on contraceptive use despite the availability of this variable in dhs data there were many missing cases nonetheless we used womens decisionmaking ability about their own health as a proxy for their autonomy in using contraception we also did not take into account cultural variables in our regression equations lack of variables that could measure cultural influences in dhs data sets is a limitation especially when studying behavioural practices that are highly influenced by cultural norms of the study populations it is important to bear in mind that this study used crosssectional survey data and therefore interpretations of findings in this study are limited to associations rather than causal relationships of the determinants of contraceptive use conclusions and recommendations this study has demonstrated that women with a history of a previous mistimed pregnancy were more likely to be using a modern contraceptive in the east african region differencesvariations in geographical residency educational attainment access to fp information and products and wealth accumulation play a significant role in regard to fp access these among other differences and inequalities should be addressed decisively as part of any upcoming strategic interventions to improve access to reproductive health services effective data collection analysis and use for decisionmaking would be key in highlighting and addressing such differences and inequalities thereby equitably expanding the health benefits of regional integration in the region as outlined in the 4th eac development strategy 32 2024 by guest protected by copyright bmj open first published as 101136bmjopen2015009991 on data sharing statement no additional data are available contributors pb conceptualised the study participated in the interpretation of the data managed the literature searches and wrote part of the first draft of the manuscript djm partly conceptualised the study ran the statistical analysis and wrote part of the first draft of the manuscript ma contributed in the analysis and writing of the manuscript ra jr cm and da contributed to the drafting of the manuscript all authors read reviewed and approved of the final manuscript competing interests none declared provenance and peer review not commissioned externally peer reviewed

objective to examine the relationship between pregnancy history and the use of contraception among women of reproductive age 1549 years in east africa methods demographic and health surveys data from burundi 2010 kenya 20082009 rwanda 2010 tanzania 2010 and uganda 2011 were used in the analysis logistic regression was used to determine the effects of womens pregnancy history on their use of contraception

female 22 having poor balance 85 having limits in doing vigorous physical activity 71 having limits in performing moderate physical activity and 635 having pain interfere with normal activities about half had financial problems sometimes and 68 reported living with a spouse and children 30 had hypertension and took antihypertensive medication 16 felt tired most of the time and 11 felt nervous all the time we found that urban older adults had a higher fall rate than rural older adults urban older adults also had a higher level of fear of falling than rural older adults additionally urban older adults had significantly worse general health than rural older adults there were no significant differences in balance performance and fall selfefficacy scores it is important to recognize and identify fall risk factors among urban older adults and provide access to systematic communitybased fall prevention programs incorporating screening and tailored interventions based on those risk factors session 2390 abstract citation id igad1040786 engaging in artistic and creative opportunities to help understand the aging experience chair alexander bishop cochair melinda heinz discussant victor fung this symposium provides an overview of artistic and creative engagement methodologies to understand aging experiences the first presentation examines a collaborative effort involving a researcher and filmmaker to film edit and produce a documentary about irish mens sheds to increase awareness of diversity within the dissemination of narrative stories the second presentation focuses on drawing investigating how young children socially and cognitively represent perceptions of human longevity and of the concept of what constitutes old children were asked questions regarding what it means to be old and what they might look like at 100 years and to draw a selfportrait image findings demonstrating internal working models consistent with sociallylearned attitudes beliefs and stereotypes of aging the third presentation explains digital narrative gerontology and a life story project of the older adults life created by younger and older adults thematic analysis revealed improved wellbeing reduced generational stereotypes and feelings of loneliness and isolation the fourth presentation details an intergenerational project involving university students and older adults with cognitive impairment participants engaged in a sixweek telephonebased reminiscence experience and then cocreated a storyboardscript to create a digital story thematic analysis demonstrated six themes family religion and purpose in life loves and hates careerwork stresscoping and major life turning points the final presentation details music as a therapeutic intervention to improve older adults quality of life and foster social connections selfunderstanding and expression observations from working with older adults in a variety of environments and preferred music styles will also be discussed creating a documentary capturing the narratives of men attending irish mens sheds melinda heinz 1 and laura gleissner 2 1 upper iowa university fayette iowa united states 2 university of northern iowa cedar falls iowa united states how do we engage more individuals to consider and care about issues impacting older adults diversifying the mediums of how older adult stories are told offers one solution filmmaking is one medium where the narratives of older adults can be captured seeing and hearing directly from older adults speak about the issues that affect them provides a distinct way to understand experiences of aging i interviewed men in county limerick about how mens sheds promoted purpose and meaning in the lives of older men after transcribing each interview i partnered with a filmmaker to help create a documentary to tell the story of how mens sheds create an inclusive atmosphere for older adult men to continue feeling useful in older adulthood this presentation will explain how researchers who conduct interviews with older adults are uniquely positioned to collaborate with filmmakers to help tell the stories of older adults the aim of this investigation was to understand how young children socially and cognitively perceive human longevity through drawing data for this study were collected from young children ages 3 to 6 enrolled in prek and kindergarten classrooms through a universitysupported early childhood education center investigators first conducted brief openended interviews to gauge participant understanding of the concept of being old participants were then asked to draw a selfportrait image of what might look like at 100 years of age finally participants were asked to describe their picture as well as share a story regarding the selfportrait image they had crafted images were decoded and analyzed relative to depicted content pattern and position and color preferences findings highlight reliance on internal working models which appear to highlight socially emergent and learned attitudes beliefs and stereotypes about growing old further discussion relative to underlying indication of emotional development will be highlighted abstract citation id igad1040789 digital narrative gerontology as bridges between generations to improve wellbeing learning and shared experiences béatrice crettenand pecorini and emmanuel duplàa university of ottawa ottawa ontario canada elders are an essential society component for the collective success of the demographic transition for social inclusion and the fight against ageism ageism discrimination by age is a very present concern one way to respond to this challenge is to build bridges between generations in society intergenerational programs can reduce the perception of stereotypes about other generations strengthen intergenerational solidarity and help develop capital and social cohesion based on the theories of lifelong learning and intergenerational learning our research engages digital narrative gerontology we have organized several meetings in pairs where each pair created a digital narrative from the oral narration of the elder life story supported by the multimedia skills that the young adult acquired during the workshop we have set up from individual and pairs semidirected interviews logbooks debriefings and digital narrative based on case study thematic analysis our preliminary results confirm the results obtained in 2019 improved general wellbeing reduction in the perception of generation stereotypes reduction in feelings of loneliness and isolation strengthening intergenerational solidarity satisfaction to rediscover ones life or the projection of ones life stimulated by example new knowledge acquisition as well as the pride of artifact creation and its sharing this innovative project can be applied in schools colleges and universities as well as in community centers and seniors residences reminiscence strategies combined with an intergenerational approach may yield social and mental health benefits for older adults with cognitive impairment there is also evidence to support the use of digital storytelling with persons with cognitive impairment combined with intergenerational programs dst typically involves the production of a twotofiveminute audiovisual clip combining text images music photographs voiceover narration and other audio however there are few studies that combine reminiscence dst and an intergenerational approach with persons with cognitive impairment the current study is a thematic analysis of dst products created by university students in collaboration with older adults with cognitive impairment as part of a larger project examining how intergenerational reminiscence using dst may improve the social and emotional wellbeing of persons with memory loss after the completion of a structured sixweek telephonebased reminiscence the younger and older adults cocreated a storyboard and script as well as selected photos and music to accompany the narrative in the dst an interactive team approach using the phases of thematic analysis of the dst products resulted in six themes 1 family 2 religion and purpose in life 3 loves and hates 4 careerwork 5 stress and coping and 6 major life turning points subthemes included childhood and early adulthood family legacy faith volunteering travel music and resilience findings from the study extend current research by examining intergenerational connections reminiscence and the use of dst with persons with memory impairment we close with recommendations for practice and research

this study aimed to examine the prevalence of falls fear of falling fof activities of daily living adl and quality of life qol in communitydwelling older adults in thailand a crosssectional survey of 433 communitydwelling older adults was conducted we used a simple random sampling method to recruit urban and rural adults aged 60 years and older from 23 districts in thailand the measurements included demographics fear of falling history of falls qol the modified barthel adl chronic diseases and medications data were analyzed by using both descriptive and inferential statistics among the participants 453 reported having at least one fall in the past year and 80 reported high level of fear of falling compared to nonfallers and persons without fear of falling fallers and persons with fear of falling were more likely to have at least one chronic disease hypertension and stroke fallers and persons with fear of falling were more likely to take more medications or antihypertensive drugs daily activities including eating bathing dressing toileting and walking differed significantly between nonfallers and fallers p 001 for all and between persons with and without fear of falling p 001 quality of life measures also differed significantly between fallers and nonfallers p 001 in conclusion fallers and persons with fear of falling were more likely to have poorer health more medications lower quality of life and different daily activity patterns future interventions should consider the differences between fallers and nonfallers and persons with and without fear of falling

introduction folk literature is a collection of the traditional values behaviors and narratives of a society that have been verbally transmitted down the years it is the collection of practices and tales that have been passed down orally through the generations it includes the unwritten traditions of a community the development of the discipline of folk literature coincided with the growth of romantic nationalism in the late 18th and early 19th centuries folktales from the countryside started to be collected and published by figures like the brothers grimm oral transmissions of stories were collected and preserved as permanent collections many of the tales were later published as childrens books and were taught to kids in schools or by their parents folklore has played a significant role in national freedom movements ever since the job of the storyteller in early human societies was similar to that of the historian in modern times which was to preserve the past by recounting its events in the late 18th and early 19th centuries under the influence of romantic nationalism the field of folklore evolved globally pakistan has a rich history of oral folk literature which goes back to time folk lore tradition undergoes a change with the changing in the oral and written discourses around the globe art is mostly assembled or fabricated for two classes the elite and the general public in the beginning the main focus of art was social issues but later on it expanded its role to include communities and their problems in everyday life art has different forms and truck art is one of them which is solely a representation of pakistani indigenous culture and only one of its kind throughout the world it has analogous status it does not only represent the communities to which it belongs rather it offers a mixture of ideologies philosophies narratives and parables it should be valued in the same way as other fine arts in particular differences in the design and content of the decor reflect changes in the status of religion in pakistani society the way a vehicle is decorated it discloses a lot about the religious identities of the persons involved truck poetry is a stunning form of art of pakistani culture that is aligned with those who work in the automotive industry such as vehicle drivers painters and designers these individuals obviously go to great lengths and put in a lot of laborers to create a distinctive work of art that is written with powerful verses and comments and embellished with the most exquisite pictures that are both a source of pleasure for the viewers and a way to peep into the lives of all this art give painters some insight on how to communicate through writing on vehicles in a culture rich of poets and thinkers who offer a lot to express through words in his book on truck art and how it reflects the specificity identity society and culture of its drivers elias noted that the initial study or research on this type of art was carried out in afghanistan in the 1970s subsequently numerous researchers from all over the world turned their curiosity to truck painting as a form of art epigraphs are the most fascinating aspect of a truck decoration which consists of various lyrical passages together with the owners name or a local proverb unknown unrecognized poets are hired to create poetry truck inscriptions in their native tongue for truck owners in pakistan writing on public transportation vehicles is a relatively prevalent occurrence while travelling on pakistans highways one can see various texts on several public transportation vehicles this material is written in a variety of styles on the vehicles including quotations slogans poetry phrases and occasionally only words and images this text includes wisdombased religious romantic and humorous messages and occasionally draw attention to the existence or absence of moral and ethical standards or socioeconomic issues they also convey a persons affection for their country beloveds parents or religion additionally political messaging has begun to take up residence on the automobiles according to discourse is the sequence of sentences it concerns the connections and relationships between sentences in voice and writing across time he asserts that a speaker or writer chooses a particular order to arrange his words and sentences when speaking or writing a postmodernist continuation of cultural traditions truck art and its artists contributed to pakistans national identity the influence or characteristics of the art surrounding us do not take a single form it has innumerable designs varieties kinds displays and styles this research aims to focus on the portrayal of indigenous culture folklore and its application to modern society and to originate meaning through the art that is written on the rare view side of the truck in the form of poetry although it is considered a low art form it conveys messages on a much larger scale this form of art is the best source of communication as the images portrayed in truck art are not merely supposed to be observations of nature rather they reveal something about the philosophical views of the artists truck bodywork is meticulously painted by trained painters all painted symbols and motifs have either been passed down from generation to generation or copied from photographs and periodicals the research aims at originating and analyzing the data twofold at the narrow level the focus is to delineate the importance of truck art and at the wider level the focus is to explore or construct the meanings through the art that is being written on the rear side of the trucks in the form of poetry in a very colourful manner the study encompasses the social issues political strife and embedded ideology under humorous chunks depicted on the images taken from the vehicles which is an insight to the prevailing conditions in pakistan significance of the study in the context of indigenization and its culture different the academic and research oriented activities are evident but research on folk literature with reference to logistic vehicles has not been studied so through this research the readers and audience will comprehended and understand the importance of their local norms and traditions through the representation of folk literature displayed on logistics vehicles literature review folk literature is the sole representation of the indigenous culture and the ethnic diversity of a nation presented in different modes and channels not only written and academic literature is elusive but apart from the said other modes are prerequisite whereas in pakistani society different vehicles are the sole representation of folk literature where poetry and images are replicated in accordance with the said the current research is undertaken to examine the implications of folk literature depicted on logistic vehicles like trucks the term indigenous people refers to several socioeconomic and cultural groups that have shared ancestral links to the lands and natural resources that they currently reside on or have been displaced from the land and natural resources they rely on are integral to their identities cultures ways of life and overall bodily and spiritual health so it is knowledge or any reliable information that is specific to a particular culture or community and is held by indigenous peoples although vehicle adornment is widespread throughout the world according to elias pakistani truck art stands out for its scale and uniqueness because nearly every square inch of the trucks and buses is lavishly decorated with handcrafted paintings and decorations like mirror work dangling chains pendants decorative wood carvings and reflectors the study on semantic analysis of the language delineates the importance of meanings the study of semantic meanings involves the study of meanings of words sentences and utterances as well as sentences which are used in context a research on connotation delineates different definitions of connotation it is the sentimental associations or the emotional and imaginative association surrounding a word that it evokes which is necessary to be similar among two members of the same community similarly another research on stylistic meaning shows that language is used to establish and regulate social relations and to maintain social roles the study on the decorative truck as a source of communication delineates the importance of poetry quotes and verses written on the back of the truck which have some meaning associated with the specific culture sometimes they are very deep in nature the study on language explores that language is not just a source of communication or exchange words between people rather it has become a commodity to earn money it is in the business world the most powerful device of exposure delinquent to its alluring nature ethnography is an approach to the study of language and social interaction as observation of the data is done in the field with an emphasis on a more active role that involves multiple cognitive modes such as observing questioning and scrutinizing the truck art has been observed as a byproduct of a local culture that values and upholds the value of using pictures paintings and other visuals to communicate and convey the societys public face this type of moving art represents many religious mythical cultural social political and folk topics and can be thought of as a form of visual language and expressive communication the heavily painted and decorated vehicles are a wellknown aspect of pakistani culture another research paper on truck art as arena of contest explores viewing pakistani truck art as a type of popular culture with a promising future as a venue for competition the research paper on the visual semiotics of truck art thoroughly examines several fundamental ideas from the field of visual semiotics to investigate the significance of the artwork displayed on trucks in the punjab region the signage on trucks can shed light on local trucking cultures and the meanings that different signs on trucks negotiate when considered in the context of the sociopolitical and cultural knowledge of the area since most of these drivers spend days away from home a truck is like a second home to them in these circumstances the truck becomes the drivers friend which he decks out and exhibits with pride as though it were his home the research on visual rhetoric framing the methodology for truck visuals through visual rhetoric theory and rhetorical appeals explores the cultural importance of truck art visuals by using an ancient relic theory named visual rhetoric visual rhetoric aims to help identify meanings and look at the variety of texts and imagespictures in steve evanss study the impact of cultural folklore on national values conducted in bhutan is about the uplifting of the local and indigenous cultures which have been represented on different painting similarly a study of folk literature reflects the culture of the people who created it it reveals the cultural nuances of the people disbelieving their own perceptions while offering hints about historical events and their antiquated traditions therefore it is crucial to grasp the cultural background in order to comprehend the folk literature of a community or group of people methodology data collection data has been collected from the social website instagram as it is an emerging trend to use this truck art codes to convey messages not only in a humorous manner but also for the political and religious purposes they do carry such signs and codes which is shared by both the participants and impart successfully what they can not say directly sampling technique and data classification the researcher has taken 25 images from the trucks shared on the said website and shortlisted 3 images in the each category discussed below as far as their diversity is concerned 1 political strife 2 socioreligious concerns 3 humorous chunksversesphrases embedded messages for youth theoretical framework this study takes dell hymes speaking model as the lens to examine and explore this indigenous side of our culture as this language model describes language not in the way it should be spoken but how it has been spoken in the real life while being at the field not in the lab our social and cultural settings do not take language in the perfection as perceived by cognitive and structuralist schools one must learn not only its vocabulary and grammar but also the context in which words are used to get the meanings in entirety hymes ethnography of communication considers language used in specific context along with the time and place it is spoken in not language in isolation hymes speaking model consists of sixteen components that can be applied to many types of discourse message form message content setting scene speakersender addressor hearerreceiveraudience addressee purposes purposes key channels forms of speech norms of interaction norms of interpretation and genres these sixteen elements are grouped in eight categories by constructing an acronym for the said purpose as given below data analysis pakistan is a country enriched with cultural diversity and multiplicity of languages which created a unique blend of value system followed by the residents of different regions this shows the importance of social and historical background of our indigenous culture which is the point of discussion in this study folk traditions in the form of literature story telling creative writing skills and artistry of the workers in different fields arts food behaviors traditions and norms faith and language unite us in one string names pakistan this paper studies language on the rear view side of the trucks transmitting messages and creating meaning for the public in the current pakistani scenario with respect to hymesspeaking model which reveals how folk literature specially language of a particular region creates meaning by using the same code and applying different signs the data collected for thus purpose divided into three categories which is discusses one by one in section below representing political strife this first section of the analysis deals with the running political strife in the country and how with the aid of poetry in different languages truck divers catches the attention of public by utilizing the trucks as a medium and poetry as a genre to deliver their messages the pictures selected for the study by applying the speaking model are figure 1 situation as far as the situation is concerned the setting and scene of all the three images are informal and participants are far away from each other a kind of setting where adressor has imprinted the message on the rear view of the vehicle and addressees are anywhere and everywhere passers by or onlookers somewhere on the roads participant the participants of the first image ie koee manzur e nazar shaks he haara hogaa tab hi elaan huwa khel dubaara hogaa are the addressor and adressee masses and social institutions who have been involved in favoring the powerful people unlawfully it is an obvious and clear indication of the social injustice which has deprived the masses from their basic right of social equality whereas in the second image ie rakh kar raasty main nafarton k container tum ny dil ko islamabad bna dala apparently a lover is reprimanding his beloved but this analogy of using containers road blockage and not letting anybody come close is directly pointing towards the political upheaval in the country which has made life hard for people and they dont have anyone to approach for the solution of their problems as public administrative institutions and political parties are at battle ground for power gain so here participants on the apparent level are lover and beloved whereas on a deeper level the adressees of this verse is our political system which is making things hard for people as portrayed in the capital islamabaad similarly in the third image hun ghin mazy tabdiliyaan dy there is an obvious qlantic journal of social sciences volume 4 no 3 stance of addressing the masses by the truck owner on the plight they are facing due the political slogan of change raised by the particular political party to catch the voter by a positive sign change but the things got worse while pursuing this slogan so the adressor is actually angry at the decisions turned out foolish on the part of the public who voted and selected that particular party including himself ends the letter e stands for ends in the speaking model proposed by hymes it describes the anticipated outcomes of a trade as well as the participants personal goals to accomplish on particular occasions the goal of the first image ie koee manzur e nazar shaks he haara hogaa tab hi elaan huwa khel dubaara hogaa expresses that the speaker wants public to know the reason of social injustice prevailing in the country which is not permitting people to grab the opportunities offered them equally by the state and their religion too but deprived of due to favoritism and nepotism power dynamics in our social system intersects people at every ground and in every field without any hindrance whether issues are official or nonofficial similarly the second image ie rakh kar raasty main nafarton k container tum ny dil ko islamabad bna dala is an ironical statement from the owner of the truck where he apparently addresses his beloved who is putting hindrances before him to stop him from the very action he is going to perform but indirectly he is commenting on the political situation being observed in the capital the ends of this situation according to hymes is public awareness regarding haphazard state condition the institutions and people who are responsible and making it worse day by day the sender of the visual message is very clear in his intentions to highlight the issues which is achieved successfully when travelers comprehend this message that is why the language of the visual messages and images painted on the trucks are aligned and do compliment each other to convey it fully in the local codes image three ie hun ghin mazy tabdiliyaan dy serves the purpose of the resulted situation in the above two cases imprinted on the trucks shared by the owner in the image one and two respectively so the aim of the sender of this visual message is to reprimand people and tell them to bear this situation as it is the outcome of their own action done previously act sequence the acronym a stands for act sequence it refers to the particular words used in the communication how they are employed and the relationship between all selected phrases the message form used in the all three images is formal as urdu is the national language of pakistan punjabi saraiki pashto represents regional languages written on the rear view side of the truck so the code used by the truck owner makes situation meaningful when evaluated contextually as per pakistani political history whereas the content of the message is inviting in sense that it allows to ponder upon the situation when someone reads koee manzur e nazar shaks he haara hogaa tab hi elaan huwa khel dubaara hogaa rakh kar raasty main nafarton k container tum ny dil ko islamabad bna dala and hun ghin mazy tabdiliyaan dy these three visual messages actually follow the act of sequence as highlighted in the model which expresses the heartfelt criticism of the truck driver like an experienced analyst who is commenting on the regime change and the aftereffects of that change the very word tabdeeli shows the abstract psychological contexts of the situation instrumentalities the alphabet i mentioned as instrumentalities refers to the method of communication whether it is oral or written and speech pattern that can be language dialect code or register the language which is shared by the speaker and the listener both also called code which can be written or oral the method of communication used in the selected images is written whereas the speech pattern is formal national language urdu in the first two images ie koee manzur e nazar shaks he haara hogaa tab hi elaan huwa khel dubaara hogaa and rakh kar raasty main nafarton k container tum ny dil ko islamabad bna dala and a dialect of saraiki a regional language in the third image ie hun ghin mazy tabdiliyaan dy norms norms extracted from n represents social standards that regulate an activity the actions and reactions of the participants or customary laws that direct behavior in speaking interpretation standards are equally crucial especially on events and generally crosscultural exchanges similarly court cases or employment interviews if norms are not taken into consideration may result in serious consequences the social norms that direct behaviors are followed in the selected images as no one called bad names whether the written messages are formal or informal as in hun ghin mazy tabdiliyaan dy the contextual situations are handled well as in rakh kar raasty main nafarton k container tum ny dil ko islamabad bna dala so that nobody gets hurt by those exchanges and the message might not get lost due to the biased attitude of the sender genere genre is referred as g in the speaking model hymes presents the last and most important feature of the speaking model is genre which attracts people more as poetry and phrases of local language are more direct and appropriate in nature to convey what is hidden hence this discourse generates a course for the uneducated as well as educated class by utilizing local regional and folk traditions of literature to convey their message so mostly the genre of poetry along with phrases are usually selected by the truck owners to communicate in formal as well as local languages as in the above selected images they do have a directness in phrases and symbolic references in poetry which express their intentions as well as save them from possible negative circumstances they have to face otherwise socioreligious concerns the second category of the data is based on the contextualization of the religious knowledge and through that symbolically giving a word of wisdom to the onlookers to focus on the believes they have inherited from their ancestors and from their religious practices to have a better society for living our social system does reinforce those believes somehow being social animals we propagate the ideology we live through same concepts reflects in our day to day life our professional life and our cultural fabric has been woven with the same social and religious threads pakistan is having a diverse religious background where people of different ethnicity and different religious backgrounds creates a blend of thoughts and beliefs which runs through the young blood and the forthcoming generations obviously this indigenous trait of the country gives nation a sense of unwavering faith that although they are different from each other in their belief system and local languages yet they are living in harmony due to the faith they have and the teachings these believes impart to people the images under evaluation are figure 2 situation the tacit rules and expectations surrounding the speech event are usually considered as the setting and scene the location determines who should and shouldnt speak what speaking style is appropriate and when an interruption is allowed same is the case with above presented images where interruption is not possible however other tacit rules and expectations apply at social events and in the workplace which have some limitations observed by both the addressor and addressees in this study the scene affects the overall mood and context as here in the given images which are taken on roads and most of the times viewed by people while traveling ends end defines the central idea and sensing of the sender to monitor whether the aim is being reached or not the gap the gap between a priori mutual understanding and lack of it can therefore be bridged if sensing is provided so the first visual naa surat buri na seerat buri bura wo hai jiski neeyat buri conveys the message aptly as no analogy or rhetorical devices used by the sender which shows that he wants to keep it simple as per his targeted readers onlookers second image ie jaga gee lagaany ki duiyaa nahi hai ye ibrat ki jaa hai tmaasha nahi hai does reveal the philosophical yet religious mindedness of the truck owner who is trying to describe the transitory stay of human beings in the world and if they forget the day of judgement then karma always plays its role to expose the hidden intentions of the humans by punishing them here in the world the same image has another message as maan ki dua jannat ki hawa displaying the importance of females especially mother in pakistani society whereas the third image ie gutugu hum sy or khyaalon main koe or haal aapka bhi hmaari nmaazon jesa hai is a clear indication to avoid worldly attractions which mislead human beings and they lost their connection with god as being a hypocrite religiously act sequence it refers to the actual format and content of the message and how the sociocultural context of speech in a particular speech community affects both the messages form and content the data is related to sociological context and psychological links shared by the the sender so the there is a strong relation between all selected phrases and chunks as naa surat buri na seerat buri bura wo hai jiski neeyat buri jaga gee lagaany ki duiyaa nahi hai ye ibrat ki jaa hai tmaasha nahi hai or the phrase haal aapka bhi hmaari nmaazon jesa hai all carry religious connotations as content the form used in the messages is understood by people easily key as it defines tone style manner and the spirit of the given message the printed messages do have a serious tone while manner of the message sender is quite religious as in maan ki dua jannat ki hawa and philosophic such as in the image two jaga gee lagaany ki duiyaa nahi haiye ibrat ki jaa hai tmaasha nahi hai the style of the these visual messages is expository as the truck owner wants to explain and educate its readersreceivers rather than entertaining or attempting to persuade them in other words this kind of style is used to expose facts instrumentalities in order to comprehend the message both of them must use the same code to communicate with each other both the sender and the recipient are permitted entry and stay if they have a contact a physical conduit and a means of a psychological link instrumentalities of the current discourse on the rear view side of the trucks include certain features such as a range of formality and a sense of seriousness whereas the sender and receiver both share a psychological link with code used on the trucks they are efficient enough to understand urdu punjabi and saraiki the codes used here are very much familiar to the masses and they often use them in their conversation as maan ki dua jannat ki hawa is common among every one of them norms the language of poetry written on the trucks in pakistan is a rich and varied reflection of the linguistic cultural and social context in which it is produced and consumed the use of regional languages simplicity directness the metaphors and symbolism all contribute to its unique cultural significance and norms followed by the folksbecause some or the other in floating these visual messages truck owners are displaying there centuries old norms traditions and cultures as the very word neeyat in the first image the transient nature of life in the second image ie ye ibrat ki jaa hai tmaasha nahi hai the value of a mother in our lives in the phrase maan ki dua jannat ki hawa and a message to be sincere and avoid hypocrisy in the third image ie gutugu hum sy or khyaalon main koe or is embedded in the folk traditions of pakistan irrespective of region or creed genere another important feature of truck poetry is the language the use of metaphor and symbols to convey complex ideas and emotions in a simple and direct way for example a poem about longing for a loved one may use the image of a bird flying toward its nest to convey the speakers desire to be reunited with their loved one in addition to its linguistic characteristics the language of truck poetry also reflects the social and cultural context in which it is produced and consumed the very first image naa surat buri na seerat buri bura wo hai jiski neeyat buri expresses the hidden religious belief on which major social behavior is settled as the very word neeyat shows that if this belief seeps deep down to avoid may discrimination and status issues on the basis of color cast and creed which will bring positive social change similarly gutugu hum sy or khyaalon main koe or is symbolic in the sense it advises us to be loyal to god as he demands obedience and complete submission to him but we lack that embedded humorous chunks the third section of the data is consisted of humorous chunks and statements with embedded meaning for the masses the selected data consists on two languages urdu and punjabi vernacular which actually highlights diversity of the characteristics a society can have as whole codes are interpretive frameworks which are used by both producers and interpreters of texts in creating texts we select and combine signs in relation to the codes with which we are familiar in order to limit the range of possible meanings they are likely to generate when being read by others following images are evaluated in this section to understand the motives behind these humorous chunks figure 3 situation the setting refers to the time and place of a speech act and the physical circumstances under which it is spoken the location of the participants or any hindrance lies between them are also part of the framework such as the participants are facing each other their body language and they are separated by a table or space in the room as here in image i dil braay farokhat qeemat sirf aik muskurahat image ii saanu lutt kay khaa par chadd k naa jaa and image iii fasla rakhein warna pyar ho jaiga are spoken on a lighter note but it is a portrayal of youth and their emerging engagements which not not only gives a visual treat but a satire on the selfishness and degeneration of the values maintained by our forefathers ends it refers to the speech acts goals and real results we speak of outcomes when we talk about ends occurrences and goals the messages sender and recipient can assist one another in achieving goals by enunciating their phrase using an animated voice and appropriately pronouncing words using nonverbal cues to convey ideas further aids in communication clarification here the results achieved when a passer by or people on the road passes a smile to the driver wave his hand or make some gestures as thumbs up sign etc to show that the purpose is fulfilled as in the image i dil braay farokhat qeemat sirf aik muskurahat image ii saanu lutt kay khaa par chadd k naa jaa it provides entertainment as well as a serious message on the plight of youth who are not serious about their life and wasting it in such frivolous activities act sequence the selected chunks for the study both sender and receiver are not present there in person yet they have that connection of shared knowledge context and code which creates a bond of friendship among them as saanu lutt kay khaa par chadd k naa jaa can only be said jokingly to stop somebody from leaving himher in the real sense similarly dil braay farokhat qeemat sirf aik muskurahat is the outcome of a happy go lucky state of mind for the speaker and listener the sequence of the words arranged in a manner that aggravate the lively situation if spoken in front of somebody or a group of people key the manner of the speaker truck owner is humorous and carefree attitude of the speaker who is friendly enough to portray what youth feels and expresses openly the truck owner speaks in a lighthearted tone in the selected data taken from the truck poetry and he is quite in high spirits it feels that there is no age gap between both the persons sender and receiver instrumentalities for a successful communication the codes must be shared by both the participants because codes provide a framework within which signs make sense we cannot grant something the status of a sign if it does not function within a code here the codes used by the truck owner is common enough for the receiver as urdu and punjabi used on a large scale in the country as per population of the punjab province the data selected for study do not have any symbolic language or terminology which receiver can not understand as people do quote such phrases on and off norms truck poetry is often created and consumed in a social context with truck drivers and other travelers sharing and discussing the poetry with one another this social aspect of truck poetry is an important part of its cultural significance as it reflects the social ties and connections that exist within pakistani society as saanu lutt kay khaa par chadd k naa jaa is used to show loyalty and solidarity to ones friends and family as one doesnt want to lose them genere it refers to demarcated types of utterances for example poems proverbs riddlesermonsprayers lectures and editorials etc but there is no such thing as a complete language all languages are sporadic incomplete and can be compared to a web of utterances the poetry is metaphorically referring to the idiomatic language in different context of pakistan such as in image one dil braay farokhat qeemat sirf aik muskurahat image two saanu lutt kay khaa par chadd k naa jaaand image three fasla rakhein warna pyar ho jaiga all embedded in the contextual settings of the society where youth do pass such remarks verbally in the written mode and through their body language as well to attract any possible lover whereas these humorous chunks ironically used on the trucks through visual messages with the purpose to scold the lover that the attention is not given however the fact truck drivers contextualize the said for the road safety as hymes setting of the discourse is contextual whereas the referring one is about to keep other vehicles distant because of road safety instructions by cops that keep distant space from other vehicles conclusion poetry is the core artifice that has been the frequent art of representation on truck vehicles though it is the traditional facet and representation of folk literature but on the other hand the poetry has pragmatic perspectives truck decoration is one of the common practices that are performed in pakistan where almost all trucks are embellished with a diversity of figurative imagery epigraphs repetitive patterns of language symbols and poetry they are a representation of indigenous culture through the language in real life and the paintings of different symbols of those unique local cultures the language contextualized in this way produces a meaningful written discourse which convey messages of the truck owners about a political social religious or psychological situation which has been observed by them and they want to share that with masses infact they are developing a public opinion by presenting their critique on the issues mentioned above which is reshaping the whole scenario nationally

the current study examines the relation of culture and language conveying a range of forms resulting in diversified meanings contextually enriched with a visual representation pakistani culture presented on vehicles such as trucks and public transport buses rickshaws and coasters are also the representation of the indigenization of the cultures through respective languages the data has been collected from the truck pictures frequently shared on instagram for the propagation of indigenous culture language and business purposes to attract customers by putting those phrases and verses written on the rear view side of the trucks a qualitative approach has been implied to evaluate the data whereas the nature of the study is analytical using the images the main objective of the study is to analyse the visualized and scripted poetry with reference to hymes social interaction model of speaking 1974 as a theoretical framework the research suggests that the representation of folk literature on truck vehicles gives us glimpses of the public opinions such as political system social injustice economic injustices and more prevalent issues in the countrythe findings of the study signifies that indigenous languages permeate the message through printed stuff on trucks

introduction aging is a worldwide phenomenon more than 15 billion people will be aged 65 and over accounting for 16 of the total population in 2050 the concurrent increase in the nuclear family as well as the aging population implies that a number of older adults will have an emptynest experience emptynest elderly refers to the elderly with no children or those who do not live with children but with a spouse or alone the problem with emptynesters has become more acute in china in 2010 the number of emptynesters aged 60 years and above accounted for 50 of the total number of the elderly which is expected to reach 90 by 2030 the onechild policy acceleration of urbanization and imbalance of economic development are considered as major catalysts contributing to this situation the diabetes prevalence rate is also rapidly increasing among the elderly population of china china has the largest number of diabetics worldwide aged 65 and older along with a deepening social aging more than 95 of these individuals were type 2 diabetes mellitus an emptynest status has a significantly adverse influence on different areas of elders health such as cognitive ability psychological health and physical health and emptynest elders had significantly poorer health than nonemptynest elders owing to less economic support spiritual consolation and daily care from adult children selfcare is considered to have an important role in improving the quality of life and delaying the occurrence of complications a high level of selfcare is associated with improved blood sugar control and reduced allcause mortality ma conducted a crosssectional study to explore the impact of emptynesting on selfcare among older adults with diabetes the results indicated that selfcare in terms of diet physical exercise blood glucose monitoring medication and foot care were poorer among emptynesters than those living with children the results may be related to the disconnection between emptynesters and adult children relatives and friends which can lead to an inadequate knowledge of dm selfcare and a limited number of information sources the experiences of selfcare among emptynest elderly with t2dm have not been investigated this study calls for more attention to the selfcare needs of emptynesters with t2dm a more comprehensive understanding of their experiences with managing diabetes can shed light on their unique needs and corresponding care advancement understanding what emptynesters realize about their condition and what influences their motivation is needed for health care professionals to recognize barriers to effectively managing and controlling diabetes materials and methods study design a descriptive phenomenological design was used in this study the main methodological consideration of descriptive phenomenology is to describe explore and analyze a phenomenon in adequate depth and breadth so as to elucidate the comprehensive picture of interest descriptive phenomenological design has become a popular method for understanding the life experiences of a unique group of individuals and its meanings and interactions with others and the environment participants and recruitment purposive sampling was used to recruit emptynest older adults with t2dm from the department of endocrinology in the qilu hospital of shandong university china the inclusion criteria were as follows aged 60 years and above having a medical diagnosis of t2dm an emptynest status as defined by not living with children for at least 12 months and a frequency of children visits less than once a week interviews were conducted until the point of saturation was reached data collection semistructured interviews ranged from 40 to 60 min and were conducted in a private room in the department of endocrinology a selfdeveloped semistructured interview guide based on literature on the challenges of diabetesrelated selfcare and expert opinion was developed key questions were asked as follows how do you manage blood sugar in your daily life how much do you know about diabetes management and the prevention of complications and how does your family support you in your disease management to protect the privacy of participants the interviewees negotiated the time with participants and completed the interview in a private meeting room after the end of routine treatment and when their condition was stable the interviews were implemented by the first author who is a postgraduate student with diabetes care experience and good communication skills but has not yet participated in patient care all interviews were conducted facetoface and audiorecorded with the permission of participants memos or notes were also written and used for data analysis ethical considerations the research was approved by the human research ethics committee of school of nursing shandong university written consent was obtained from all participants verbal consent was obtained to use a digital voice recorder prior to the commencement of each interview personal information and interview content were kept anonymous and confidential all participants had the right to withdraw from the interview at any time data analysis all interviews were transcribed by students in nursing school jh checked the scripts against the audio recordings xy and jh analyzed five transcripts independently and themes were checked by the research team for consensus afterwards the coding scheme was used only for the remaining transcripts new codes were inserted when necessary rigor in order to guarantee the reliability and rigor of this study guba and lincoln standards were adopted including credibility transferability conformability and dependability the researcher in this study had been practicing in the department of endocrinology and had established a good relationship with patients during the interview participants words were fed back to them for confirmation and to assure the credibility of the data to improve data transferability detailed descriptions about research steps were applied for a better understanding of the data an audit trail was put in place to demonstrate the process of data interpretation and induction and to increase the conformability for dependability the interview manuscripts were reviewed by members of the research team and themes were extracted and discussed within the team results a total of 15 emptynesters with t2dm were recruited to participate in the indepth interview the characteristics of the participants are shown in table 1 the mean age of the participants was 65 years the mean duration of diabetes was 11 years five major themes were identified to illustrate the selfcare experiences of emptynesters with t2dm including a selfcare deficit in blood glucose monitoring with medication compliance lifestyle modification in preventing diabeticrelated complications and coping with negative emotions themes and subthemes are presented in figure 1 and the participant responses to each question were presented as positive or negative feedback in figure 2 through stacked bar charts responses of participants associated with themes and subthemes were described in supplementary file theme 1 selfcare deficit in blood glucose monitoring inadequacy in blood glucose monitoring the participants were found to have poor compliance with blood glucose monitoring the results indicated that the mean interval between two blood glucose tests was 15 days to six months regular monitoring was limited to the time when participants were newly diagnosed with t2dm or the disease exacerbated as they paid more attention to the management of their disease during such a critical period otherwise they had irregular monitoring and took blood glucose measurements only when they felt uncomfortable symptoms such as dizziness and heart palpitations i will record blood sugar for a few days if health care providers ask me to do this recording is decreased after this period i measure blood glucose about once a month when it occurs to me i tested my blood sugar every day when i first suffered from diabetes its different now i will not examine my glucose until i feel uncomfortable barriers for regular blood glucose monitoring the main barriers for regular blood glucose monitoring are as follows the pain associated with blood glucose monitoring a misconception that the monitoring was not needed when they had a desirable blood glucose control increased psychological stress associated with unsatisfactory results economic burden caused by blood glucose test strips physical function impairment such as inadequate eyesight to engage in the monitoring the following are several quotes for illustration sometimes i do not want to test my blood sugar im in a terrible temper when the reading rises the test strips were used up so fast 50 pieces were gone in a few days it is pretty expensive to buy strips and needles can be used repeatedly for another time after first disinfecting with alcohol i know my condition of blood sugar control and i dont think its necessary for me to measure it regularly i suffer complications with my eyes it is difficult for me to install the blood taking needle there is nobody available to help me do this its very painful for me to measure my blood sugar so i never test myself inadequate selfcare responses to abnormal blood glucose when patients have physical discomfort caused by hyperglycemia such as leg dancing dry mouth or headache they do not have the skills to deal with this situation and usually do not seek the help of healthcare providers until they cannot bear it they are used to these experiences and think it is not a problem to worry about going to the hospital is full of challenges for them because the hospital has made a lot of electronic reform which requires certain experience and health literacy they can hardly adapt to the rapid development of the new mode of medical treatment and examination without help the following are quotes for illustration perhaps because i am old going to the hospital to see a doctor is really a big challenge for me now the hospital and the city is developing so fast and use many intelligent equipment i will not come to the hospital until my condition is particularly serious theme 2 selfcare deficit about medication compliance adherence to medication order most participants took medicine regularly according to a doctors prescription especially those who received insulin treatments a few patients stated that doctors did not tell them how to take the different drugs and lead them to take the drugs incorrectly participants are accustomed to asking friends or a spouse rather than healthcare providers about confusion related to taking medication the advice of friends and spouses was more accessible than that of healthcare providers it was a universal phenomenon for them to forget whether they took their pills or not owing to too many kinds of drugs and memory impairment even though they were reminded by a spouse there was also poor compliance with the medication for patients whose spouses suffered from diseases which lead to difficulties in selfcare because they were too busy taking care of their spouse to take their medication regularly i often forget to take my medicine and insulin injection although i have been unwell for a long time sometimes i fail to bring an insulin pen with me when i go out when i encounter confusing questions i will ask my spouse and friends first because it is more convenient to communicate with them and the doctor is far away from me my spouse is hemiplegic sometimes when i am busy taking care of him i forget to take my medicine i am the only one in the family who cant cope with it at some time not to mention also managing diabetes using health products to supplement the action of medications apart from formal medication prescribed by the doctors some patients were relying on health products to control blood sugar emptynesters had a tendency to spend lots of money purchasing these health products when they heard effective remarks they have a great desire to cure diabetes and hope they can recover and reduce the burden on their families and children rather than become useless to them peer recommendations make them full of expectations about the effects of health care products the lack of adult childrens judgment and supervision of diabetes management behavior was also one of the reasons for patients to buy health products as i get older i feel useless i cant help with my childrens affairs and i dont want to bother my children with trifles what i hope for the most is that there are some ways to cure diabetes so that i can suffer less and be less trouble for my family she told me that her blood glucose level dropped after taking health products without any diabetes medication intake i spent 5 thousand rmb to buy it for its good effect i took it for 2 months and there was not any improvement in my blood sugar i havent finished it yet theme 3 lifestyle modification being emptynestersa facilitator for diet management most patients expressed that they pay great attention to their daily diet including eating a fixed amount on a fixed schedule and one third stated that they did not follow any dietary restrictions they can better follow dietary modifications when they are eating at home by themselves or with a spouse when children visited and had meals with them they would override any dietary restrictions to adhere to the food preferences of their children they did not want to eat differently when codining with their children in addition some adult children lacked knowledge about diabetes and believed that the dietary restrictions were merely limited to sweet foods they bought and persuaded their parents to eat food that did not include the proper dietary restrictions patients did not resist the temptation and would break dietary compliance this indicated that living alone or with a spouse was beneficial to reduce dietary noncompliance i compliance with physical activity most patients expressed they had more leisure time because they live without adult children eleven participants indicated that they would do 30 minutes to 25 hours of outdoor exercise almost every day their willingness to exercise and the duration were affected by disease some patients rarely exercised outdoors because of multimorbidity participants believed that both their friends and their spouse played a positive role in terms of supervising and assisting outdoor activities i poor knowledge about complications they put more focus on the control of blood sugar and little was known about the prevention and management of complications many patients indicated that they did not know the complications that came with diabetes such as foot lesions and diabetic retinopathy before their hospital admission several patients realized that their eyes would be impacted by diabetes however they knew less about how to prevent eye complications and the methods by which they could take care of a few patients examined the condition of eyes regularly though many suffered from eye complications already most patients checked complications when they were required to do so by doctors in the hospital i didnt know the complications of diabetes before nor did i know how to deal with them i have no discomfort i used to know little about the complications of diabetes but ive got eye complications now and its hard to see things theme 5 coping with negative emotions negative emotions associated with diabetes emotional fluctuations and negative emotions are common in emptynester elderly individuals with t2dm they felt stressed upset and confused particularly when their diabetes was under poor control with increasing symptoms and when their blood glucose was fluctuating to a great extent and they had no idea how to deal with it patients considered that it was unbalanced for them when compared with nondiabetics most patients agreed that diabetes selfcare costs them a lot of energy and time there were also numerous restrictions that made it hard for them to relax the last time i sick i was thinking about how hard it is for humans from birth to death i suffer living with diabetes i get upset and dont want to communicate with others when my blood sugar is not under control it is suffering to have diabetes you must pay attention to your diet physical activity and insulin injection it is imbalanced compared with the responsibilities other people have psychosocial support from family peers and healthcare professionals patients shared most of their negative emotions with their spouse and friends with diabetes instead of with their children most patients indicated that friends and spouses gave them spiritual motivation sympathy and stress relief some participants expressed that they accepted little support from their spouse because of limited understanding about their disease and needs most patients chose to bury their negative emotions and considered that if they poured their frustration out to others it would make them annoying two patients stated that they would go to the hospital for psychological counseling when they felt depressed the majority of patients seldom discuss negative emotions with health care providers in addition to psychological support they need more life and medical support when their spouses physical condition is declining their own disease control is poor and they are far away from the hospital discussion to our knowledge this qualitative study is the first to explore the experiences of selfcare among emptynest elderly patients living with t2dm our findings show that emptynest elderly patients lack the understanding and proper implementation of selfcare behaviors they had relatively strong compliance with dietary modifications physical activity and medication yet selfcare related to blood glucose monitoring complication prevention and coping with negative emotions was compromised decreased body functioning and limited access to help from adult children are factors that affect the selfcare of emptynest diabetic elderly instead friends and spouses play a positive role in helping these patients maintain selfcare motivation and compliance participants did better in diet and medication adherence which may be owing to the obvious and direct effects on blood glucose control living without children seems to be an advantage to dietary control following a healthy diet is a wellrecognized factor that impacts ones ability to achieve glycemic targets and prevent or delay the onset of severe diabetes complications family conflicts about diet were identified as a stressor for patients when their dietary restrictions impacted household meals therefore they tended to accommodate others tastes when preparing a meal for the whole family however it is available to choose the lifestyle they prefer for patients who are living without children at home it provides a great opportunity for elders to enjoy their leisure time and spend their energy taking care of themselves zhang indicated that the health promoting lifestyle of emptynesters was better than that of nonempty nesters the possible reason was that empty nesters didnt have the pressure of work or the burden of taking care of children so they had more time and energy to communicate with others and learn how to keep healthy however nonemptynesters were more likely to be caregivers for their children and offspring the participants in this study lacked selfmanagement knowledge and available sources of health information which was consistent with previous studies diabetes is a chronic condition whose longterm prognosis is highly dependent on the selfcare behavior of the affected people diabetes selfmanagement education has become an essential part of diabetes care studies have shown that education in primary health care settings improved selfmanagement behavior reduced the burden of disease and the risk of diabetesrelated complications in the past ten years of health care reform china has been working hard to improve the primary health care system and the government has included diabetes in the national basic public health service projects including selfmanagement education however between 2011 and 2015 the rates of patients with diabetes who received health education showed a decreasing trend generally the quality characteristics of primary health care in china were poor most primary health care was only provided by doctors and nurses in hospitals whereas the number of primary health care workers was insufficient and their professional levels were uneven therefore they might be incompetent for diabetes selfmanagement education which probably explains why patients would bypass them when seeking medical help how to effectively promote selfmanagement behavior of patients with diabetes is warranted to be explored american diabetes association recommended that the members in the multidisciplinary teams for promoting diabetes education should be involved at least one registered nurse one registered dietitian nutritionist or one pharmacist with training and experience on diabetes selfmanagement education or another health care professional holding as a diabetes educator or board certification in advanced diabetes management they were responsible for patient selfmanagement plans and education such as blood glucose monitoring exercise diet and medication these plans and decisions were also shared with the primary care provider and reinforced during subsequent visits team members negotiated with patients to determine management priorities and action care plans tailored to reflect patients knowledge and selfcare behavior of diabetes and shared decisions within the team which improved patient outcomes and reduced the utilization of hospital services moreover the composition of team members is flexible for instance exercise instructors and psychologists can be involved in physical activity guidance and mental health maintenance if accessible nondidactic interactive and collaborative educational approaches can be adopted to patientcentered or familybased diabetes education the patient was considered the partner in the discussion rather than the audience of the lecture which could motivate patients to participate in selfassessment and diabetes education plan development and transform from passive healthcare recipients to active empowered and informed health coproducers in addition digital technologies have been increasingly adopted in studies that focus on improving selfmanagement the utilization of technology provided more resources for motivation selfmonitoring personalized education and promoting the homogenization of medical services which were facilitators for improving selfcare behavior and glycemic control especially in rural areas meanwhile there is a need to provide less complex technologies for those elderly patients with impaired cognition and limited technical ability our study showed that support from spouses and peers was vital for helping elderly patients to maintain selfcare it is also necessary for health care providers to enhance health education on diabetes for family members and peers due to that their knowledge and attitudes toward diabetes are positively associated with patients selfcare emptynest diabetes patients tended to have low utilization of health care services which was consistent with zhou with the rapid development of urbanization and the regional imbalance of economic development the majority of adult children choose to work in provincial capital cities or firsttier cities usually far from their homes for the consideration of not bothering their children who were busy with work taking care of their families and far away from home the elderly didnt choose to inform their children that they have to go to the hospital until their condition has developed beyond control this may lead to delays in their disease treatment and have negative effects on their health additionally financial difficulty was one of the factors affecting the selfcare and physical health of empty nesters the income of the elderly is lower than the average level for the whole province many of them have limited pensions and cannot afford medical expenses especially in rural areas nonempty nesters living with their children could rely on their children while emptynesters did not receive regular and meaningful financial support from children and relatives financial difficulty is the leading cause for nonvisiting and nonhospitalization and it exerts a larger negative effect on access to healthcare for emptynest elderly than nonemptynest ones selfcare ability is also a major factor affecting their health in china care for the elderly is mainly provided by families at home with the gradual reduction of family size and the disintegration of the traditional large family structure the function of family endowment is gradually weakened and the elderly cannot get direct living care comorbidities are common in older adults with diabetes more than 97 of them had at least one of the comorbidities comorbidities not only increase the health care needs utilization and mortality of people with diabetes they also increase the complexity of disease management and the burden of selfmanagement which is a challenge for emptynester patients to cope with decelerated physical function and care for a sick spouse in an emptynester may be associated with reduced selfcare leading to decreased selfmanagement of diabetes there is a need for policymakers to shift the responsibility of care from family to public source and establish social security system for the emptynesters who lack selfcare ability and care resources especially in rural areas older people with diabetes are at a higher risk for psychological challenges such as depression anxiety and diabetes distress and about 1428 have depression that is two to four times more than the general elderly the incidence of depression in chinese emptynesters was 386 which was higher than that in nonemptynesters the departure of adult children as the most important source of emotional and social support for the elderly may increase the negative emotions of emptynesters previous studies have shown that compared with nonemptynesters emptynesters are vulnerable to suffering loneliness anxiety and depression in contrast chang indicated that there was no difference in the incidence of depression between emptynesters and nonemptynesters guo found that the mental health status of the emptynest elderly was better than that of the nonemptynest elderly in a longitudinal study of kristensen the transition to an empty nest of the family life cycle was shown not to be associated with parents psychosocial health in terms of loneliness and depressive symptoms these outcomes may vary with the health status and cultural background of the participants the inconsistency in research results on the psychological impact of emptynesting on the elderly needs to be further explored it is worth noting that social support is an important factor of emptynest elderly mental health maintenance and diabetes control especially support from adult children which seems more important under the influence of the traditional chinese conception of raising children for the old however it is certain that anxiety or depressive symptoms have a negative impact on disease management which can reduce selfcare behavior healthcare professionals and caregivers should pay great attention to the mental health of emptynest elderly diabetic patients our study findings have some practical implications for the management of emptynest elderly living with t2dm firstly more diabetes management programs are needed in primary health care especially in rural areas with poor access to health resources secondly healthcare providers can explore the feasibility and effectiveness of telemedicine in emptynest elderly living with diabetes to improve the accessibility to health resources for those who do not seek treatment in time thirdly the role of family support and peer support in disease management can be demonstrated through diabetes education for spouses peers and adult children to improve patients selfmanagement behaviors fourth strengthen the screening and treatment of depressive symptoms in elderly patients with empty nests fifth it is urgent for policymakers to establish a social security system that can not only provide economic support and medical assistance but also pay attention to the spiritual needs and social activities of the emptynest elderly patients to promote health due to the rapid growth of the number of emptynest elderly and their requirements for services limitations there are some limitations to this study first this study was conducted entirely in a thirdlevel gradea hospital and participants may have a lower selfcare than those in a different community second participants were collected from the hospital and their disease control may be worse than emptynest elders with diabetes in outpatient and other communities and is limited to other emptynesters in respect to selfcare in addition the current study requires a larger sample size and further studies from different clinicalcommunitysocial groups are also needed conclusions this qualitative study explores the experiences of selfcare among emptynest elderly patients living with t2dm in terms of blood glucose monitoring medication compliance lifestyle modification prevention of complications and coping with negative emotions emptynester patients with t2dm perform better in the areas of medication compliance and lifestyle modification compared with blood glucose monitoring prevention of complications and coping with negative emotions their selfcare behavior is affected by the status of living alone or living with a spouse which is accompanied by less social support and limited sources of health information in addition friends and spouses play an indispensable role in patients selfcare education access to medical resources economic and emotional support play an important role in improving their selfmanagement and maintaining mental health under the assistance of health care providers families and peers the findings suggest an urgent need for more diabetes management programs in rural areas for emptynest elderly with t2dm to improve selfmanagement as well as for policymakers and health care providers to develop strategies to improve the health status and provide health services for emptynest elderly with t2dm in the context of aging and urbanization data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding author ethics statement the studies involving human participants were reviewed and approved by human research ethics committee of school of nursing shandong university the patientsparticipants provided their written informed consent to participate in this study supplementary material the supplementary material for this article can be found online at 745145full supplementarymaterial 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 publishers 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

background the number of type 2 diabetes mellitus t2dm cases among emptynest elderly increases with increasing aging in china selfcare plays an important role in preventing and reducing adverse outcomes of diabetes however few studies focus on selfcare experiences of emptynest elderly with t2dm objective to explore selfcare experiences for a chronic disease among emptynest elderly patients with t2dm in mainland china methods a descriptive phenomenological design was used in this study semistructured interviews were conducted for 15 emptynesters with t2dm interviews were implemented in department of endocrinology at a tertiary teaching hospital located in shandong province east of chinathe participants were poorly adept with monitoring their blood glucose and lacked the ability to deal with abnormal blood glucose levels most participants had a good relationship with medication and physical activity living without children was perceived as a benefit that improved dietary management and is a disadvantage in terms of economic and emotional support and access to medical resources elderly emptynesters also lacked knowledge about diabetes and paid little attention to potential complicationsemptynest elderly patients with t2dm value medication compliance and lifestyle modification more than blood glucose monitoring complication prevention and coping with negative emotions friends and spouses play indispensable roles in patients selfcare motivation and maintenance diabetes education on selfcare access to medical resources and social support is needed for better diabetes management

introduction smoking cessation for socially disadvantaged groups is a public health priority in most developed countries due to the disproportionate disease burden attributable to tobacco smoking among these groups 1 2 however smoking cessation trials which have attempted to target members of socially disadvantaged groups have usually achieved only small sample sizes and low consent rates 3 trials that draw samples from the general population are rarely powered to adequately examine outcomes according to social group 3 as a result knowledge of effective ways to improve smoking cessation among socially disadvantaged groups is lacking generally in health and medical research groups from socioeconomically lower status have been underrepresented a recent comprehensive systematic review of the barriers strengths and limitations of this study ▪ this is the first study to look at which disadvantaged individuals are more likely to participate in a smoking cessation trial reporting the demographics of individuals less likely to consent to participate in a smoking cessation trial ▪ we identified that lowincome smokers who are motivated to quit are not enjoying smoking had family or friends who smoked and are interested in gradual cessation approaches may be more likely to participate in a smoking cessation trial ▪ a limitation of this paper is that it utilises a twostep recruitment process which while useful in providing depth and breadth of information about trial participants and nonparticipants excludes eligible individuals who were not interested or did not consent into the initial health survey ▪ a further study limitation is that external factors not explored in this study such as lack of time a high crisis situation for visiting the nongovernment social and community service organisation and low literacy levels may also contribute to nonparticipation to participation in medical research for disadvantaged groups were numerous including difficulties in identifying and sampling the hidden populations mistrust of medical research and researcher cultural or language barriers low literacy and low education levels 3 to improve consent rates for trials targeting samples from socially disadvantaged groups it is important to gain an understanding of the characteristics of individuals who are likely to consent to participate in trials and those who are less able or willing to participate this information can help inform the development of recruitment strategies for smoking cessation trials few studies have compared the characteristics of smoking cessation trial participants to nonparticipants with smokers from socially disadvantaged groups 4 5 in the usa warner et al 5 described the factors associated with eligible consenting smokers recruited from homelessness shelters returning for a randomisation appointment the authors found that those who returned were older and more likely to have a phone contact than eligible participants who failed to return this study is limited however in that it only compared a small number of factors affecting participation and no data were available on those smokers who declined participation at the consent stage this paper will describe consent rates for a sample of socially disadvantaged smokers who were approached to participate in an australian trialcall it quits to increase cessation among a socially disadvantaged group of smokers 6 in order to obtain a large sample of smokers who experience high levels of multiple forms of disadvantage including homelessness unemployment mental illness substance abuse and indigenous status recruitment took place within a nongovernment social and community service organisation these services provide a range of counselling material and emergency welfare aid to people in need across australia previous research has shown that smoking prevalence is between 60 and 70 among the adult clients of scsos 7 a number of evidencebased strategies were used to increase response rates for the trial 3 including the offer of smoking cessation support at no cost which included an offer of free nicotine replacement therapy financial reimbursement for time spent completing the trial surveys the use of simple low reading age study materials and use of an engaging and acceptable computerised health survey 3 8 the current study will examine the sociodemographic smoking alcohol use and psychosocial characteristics associated with consent to participate in the ciq trial data for this study were collected during a baseline survey which was administered prior to seeking consent for the trial enabling participant and nonparticipant characteristics to be compared this provides new and unique information on the differences between smokers from socially disadvantaged groups who agree or decline consent to participate in a smoking cessation trial methods study design a selfadministered crosssectional survey was conducted to assess eligibility for inclusion in a trial to collect healthrelated data and to collect baseline trial data the ciq trial which has been described in detail elsewhere 6 is a randomised controlled trial of a fivesession scso caseworker delivered smoking cessation intervention for socially disadvantaged smokers setting and sample study participants were recruited from a large scso in regional nsw australia participants eligible for inclusion in the baseline crosssectional survey were scso clients who were aged 18 years and above sufficiently fluent in english and well enough on the day of recruitment to give informed consent and complete a survey scso clients who presented as agitated distressed or under the influence of alcohol or other drugs were ineligible to participate individuals from socially disadvantaged groups are expected clients of these services including those who are aboriginal australians unemployed and living on government welfare homeless with a mental illness or drug addiction and young single parents 9 most scso clients report multiple forms of disadvantage procedures a twostage consent process was used where clients were asked to consent to complete a general health survey and if they completed the survey and were identified as eligible were asked to consent to participate in a smoking cessation trial initially all clients who presented for their scso appointment were informed by staff that the service was involved in a university health survey scso staff asked eligible clients interested in participating to present to the research assistant who reassessed eligibility provided the client with a participant information statement and sought written consent to participate in a health survey those clients who completed the computeradministered health survey and were identified during the survey as current tobacco smokers viewed a final survey screen inviting participation in further research where they may receive a servicebased smoking cessation programme the ra provided willing clients with the ciq trial participant information statement and sought written consent for participation in the trial all participants who completed the health survey received a 20 grocery voucher regardless of whether or not they enrolled into the ciq trial during recruitment those participants who were eligible for the trial were advised that they would receive a further 50 voucher at each followup data collection period all study procedures were approved by the university of newcastles human research ethics committee survey instrument a 62item computer survey was administered using digivey survey software 10 to assess eligibility for inclusion in the smoking cessation trial the following two items were used to determine smoking status do you currently smoke tobacco products with the following response options yes daily yes at least once a week yes but less often than once a week and no not at all and have you smoked at least 100 cigarettes or a similar amount of tobacco in your life with response options yes no not sure current smokers were defined as selfreported daily or occasional smokers who had smoked at least 100 cigarettes in their lifetime only those participants who identified as current smokers were invited to participate in this study lifetime quit attempts were assessed by asking all participants have you ever tried to quit smoking before 11 abrupt versus gradual cessation preference participants were asked if you were thinking of quitting smoking would you prefer to stop suddenly or gradually cut down on the number of cigarettes you smoke response options were stop smoking suddenly gradually cut down the number of cigarettes i smoked or i would not have a preference 12 intentions to quit were assessed using the following questions what are your intentions regarding quitting do you plan to quit in the next 30 days quit in the next 6 months quit but not in the next 6 months never quit or dont know selfefficacy was assessed by asking if you decided to give up smoking completely in the next 6 months how sure are you that you would succeed response options were not at all sure slightly sure moderately sure very sure or extremely sure 11 enjoyment of smoking was assessed by asking how much do you enjoy smoking response options were very much quite a bit not particularly not at all or do not know 13 smoker identity was assessed by asking which of these statements most applies to you response options were i hate being a smoker i am unhappy about being a smoker i am happy about being a smoker or do not know 14 motivation to quit was measured on a 10point likert scale on a scale of one to ten please rate your current motivation to give up smoking responses were collapsed into the following categories 13low motivation 46moderate motivation and 710high motivation and used as a categorical measure 15 nicotine dependence was measured using the twoitem heaviness of smoking index 16 the heaviness of smoking index uses time after waking to first cigarette and number of cigarettes smoked per day to form an index from zero to six with higher scores indicating higher levels of nicotine dependence alcohol use the alcohol use disorders identification testshort form was used to measure alcohol use 17 scores of 4 or more for males 17 and 3 or more for females 18 indicated risky drinking financial stress was assessed using the financial stress scale 19 which uses a yesno response scale to assess participants experience of financial stress in terms of eight items of financial or material deprivation for example being unable to heat home scores on this scale range from 0 to 8 with higher values indicating higher levels of financial stress depression and anxiety the patient health questionnaire4 an ultrabrief screening measure for anxiety and depression was used this is a composite measure of anxiety and depression within the past 2 weeks higher scores indicate higher likelihood of underlying depressive or anxiety disorder 20 social contact was measured by using two questions how often are you in contact with any member of your familyincluding visits phone calls letters or emails and how often are you in contact with any friendsincluding visits phone calls letters or emails response options were nearly every day 34 days per week 12 days per week 13 days per month less than once a month never no familyfriends 21 resilience was measured using the brief resilience scale 22 the brs comprises 6 items and conceptualises resilience as an individuals way of bouncing back after adversity sociodemographic variables participants selfreported their age gender highest level of education marital status weekly net income level type of housing and aboriginal or torres strait islander status analyses sample size and power calculations for the ciq trial are available elsewhere 6 sas v93 was used for all analyses 23 descriptive statistics of sociodemographic and smoking alcohol consumption and mental health variables are presented as numbers and percentages for categorical variables and means or median for continuous variables depending on distribution of the data comparison of characteristics between consenter and nonconsenters was performed using the χ 2 test for categorical variables and independent t tests or mannwhitney u tests for continuous variables logistic regression was used to examine factors associated with participant consent for the rct variables included in the model were selected based on clinical and scientific knowledge prior to analysis of the data multivariate model selection was performed to create the final adjusted model variables were removed if these had a p value 02 and were not of clinical significance thus ensuring that the inclusion or removal of each variable did not grossly affect either the fit of the model or the estimates for remaining variables within the multivariable model collinearity was checked using variance inflation factors and linearity assumption for continuous variables and the logit of the outcome were examined crude and adjusted ors with 95 cis and wald χ 2 test p values will be presented for variables in the final model results sample of the 906 participants who completed the baseline questionnaire 896 were screened for eligibility for the smoking cessation trial 584 were current smokers and were invited to participate in the trial of whom 431 consented and 153 declined to participate table 1 shows the sociodemographic characteristics table 2 shows the psychosocial variables and table 3 summarises the smokingrelated characteristics of those who did or did not consent to participate in the ciq trial comparison of trial participants and nonparticipants participants and nonparticipants did not differ according to sociodemographic or psychosocial variables a number of smokingrelated variables were significantly associated with consenting to the intervention trial results from the adjusted logistic regression model showed a number of factors made independent contributions to the or of consenting to participate in the trial the or of participation were twice as high for those reporting high motivation to quit compared to the moderate motivation group and five times higher than the low motivation group the ors of consenting were also twice higher for those with a preference for gradual reduction in cigarettes in quit attempts compared with no preference the ors were lower for those reporting dont know regarding their enjoyment of smoking compared to not at all enjoying smoking and reporting that about half or a fewless than half of their friends or family smoked lowered the or of participating than reporting that most or all of their family or friends smoked discussion this study is the first study to examine the characteristics that distinguish socially disadvantaged smokers who consent to participate in a smoking cessation trial from those who do not a large range of personal characteristics were examined and a number of these differentiated the participants in the trial from nonparticipants lower enjoyment of smoking higher motivation to quit smoking preference for gradual reduction approach for cessation and high numbers of family and friends who smoke were associated with consent into a smoking cessation trial for a sample of socially disadvantaged smokers the extent of socioeconomic disadvantage experienced by the sample is worth noting the sample consisted of adults with high rates of homelessness anxiety and depression alcohol abuse selfidentification as aboriginal or torres strait islander peoples and low education attainment the sample displayed exceptionally low income with 84 reporting income well below the australian singleperson poverty line of 500 per week 24 and 94 dependent on government benefits as their main source of income the high consent rate from those eligible to enter the trial may be due to interest in seeking assistance to quit smoking that is the offer made during recruitment of free nrt if randomised to the intervention group as well as financial reimbursements for their time notwithstanding the socioeconomic disadvantage of the clients in the sample these incentives may be particularly attractive to individuals under financial strain 25 it is important to identify those factors which might motivate socially disadvantaged smokers to participate in smoking cessation trials some factors associated with intrinsic motivation to quit were found to differentiate participants from nonparticipants enjoyment of smoking was found to be associated with participation whereby those who reported ambivalence or uncertainty regarding their enjoyment of smoking had lower odds of participation relative to those reporting not enjoying smoking as expected higher rating of motivation to stop smoking was associated with greater odds of participation in the cessation trial there is a need to increase interest in participating in smoking cessation research among smokers who may not be motivated to quit smoking 13 use of motivational interviewing techniques during recruitment warrants further consideration there were also greater odds of participation in the trial for those preferring an approach to quitting that allowed a gradual reduction in smoking relative to no preference reduce to quit approaches have been found to be effective for cessation 26 there may be a need to offer a reduce to quit approach which is likely to attract smokers from socially disadvantaged groups to cessation trials having higher numbers of family and friends who smoke was a surprising association with consent to participate socially disadvantaged smokers report low social support to quit smoking and being embedded in a social network and context of smoking 27 perhaps for these smokers the offer of possibly receiving a smoking cessation programme was an opportunity to gain some assistance in their attempts to quit smoking the current results may also aid stop smoking services develop strategies for attracting socially disadvantaged smokers some studies have examined the characteristics study limitations there are a number of study limitations which should be considered the twostage recruitment process while useful in providing depth and breadth of information about trial participants and nonparticipants excluded eligible individuals who were not interested or did not consent to the initial health survey there is low probability of systematic biases during recruitment given that the consent rate in the health survey was high among those who did approach the ra and attempts were made to ensure that at this stage no reference to the smoking cessation trial was made by describing the survey as a general health survey ensuring that smokers were just as likely as nonsmokers to participate however we do not know how many clients were not referred to the ra and did not approach the ra although staff was asked to refer all eligible clients to the ra there is the possibility that some were missed or that some clients did not approach the ra a further study limitation is that external factors not explored in this study such as lack of time a high crisis situation for visiting the scso and low literacy levels may also contribute to nonparticipation in conclusion based on current results it would appear important that smoking cessation trials that aim to recruit socially disadvantaged smokers incorporate recruitment strategies that provide extrinsic and intrinsic motivational techniques such as financial reimbursements use of known and acceptable settings for example the scso services intervention components including nrt at no cost offers of reduce to quit strategies and motivational interviewing components given the increasing urgency for conducting methodologically sound smoking cessation trials for smokers from socially disadvantaged groups the results of this study are pertinent of smokers attending smoking cessation clinics 28 29 using largely observational data these studies have found that the ukbased stop smoking services have been successful at attracting smokers from socioeconomically disadvantaged areas 28 and that this has translated into increased abstinence rates for 1 year

objectives this study examined sociodemographic smoking and psychosocial characteristics associated with consent to participate in a smoking cessation trial for socially disadvantaged smokers design baseline data were collected prior to seeking consent for the call it quits a randomised controlled trial setting an australian social and community service organisation sociodemographic smoking and psychosocial characteristics were compared between smokers who agreed or declined to participate participants of the 584 smokers invited to participate 431 74 consented and 153 26 declinedors of participation were twice as high for those reporting high motivation to quit compared to the moderate motivation group and five times higher than the low motivation group p0007 the ors of consenting were higher for those with a preference for gradual reduction in cigarettes in quit attempts compared with no preference the ors were lower for those reporting dont know regarding their enjoyment of smoking compared to not at all enjoying smoking and reporting that fewer of their family or friends smoked compared to most or all conclusions this study is the first to examine the characteristics of socially disadvantaged smokers who consent or decline to participate in a smoking cessation trial lowincome smokers who are motivated to quit are not enjoying smoking had family or friends who smoked and who are interested in gradual cessation approaches may be more likely to participate in a smoking cessation trial

adolescent suicidal behavior not only affects adolescents but also their family members and peers although female adolescents in puerto rico are more likely to engage in suicide ideation than their male counterparts there is no gender difference in suicide attempts resulting in injury however on average adolescent males in puerto rico die by suicide almost five times more often than females latino adolescent males living on the island are more likely to attempt suicide than their stateside us black white and latino male counterparts although completed suicides among adolescents are much higher in the united states studies have found that suicide ideation and attempts are risk factors for future suicidal attempts despite the high suicide risk for adolescents in puerto rico evidencebased treatment options are limited for those with a history of suicide ideation and attempts help seeking behavior among males males typically have more difficulties initiating and engaging in therapy than females although studies are limited treatment research results have shown that males tend to show less commitment and cooperation with the therapeutic process resulting in lower levels of clinical improvement overtime compared to females rochlen et als qualitative study examining barriers for seeking treatment among adult males showed that male norms of selfsufficiency might interfere with seeing the usefulness of psychotherapy this may also be due to existing cultural stigma against mental health treatment within this stigma framework seeking help and the expression of feelings among males shows vulnerability which is seen as a deficit andor weakness among some males masculinitybased socialization may interact with other sociocultural attitudes beliefs and values which inform culturalspecific manifestations of distress and helpseeking sens findings among a group of racially and ethnically diverse adolescents including latinx youth with past year depression and selfinjury behaviors showed that boys were less likely to seek help than girls sen suggests that particular cultural factors such as language acculturation and gender beliefsattitudes among immigrants in the us in particular might impact their willingness to seek help more generally accordingly de luca and colleagues examined latinx adolescents helpseeking behaviors within the school context when compared to nonlatinx white adolescents findings showed that latinx youth were less willing to seek help and reported less favorable attitudes toward the belief that adults at school could help suicidal youth than their white adolescent samegender counterparts the authors argue that this may be due to cultural norms that favor looking for help within the family however de luca and wyman found a positive relationship between greater school engagement and help seeking behavior among latino adolescents social context in addition to understanding the cultural context in which adolescent suicidality occurs it is equally important to understand how adverse stressorsevents affect these behaviors locke and newcombs study among a community sample of latino adolescents in los angeles california found that 80 had some suicidal ideation and a quarter had a suicide attempt history these authors identified several psychosocial factors that increased the risk of suicidality the strongest predictive factor was a history of emotional abuse followed by hard drug use sexual abuse and finally having a mother with alcoholrelated problems greater selfefficacy having a good relationship with parents and being law abiding were protective factors against suicidality a harsh family environment and poor coping skills were associated with suicidal ideation in community and clinical samples of latinx adolescents living in puerto rico psychopathology psychopathology is a robust risk factor for suicidal behavior among latinx and nonlatinx adolescents in the contiguous us as well as in puerto rico a large national study conducted stateside showed that depression anxiety behavioral and substance use disorders were linked to suicidal behaviors among 1318 year olds a study in puerto rico with two representative youth samples showed that most psychiatric disorders were associated with increased suicidal behavior risk for suicidal behavior was higher among girls with a mood disorder in the clinical sample while for boys in both clinical and community samples the strongest predictor of suicidal behavior was having a disruptive behavior disorder psychotherapy for suicidal latinx adolescents there is scant information on what treatments are efficacious or effective for suicidal ideation and behaviors among adolescents in general but particularly among latinx adolescents this scarcity exists despite evidence suggesting that culturally tailored treatments are more effective than standard treatment among latinx groups latinx individuals in the us are a heterogeneous group differing in important cultural aspects however duartévélez and colleagues argue that shared core cultural values among this group make it possible to develop a culturally informed intervention for suicidal behavior that can be individually tailored to latinx adolescents and their families from various latinx ethnicities this can be accomplished by developing a strong case conceptualization and making the treatment plan relevant to their particular sociocultural contextual experiences and clinical presentation accordingly duartevelez et al developed a theoretically derived sociocognitive behavioral treatment protocol for suicidal behavior for latinx adolescents living in puerto rico informed by empirical evidence the development of this treatment protocol was informed by studies focusing on latinx populations and two evidence based cbt protocols one for teens with suicidal behavior and substance use problems with a predominantly white population in united states and a cbt culturally adapted intervention for depressed latinx teens living in pr outcomes of a small open pilot using the scbtsb showed that treatment completers had clinically significant positive changes and reductions in suicide risk as well as positive treatment satisfaction theoretical model the sociocognitive behavioral therapy for suicidal behavior is informed by cognitive behavioral therapy and is embedded within an ecological framework scbtsb emphasizes the contextual and social circumstances that influence adolescents suicidal behavior this approach is different from traditional cbt in that it moves away from an individual conceptualization focusing on psychopathology to a multidimensional and multifaceted understanding of suicidal behavior innovative and unique aspects included in this new treatment approach are the inclusion of developmental feminist and family systems perspectives in many families the task of adolescent identity exploration and development creates family tension family conflict in combination with other stressors leads to negative adolescent outcomes the developmental perspective emphasizes adaptive adolescent identity formation as a major task of normative development thus in addition to symptom reduction this understanding is an essential feature of scbtsb treatment conceptualization and collaborative treatment planning and goalsetting the feminist perspective emphasizes understanding the role of gender socialization practices recognizing and challenging social norms and expectations about what it means to being a male or being a female this is particularly important in understanding and conceptualizing the manifestation of adolescent psychological distress and suicidality within latinx families finally the family systems perspective emphasizes understanding systemsbased interactions within families which can consist of unhealthy alliances and rigid or diffuse hierarchies among family members affecting the wellbeing of the family unit and its individual members thus this theoretical framework is used to inform each individuals unique case conceptualization in order to provide a clientand familycentered tailored intervention sociocognitive behavioral therapy for suicidal behavior protocol scbtsb uses a modular approach to the treatment of adolescent suicidality after the first mandatory module and at the end of each subsequent module the therapist works with the adolescent and caregivers to determine the next treatment module andor treatment termination the full treatment plan is determined by what skills would be the most helpful for the adolescent and the family the main objective in the crisis module is to understand and manage the suicidal crisis and the provision of core skills main topics discussed and skills taught in these module include a chain analysis to understand the unfolding of events leading to the suicidal crisis personal and family emergency planning understanding the power of thoughts and cognitive restructuring learning effective communication skills engaging in adaptive decision making learning acceptance of uncontrollable events and family interactions learning about effective parenting styles and learning effective family communication the following optional modules include three to five sessions covering one major topic each thoughts emotional regulation family communication social interactions activity trauma substance and identity at least one caregiver or family session is included in each module typically at the end of a module however the number of sessions used to cover the content of any module could vary depending on the specific needs of each patient the family communication module is composed of family sessions focused on improving communication among family members the last phase of treatment consists of termination processing relapse prevention and follow up booster sessions the only cbt protocol currently considered probably efficacious for adolescents with suicidal behavior used two therapists one for the caregivers and one for the teen providing individual parent training and family sessions in the scbtsb one therapist provides all the interventions primarily individual with the teen but also including family and caregivers sessions method this case study is the third in a series of case studies resulting from an open trial conducted in puerto rico as part of the treatment development process of the scbtsb protocol the open trial inclusion criteria were being 13 to 17 years of age admitted to an emergency department for suicidal ideation or a suicide attempt hospitalized stabilized and then referred for outpatient care and having a legal guardian willing to participate exclusion criteria included a psychotic disorder or a pervasive developmental disability an iq below 70 already receiving psychotherapy and involvement in a legal proceeding that required psychological care mandated by the judicial system as part of this trial eleven families were enrolled in the scbtsb for a more detailed description of the treatment development process including the rationale for cultural adaptations the treatment protocol and the open trial see duartévélez and colleagues this is the first male case study consequently the principal aim herein is to illustrate the therapeutic process considering the experiences of a puerto rican heterosexual cisgender adolescent male and to illustrate how developmental feminist and systemic perspectives were incorporated in treatment conceptualization and implementation procedures julio was referred by his treatment team after being hospitalized in an inpatient psychiatric unit due to homicidal and suicidal threats maternal consent and adolescent assent were obtained during their time on the unit and baseline assessments were completed immediately after discharge by a doctoral level student evaluator a posttreatment assessment was done at six months after baseline assessment as part of the scbtsb open trial study to assess clinically significant outcomes a diagnostic interview the reliable clinical index change in selfreport instruments and julios and his mothers verbal report during therapy sessions informed treatment planning and termination the rci measures the degree to which one person has a substantial change according to hisher baseline scores the rci is calculated by subtracting prefrom posttreatment scores and dividing by the standard error of the difference indices above 128 are considered clinically significant improvement at the 90 confidence level this study received irb approval from the university of puerto rico measures assessment instruments included the diagnostic interview schedule for childrenspanish version the columbiasuicide severity rating scalespanish version for suicidal behavior and history a spanish translation of the selfreport suicidal ideation questionnaire the childrens depression inventoryspanish version the hopelessness scale for children spanish version the piersharris childrens self concept scalespanish version and the family assessment measurebrief versionspanish version presenting problem julio was a 17yearold puerto rican male of mixedrace ancestry living with his mother three siblings grandmother and uncle in a twobedroom house julios mother was his primary caregiver and the one who consistently participated in treatment at treatment initiation julio met criteria for recurrent major depressive disorder with psychotic features disruptive behavior disorder nos and attention deficit hyperactivity disorder combined type he did not have any general medical conditions he received psychiatric treatment and counseling for add for four years while he was a child but was not taking any medication at the time of the suicidal crisis according to his mother julio failed two years in high school because he was not paying attention and skipping classes julio also engaged in verbally aggressive rude and challenging behavior as well as occasional physical fights that affected his relationships with family members schoolmates and school staff however at the time of scbtsb treatment initiation he was able to function and perform general obligations at home school and extracurricular activities julio was hospitalized in a psychiatric unit due to threatening to kill everyone at school and then himself by jumping from a second floor his baseline evaluation revealed a significant life history of undisclosed suicidal ideation including thinking about different ways of killing himself and both nonlethal and potentially lethal suicide attempts julio did not have any prior psychiatric hospitalizations there was no history of suicidal behavior in the family according to his mothers report however there were two family members with learning disorders one with depression and two close relatives with substance use disorders case conceptualization family and community contextjulio reported numerous psychosocial stressors including witnessing domestic violence since he was little perpetrated against his mother at the hands of his stepfather an escalation of physical aggression toward his mother in the year prior to treatment initiation forced their family of 5 to change their living arrangements and move into a single bedroom at his maternal grandmothers house which was located in an under resourced and violent neighborhood in puerto rico julio reported not having a relationship with his biological father since childhood this was a significant source of stress for julio as he reported feeling pressured by his family to develop a relationship with his dying biological father the nuclear and extended family experienced severe economic difficulties which in combination with the stress resulting from crowded living conditions lack of financial and social resources and exposure to substance use often led to family arguments namely there was a constant cycle of misunderstandings and aggressive communication between family members additionally the two primary caregivers mother and grandmother often disagreed about discipline julios interactions with his grandmother were particularly negative he reported in therapy that she would on occasion come home drunk and initiate fights with him moreover there were significant conflicts between the siblings however julio was often identified as the scapegoat academic contextjulio was on academic probation and also experienced difficulties with his peers and teachers nonetheless he expressed that school was a relief from family conflict and on occasion a place where he was able to enjoy himself julio was involved in athletic extracurricular activities which was a source of stress relief his involvement in sports formed a central part of his identity as he wished to become a professional athlete and wanted to go to college in order to become a physical education teacher cultural contextcultural messages about hypermasculinity related to general societal norms and machismo specific to the latinx context affected julios developing identity and was relevant to understanding his externalizing behaviors and suicidality machismo is understood in the literature and colloquially as beliefs values manifestation performance and embodiment of traditional malegender role socialization machismobased socialization and beliefs can have toxic effects on psychological social and interpersonal functioning further this form of masculinity can stigmatize helpseeking witnessing extreme behavioral manifestations of these beliefs were a central part of julios lived experience and informed his own gender identity and expression namely the expectation that as a male he had to act tough informed his personal beliefs that showing or expressing his emotions particularly sadness or sorrow would make him seem weak or un bobo a chump he was verbally and sometimes physically aggressive at school with peers authority figures and at home with family members according to his narrative he found himself in a position where he had to constantly defend himself in order to survive in a tough environment a nuanced understanding of the construct of masculinity provided opportunities to develop a culturallycongruent and personallyrelevant treatment plan namely an oftenignored aspect of traditionally gendered masculinitybased socialization known as caballerismo loosely translated as chivalry is associated with interpersonal connection and adaptive coping the cultural messages julio received about what it means to be a man also informed a sense of selfdetermination and social responsibility he envisioned a future in which he would become independent achieve his career goals get married and start a family he expressed a wish to be the father he felt he never had intrapersonal contextthe stressors experiences and cultural messages described above in combination with his temperament affected his core cognitions i am always the bad one in my family things will never change in my family and if i dont act aggressively i will be seen as weak and a chump these cognitions in turn triggered sadness hopelessness disappointment and anger cognitions about himself and his family were inflexible he thought it was impossible for his family to change because they were bad and hypocrites and believed he could not change lest he be perceived as weak his cognitive style often led to feelings of anger which often resulted in impulsive and aggressive behaviors these cognitions emotions and behaviors formed a constant reinforcement loop culminating in the suicidal crisis at the same time julio exhibited many strengths he was highly motivated to reach his treatment and life goals in the face of family conflicts he valued the ideal of familismo he sought out and received emotional support from a close friends family who he perceived as supportive and wished to one day have a close family of his own julio said he believed in god when spiritual beliefs were explored during the identity session but religion did not play a central in his life in therapy julio was able to build rapport with his therapist was cooperative receptive to feedback and practiced the skills taught in each treatment module in summary based on julios report and assessment his threat to kill others and himself at school was precipitated by an accumulation of family peer community and academic stressors course of treatment julio began treatment immediately after being discharged from the psychiatric unit and started concurrent pharmacotherapy with an antidepressant and two antipsychotic medications the active treatment phase was composed of 33 sessions therapy was conducted in spanish the native language of all the family members and the therapist in total treatment lasted six months on average julio attended one session per week the modules added to his treatment plan after completion of the crisis module were emotional regulation thoughts social interactions and family communication he then received a booster session two weeks after completing treatment after three months of treatment his medications were reduced to one antidepressant crisis module the objective of this module is to reduce the immediate suicidal crisis via safety planning and teaching skills to manage future crises the initial session in the crisis module is designed for the entire family however only julio and his mother attended this session here each member is asked to describe the suicidal event from hisher perspective treatment objectives are explained and a case conceptualization per the sociocognitive treatment model informed by the familys narrative is presented both julio and his mother concurred that an argument with his grandmother precipitated the initial suicidal crisis his mother mentioned this to the school counselor who in turn attempted to talk with julio about it however perceiving the counselors action as threatening julio reacted with anger and verbal aggression subsequently threatening to kill himself and kill them all referring to the people in the school this interaction was the antecedent that triggered the suicidal crisis leading to an evaluation in the psychiatric emergency department and hospitalization for a week thereafter julios identified treatment goals were to better manage his emotions improve his communication skills with his family improve interpersonal relationships and achieve independence during the course of the crisis module julio made a suicide attempt precipitated by another argument with his grandmother in which he ingests several pills from his own prescribed medication he went to sleep expecting to die but awoke with an upset stomach but did not tell anyone about the attempt when the therapist assessed for suicide risk during the next session julio reported the incident the suicide attempt was addressed during the therapy session but there was no need to refer the patient to the ed because there was no imminent risk at the end of the session the therapist followed the suicide risk protocol informed his mother about the attempt and reviewed and reinforced safety measures at home automatic thoughts such as they only see the negative and i am always seen as the bad one often triggered impulsive aggressive behaviors in response to arguing with family members though proving challenging at first through a careful step by step analysis of the events leading to the suicidal crisis along with a discussion of what it means to be a man in this society helped julio understand how gendered messages of maleness and hypermasculinity were related to his aggressive and suicidal behaviors after identifying thoughts associated with each event during the chain analysis he initially believed that asking for help and expressing his feelings were not options this led to a conversation between the therapist and julio about the disadvantages related to this rigid all or nothing understanding of masculinity for example expressing feelings and displaying emotions was perceived by julio as acting like a coward because men dont cry thats for girls julio was eventually able to become aware of his automatic thoughts and to see how suppressing the expression of feelings and talking turned into anger hatred and aggression and eventually into homicidal and suicidal ideation and threats at that point julio viewed suicide as an opportunity to resolve all of his problems and end all the hatred and pain he felt these thoughts which can be understood as a manifestation of toxic masculinity were challenged and the advantages of expressing his feelings were explored and underscored for example using socratic questioning such as have you seen a man crying and how do you feelwhat would you think if you saw a man expressing his feelings julio was able to think of instances in which good and respectful men cried and expressed themselves without losing their manhood additionally by identifying his reasons to live an exercise to help delay aggressive behavioral responding and seeking social and emotional support among his friends and his friends family he was able to develop a personal emergencysafety plan to prevent future suicidal crises working to explore and understand his identity was the main goal at the first individual session this exploration helped build the stage for working on gaining selfconfidence and on effective communication further on reframing the negative messages that he perceived from his family focusing on who he really was at his core and his strengths helped julio gain selfconfidence and openness to trying a different communication style for example in the identity session the main objective was to discuss who am i where different aspects of his selfconcept were explored and understood in context the insight gained helped julio further challenge and change his corebelief from being a chump if he didnt act aggressively to being a fighter referring to his resiliency in the face of adversity he also challenged and changed the internalized belief and attribution of being the bad one into an adaptive external attribution of its not just me at the communication session the therapist and julio worked on identifying his and his familys main communication styles having a discussion about his gender identity and cultural messages related to his avowed masculinity facilitated a conversation about how his socialization influenced thoughts such as they think i am a chump and subsequent aggressive and passiveaggressive communication styles thus his aggressive communication pattern was a way of demonstrating to his family that he was not a chump and that no one messed with him taking on the task of practicing assertive communication proved to be very challenging particularly at home as julio believed that communication patterns in the family were so entrenched that they would never change at one point sharing with his therapist if that changes you guys are geniuses the idea that changes could start at any point was emphasized and the therapist explained that even though all of them were part of a negative communication patterns one person could act differently and provoke a different reaction in others he added yo respeto si me respetan i respect if they respect me using the cultural message of respeto the therapist encouraged julio to engage in a behavioral experiment in which he was asked to try to respond to communication challenges assertively and with respect for others in order to practice this skill and test whether he received a different response practicing assertive communication was also emphasized in a caregiver session in which his mother acknowledged that this was an important family goal the crisis module concluded with a decisionmaking session to help julio develop healthy decisionmaking skills when responding to challenging situations he and his therapist used the recent suicide attempt to help him think through options other than suicide that were at his disposal and the consequences for each option with this exercise julio was able to identify thoughts that informed the attempt including me sentía demás i felt like an outsiderburden and i wanted to end the pain and then generated a sizable list of adaptive alternatives that he could have engaged in instead he selected reaching out to others for support as the best alternative to suicidal behavior which was consistent with his personal emergency plan when reviewing the therapeutic gains made in the first phase of therapy julio recognized how his thoughts feelings and behaviors were interrelated he was able to articulate that the first step in changing his behaviors and emotions was to become aware of his thoughts and think through the different options in order to practice adaptive coping skills he also acknowledged a shift in how he viewed himself from all negative to more positive finally he identified therapy as a place where he felt valued respected and heard and where he was given the space to vent his frustrations without having to fear judgment summary of crisis modulesome of the major challenges initially encountered in this module were gaining julios trust and reducing his urges to die as a response to these persistent urges follow up calls after every session were incorporated into the treatment plan in order to help julio practice and reinforce adaptive coping skills when experiencing suicidal ideation developmental ecologicalfamily and feminist perspectives were embedded in many of the interventions conducted when questioning and debating julios negative and inflexible thoughts the main focus was to shift the view from individual problems to systemic ones that included acknowledging negative societal messages that interfered with personal wellbeing the therapy itself was a place in which julio could show his vulnerability while at the same time being respected as a young man affirming his bourgeoning sense of healthy masculinity emotional regulation module 4 sessions 3 individual1 caregiver julio had a volatile temper and had grown accustomed to reacting to challenging situations impulsively as in the previous module cultural elements ie talking about the message of hypermasculinity helped him understand how and why he tended to suppress most of his negative emotions with the exception of anger the emotional regulation module used examples from his life to facilitate the identification of difficult emotions to further develop adaptive affect regulation skills the main objective of this module were to first increase awareness of how anger in particular affected his body with the goal of identifying how these sensations escalate and placed him in his danger zone ie the point at which he started to impulsively act out in anger and second learning specific skills to cool down though difficult for him at first the exercises in this module helped julio identify angerspecific body talk in order to engage in relaxation techniques to forestall further escalation leading to impulsive and aggressive behavior the exercise that julio found the most helpful was deep breathing as it helped him regulate his anger combining deep breathing with counting served as focal point anchoring his attention in the present moment thereby shifting it from the thoughts that made him angry other strategies in this module were not as helpful such as other relaxation techniques and mindfulness exercises after julio felt he had mastered his new cool down plan both he and his therapist agreed to move on to the thoughts module as he did not feel ready to move on to family communication thoughts module the objective of this module was to help julio in identifying unhelpful thinking patterns and help him learn cognitive restructuring skills the therapist had to simplify examples by making them very concrete and anchor them to situations in his life as a result of an incident in school where he was about to be expelled the therapist helped julio identify how he used effective skills to deal with this situation this exercise proved useful in helping him restructure his unhelpful thinking patterns and gave him a sense of personal efficacy additionally he was able to point out that others came to his defense when he was about to be expelled challenging the thought that people did not care about him as the module progressed julio demonstrated the ability to challenge and restructure unhelpful thoughts by looking at the positive side of negative situations leading to more flexible thinking the therapist also used examples of thoughts related to sports when he and his team faced a tough team he was able to challenge thoughts related to his teams skills compared to that of their opponents such as although this team looks tough we are also good at this game importantly julio identified that when he began to change his thoughts using cognitive restructuring he noticed a change in his mood at the end of this module julio was able to recognize and accept that what his family was doing was because they loved him even though sometimes they had problems interacting this was noticeable to others too he was arguing and fighting less thinking through his actions challenging his unhelpful thoughts and acting less impulsively social interactions 1 caregiver the objective of this module was to help julio identify sources of social support positive and negative relationships and to understand how social interactions influenced his thoughts emotions and actions julio had many acquaintances through his involvement in sports but had very few friends he had difficulty identifying positive relationships mentioning that he did not trust others for fear of being betrayed these cognitions affected his interactions and made him suspicious about others intentions practicing problem solving and cognitive restructuring exercises helped him understand how his thoughts influenced whether he approached or avoided certain people julio was then able to identify several people as positive sources of support his best friend a woman who he identified as his second mother his mother one of his sisters his coach and god this module helped julio take actions that led to fewer negative consequences and helped him improve interactions with others before concluding this module julio experienced an instance of significant conflict with his grandmother and uncle despite this situation and experiencing a resurgence of automatic negative thoughts and goto behavioral responses at the end julio was able to manage the conflict in an adaptive manner namely he used therapy sessions as a source of support avoided family conflict practiced cognitive restructuring skills spent more time with friends and engaged in sports as way to distract himself in order to avoid conflict his mother was also a source of support during this period family communication the objective of this module was to help julio and his family practice effective communication skills and improve their interactions this was the only module in which all the immediate family members participated they all attended the four family sessions with exception of the younger brother who missed one the interaction among all family members including julio and his siblings appeared emotionally distant but given that they were all sleeping in one room there were constant clashes among them however julio reported caring about them and they all recognized that there was a time when things were better among them by the time julio started this module he exhibited significant improvement however he showed initial resistance and ambivalence about working with his family even though he had stated that this was an important therapeutic goal an individual session was held with julio at the start and end of the module to assess his perception of his familys communication and interaction process in the family sessions family members identified their main communication style as aggressive and passive passive communication patterns in the family were maintained by thoughts like they will not understand and they are hypocrites additionally julio shared that he was the only one in his family taking medication and believed that some members of his family thought he was crazy though they never spoke about this or the reason for his hospitalization the family exhibited difficulties in understanding each others perspective which made the development of healthy family communication skills challenging they engaged in blaming and pointing out each others flaws after having identified this as an interaction pattern the therapist pointed it out to the family and encouraged them to instead identify each others and the familys strengths moreover family members were taught to recognize the connection between thoughts communication patterns and how they related to one another the therapist helped them challenge and change negative and inflexible thoughts in order to improve their interactions toward the end of this module julio continued to express ambivalence about family sessions because in his view things remain the same the therapist encouraged julio to identify small changes gained by his family throughout the therapeutic process in order to help challenge his beliefs he responded by expressing willingness to practice in a final family problemsolving exercise upon concluding this module the family agreed that communication at home continued to be a challenge however they reported listening to and communicating with one another more effectively and showing more respect for one another julio reported for example that on one occasion he was insulting his brother and his brother responded by saying im not swearing at you and i respect you so you dont have to talk to me like that this comment help julio recognize his mistake and he apologized to his brother followupafter terminating treatment julio had one booster session two weeks after his treatment wrapup session in this session julio and his therapist went over the stressors experienced since treatment completion and julios response to these stressors here his adaptive responses were assessed and reinforced and a brief review of other strategies learned over the course of treatment was covered to inform future relapse prevention at the conclusion of the clinical trial after eight months of treatment even though julio still endorsed some clinical symptoms on selfreport measures he expressed benefits from treatment and did not want to continue in therapy with another provider instead he was given a list of providers and health clinic options for future consideration outcomes during the crisis module julio struggled with suicidal thoughts but by the end of treatment he had much better control over these thoughts by experiencing increased motivation to live and positive realistic thoughts about his life a reliable clinical change index was observed on selfreport measures of suicidal ideation siqjr rci 2 particularly important was julios reduction in impulsive aggression which led to fewer arguments both in the home and at school julio was still struggling with his academic performance by the end of treatment he was taking two summer courses but was able to challenge his failure related thoughts and engage in proactive behavior to pass the classes he was also able to challenge the thoughts that maintained and exacerbated his aggressive behavior during the final session a visualization exercise was completed in which a chain of stressful situations based on the initial chain analysis exercise was recreated in order to assess what he would do differently in the future julio was able to generate a list of skills that he would use in order to deal with stressful situations rather than threatening to kill others and himself he mentioned stopping to think through his options looking for the positive in negative situations and engaging in pleasant activities to distract himself in addition to all the therapeutic gains julio accomplished in therapy the most clinically significant as it pertains to suicidal behaviors in his sociocultural context was the realization that he is not the problem and that killing himself is not a solution to his problems though the family had difficulties with communication even after completing the communication module they did report instances in which julios new behaviors were helping them develop their own effective communication and decision making skills this was a significant accomplishment because it indicated that they were starting to recognize julios and their own strengths moreover from both his mothers and julios perspective their views about each other shifted his mother was better able to recognize julios positive qualities and julio was able to empathize with his mother and the sacrifices she had made for their family however there was no change in the family functioning selfreport instrument finally an exit interview revealed that julio was very satisfied with treatment he stated that he felt valued and heard in therapy sessions his mother expressed that julio was a different person and that he was managing his problems in healthier ways complicating factors among the many complicating factors in this case the main one was julios conflict with family members including his grandmother and uncle both were reported to use substances which influenced their interactions with julio due to the added stress of living with extended family in his grandmothers house the treatment team intervened by providing a letter so that the familys housing application with social services be given priority which had positive results other complicating factors in this case were julios pervasive feelings of resentment and abandonment due to the absence of his father and the domestic violence perpetrated by his stepfather these adverse experiences were a relevant and central factor in many of the maladaptive behaviors and cognitions julio worked on in treatment despite the therapists attempts to help him think about the importance of processing his feelings regarding these potentially traumatic experiences julio did not feel ready to complete the scbtsb trauma module this is not unusual as studies have found that factors such as emotional readiness or lack thereof may effect whether or not a person is willing to engage in trauma work especially among those who may not be seeking such treatment julio did however develop adaptive ways to manage his affect and learned cognitive restructuring and communication skills perhaps influencing his readiness andor ability to engage in trauma work in the future financial and transportation stressors were other barriers to care as julios mother had difficulty on occasion making it to sessions due to lack of transportation another barrier was the unwillingness of extended family members to engage in treatment and work together in a collaborative way to help julio reach his treatment goals conflicts between julio his grandmother and his uncle and even between his mother and grandmother made it difficult to engage and include extended family members in sessions this conflict was exacerbated by his grandmothers and uncles substance use despite this julios mother and his siblings completed the family communication module although change in communication was limited as not all members of the family participated the immediate family continued to work on ways to improve their communication at the conclusion of treatment from a familysystems perspective a change in one aspect of the system can influence positive change in the unit as a whole conclusion this case study is an attempt to address a gap in the literature related to treating latino adolescents who engage in suicidal ideation and attempts studies focused on understanding the familial and socialcultural contexts that influence suicidal thoughts and behavior in latinos are rare treatment for latino adolescents with a history of suicidal and aggressive behaviors can be challenging due to gender socialization as well as cultural stigma against treatment seeking and treatment engagement one way to conceptualize low treatment engagement and help seeking stigma is to understand the role of gendernorm socialization gender researchers posit that male socialization reinforces the belief that asking for andor receiving help andor being vulnerable can be seen as antithetical to being masculine thus masculinitybased beliefs may likely negatively affect male adolescents openness to seek or engage in therapy culturallyinformed interventions compared to nonculturally tailored interventions may be more likely to provide the conditions necessary for developing therapeutic rapport a collaborative working alliance and establishing trust between client and therapist cbt interventions that are culturallyadapted and responsive to a clients individual presentation such as latinx values are associated with treatment acceptability retention clinically significant treatment gains and increased quality of life these factors seem to have been operating in julios case and led to clinically significant gains and an improved quality of life for him the sociocognitive behavioral model approach to the treatment of suicidality provided the conceptual framework and guidelines to reduce julios suicide risk from a feminist perspective an open discussion of gender norms and beliefs around masculinity was crucial to facilitate a healthy masculine identity reframing his male identity and beliefs about expected male behavior allowed him the opportunity to break the aggressive cycle try a different communication style which ultimately initiated a change in his environment while still holding on to his avowed gender identity a systemic approach in which aggressive communication and behaviors were conceptualized as a cycle in which all family members were involved provided some relief for julio additionally it provoked an important cognitive shift from viewing himself as the family scapegoat to viewing himself as one component in a shared family problem from an ecological perspective a therapeutic atmosphere of respect and understanding of the sociocultural context helped him feel affirmed and safe early on treatment julio also had important protective factors that worked in his favor such as good insight and athletic abilities which promoted a sense of selfefficacy in an important area of his life furthermore julios mothers willingness to support his treatment and her positive attitude toward therapist recommendations helped her make modifications to her own behavior and consequently helped improve julios negative thoughts about his family this case underscores the relevance of using a skillsbased approach within a culturally informed comprehensive framework like the scbtsb model to treat latino adolescents with suicidality lessons learned one of the main triggers for julio was his conflictladen relationship with members of his extended family namely his grandmother although attempts were made to include his grandmother in family sessions this was not accomplished family interactions that may result from mixedgenerational households in addition to the complicated dynamics that can result when a family member engages in substance use can make it difficult to negotiate treatment engagement therefore special attention should be paid early on in treatment to address the motivation of family members although it is not always feasible or productive nonetheless increasing buyin from adolescents and families who are referred for treatment posthospitalization is very important it is also important to assess motivation and engagement at various points during treatment for this particular intervention given its modular approach motivation and engagement can be assessed and addressed at the end of each module these checkins can also serve to further tailor interventions to each individual case on an ongoing basis in the case of julio and possibly other latinos using the fighter image and the notion of internal strength associated with masculinity but in a healthy way was an effective way to cognitively reframe julios unhealthy ideas about masculinity and may have helped keep him engaged in treatment limitations and future direction this case was selected from a sample of adolescents taking part in a study that is in the early stage of the treatment development process according to the stage model of behavioral therapies research the cultural relevance of the treatment components were assessed throughout the treatment development process including consulting the literature on evidence based practice among latinx individuals clinical expertise and mentoringconsultation with experts in the field culturebased outcome measures were not incorporated during treatment development because the main purpose of this phase was to treatment refinement and determination of treatment feasibility and client satisfaction currently a pilot rct is underway stateside with latinx youth to assess the feasibility of further conducting a larger study to assess scbtsb efficacy possible psychosocial risk factors relevant to latinx youth and families in the contiguous us such as acculturation conflicts ethnic identity discrimination and spirituality were incorporated in the above mentioned study to assess their impact on suicidality finally even though the scbtsb was develop for latinx specifically puerto ricans adolescents other ethnic groups may benefit as well from a developmental feminist and ecologicalsystemic approach discussion the societal norm of who is strong is not always correct to be assertive you have to be brave i am a good person i have been good to others this is not just on me we have been like this for so long but i have other options effect breathe cool down dont explode i walked away to avoid problems

in 2015 fifteen percent of puerto rican adolescents attempted suicide in general females have more suicidal thoughts while males are more likely to die by suicide however few evidencebased treatments have been developed for this population objectivesthe aim of this study was to illustrate the therapeutic process of a male puerto rican adolescent treated with the sociocognitive behavioral therapy for suicidal behavior scbtsb a culturally informed protocol and to discuss how developmental feminist and family system perspectives were incorporated in the scbtsb treatment model methoda case study is presented julio received the scbtsb after a psychiatric hospitalization subsequent to threating to commit suicide baseline and posttreatment assessments evaluated diagnosis risk factors eg hopelessness treatment satisfaction and suicidal behaviors resultsjulio demonstrated clinically significant change in depressive symptoms hopelessness suicidal ideation and aggressiveimpulsive behaviors conclusionsthe scbtsb was feasible to implement and proved acceptable to the client and his family

sexual transmission of zikv the recognition of sexual transmission of zikv has had the consequence of a response from the reproductive health perspective sexually transmitted zikv infections were documented from symptomatic males who had traveled to regions where zikv was circulating 34 in one instance sexual intercourse occurred before the onset of symptoms whereas in other cases sexual intercourse occurred during the development of symptoms or shortly after 5 the risk factors and the duration of the risk of sexual transmission have not been determined zikv has been detected by polymerase chain reaction in semen as long as 62 days after the onset of symptoms 6 demonstrating that a long period of infectivity might occur in nonvector transmission routes however it is not known if men infected with zikv who never develop symptoms can have the virus in their semen or spread zikv through sex the observation that zikv can be sexually transmitted implies that mosquitoborne and sexual modes of transmission could bridge different groups of people and amplify transmission who and cdc guidelines on the role of men in zikv infection as a preventive measure the world health organization recommends that all people who have been infected with zikv and their sexual partners practice safer sex by using condoms correctly and consistently men who live in or have traveled to an area with zikv and whose partners are pregnant should practice safer sex wearing condoms or abstaining throughout the pregnancy 7 the us centers for disease control and prevention suggests that both men and women who have had possible exposure to zikv via recent travel or unprotected sex with a zikinfected man wait for a period of time before trying to get pregnant 8 the latest who interim guideline on prevention of sexual transmission of zikv provides more detailed guidelines for all people 9 therefore it appears that the total sum of the expected role of men in the control of zikv is limited to prevention of sexually transmitted infections this limited role for men is inconsistent with what is known about the essential role played by men in women and childrens health and the known detrimental effects of absent male involvement on reproductive health role of men in reproductive health care historically most reproductive health programs focused on family planning and in turn most family planning programs offer their services exclusively to women since contraceptives are mainly designed for women women are targeted by family planning programs in addition reproductive health research as well as policy and program formulation has generally relied on data collected from women however even for fertility control and stis the inadequacy of strategies that target only women is well known 10 because of unequal genderpower relations women are especially vulnerable but are often unable to negotiate changes in sexual behavior or to practice safe sex without the cooperation of their sexual partners the male role in reproductive health can span several themes for example men can be sources of transmission of stis to women often across networks of relationships when women get pregnant their partners are expected to be sources of financial emotional and other forms of support they also participate in decisionmaking in matters affecting the pregnancy such as seeking health care and place of delivery when pregnant women suffer complications their partners are expected to assist with decisionmaking payment for treatment care of other children and provision of additional finances for the household if the woman is unable to work men as fathers play an important role in supporting their children from birth onwards when a newborn child is affected by a disorder or is ill the role of the father becomes even more critical because the woman may find it difficult to cope with the multiple burdens of recovering from pregnancy and child birth taking care of a sick child making decisions about treatment and planning for the likelihood of longterm care of a disabled child although women bear children child rearing has an impact on mens lives too this impact is substantial if men accept the responsibility of supporting their children in a range of other ways including through ensuring the health and wellbeing of their partners and children 10 an example of the call for an increased male role is the 1994 international conference on population and development program of actions statement on male responsibilities and participation 11 special efforts should be made to emphasize mens shared responsibility and promote their active involvement in responsible parenthood sexual and reproductive behavior including family planning prenatal maternal and child health prevention of stds including hiv and prevention of unwanted and highrisk pregnancies it seems reasonable that if men are brought into a wide range of reproductive health services in such a way that they are supported as equal partners and responsible parents as well as clients in their own right better outcomes will be observed among both women and men this will be reflected in reproductive health indicators such as contraception acceptance and continuation safer sexual behaviors use of reproductive health services and reduction in reproductive morbidity and mortality the potential role of men in zikv outbreak for the control of the current zikv outbreak it is essential to consider the many ways in which men should be involved these include decisionmaking about and practice of safer sex negotiating sex while respecting womens rights and decisions decisionmaking about contraception and family planning roles as husbands or partners of pregnant women who are at risk of being infected with zikv or are already infected with zikv roles as fathers of zikainfected children born with zika sequelae participation in research including studies of natural history infectivity and clinical trials of vaccines and antiviral drugs as well as support and advocacy of zikv control initiatives these roles go well beyond current guidelines on safer sex wearing condoms and postponing conception all of which are issues in which women alone rarely have the final say we note that many of these issues also hold true for other situations as varied as the hiv aids pandemic and ebola virus disease in other words situations in which a viral infectious agent which causes severe morbidity andor mortality and can infect all age groups can be sexually transmitted and which requires a multipronged approach to control while highly desirable expanded male participation in efforts to reduce sexual transmission of zikv faces a number of potential barriers these include the fact that male dominant decisionmaking processes are prevalent in many low and middleincome countries decisions about whether and when to seek health care and use of contraceptives are made by men this is one of the major causes of gender inequality in reproductive health another barrier is the perception that contraception family planning pregnancy and childbirth are seen as belonging to the domain of womens health while this stems from social norms that assign the role of childbearing and child rearing to women this perspective often carries over to health care systems in many communities without a change in this perspective men can be seen as interlopers when attempting to involve themselves in reproductive health systems a further complexity is the fact that social tribal andor religious norms may prohibit or discourage the open discussion of sexual matters this often means that couples feel uncomfortable talking about their family planning needs and sexual concerns with their partners and with health educators most of these barriers are sociocultural and are often societyspecific 1213 however experience with the hivaids pandemic has facilitated the development of ways to mitigate these problems 14 such lessons are useful in the control of zikv recommendationssuggestions recognition of these potential roles for men and how to incorporate them into control efforts could bring a more effective community response to the outbreak equally important is that it will frame the zikv outbreak as a community problem not just a womans problem while acknowledging that circumstances vary by country and other contexts one approach is to utilize the existing modes of communicating health information in the communities these include use of the electronic and print mass media health education in community health centers and specific health education campaigns it is often useful to enlist the aid of leadership groups such as village elders church leadersministers and leaders of mens cultural groups to get men involved key ways men can be directly involved in womens reproductive health include 1 tailoring maleinclusive interventions to the specific societysociocultural contexts in cultures where men are the primary decision makers in most matters the best ways to communicate with them and involve them may not be through their spouses local public health professionals and community leaders are often the best channels of introducing such interventions 2 provide health education in other settings health education should go beyond when partners accompany their partners for antenatal clinics which is not always the case due to cultural barriers 3 involve men in all matters that require joint spousal decisions as this is crucial to achieving good reproductive health goals and care of children especially in patriarchal societies 4 involve men in counseling sessions this can help make them more supportive of contraceptive use and more aware of the concept of shared decisionmaking 5 involve men in program design and implementation men themselves are the best sources of information about effective outreach and service delivery strategies as such it is essential to involve them throughout program design and implementation to ensure that services and informational materials address their concerns and needs many programs also use men to implement the program as staff members health educators and peer motivators 6 it is also recommended that testing of both partners be done during anc visits the same way hiv testing is currently done therefore we recommend that men be involved in as many components of zikv control efforts as possible the health of their spouses unborn children sisters mothers and other family members is at stake public health education efforts should help men be aware of and follow public health guidelines during a zikv outbreak highlighting the fact that minimizing risk of zikv transmission benefits not only themselves but also their families these efforts would help men be fuller partners with their spouses especially in the countries where zikv outbreaks are occurring disclaimer the opinions expressed are the authors and do not necessarily reflect the positions or policies of the national institutes of health or the us department of health and human services

recent heightened media and public health attention to zika virus zikv infection has focused on mosquito control risks to pregnant women and controversy over the summer olympics missing from these messages is an emphasis on the essential role of men in decisions and behaviors related to zikv transmission and outcomes it is our thesis that the role of men encompasses more than strategies to reduce risk of sexual transmission men play essential roles in decisionmaking affecting the couple and the family the role of men is even more important in nonwestern countries or patriarchal structures where husbands or other family members often control healthrelated decisions that are often considered the exclusive province of women in western societies zikv a flavivirus transmitted primarily by aedes mosquitoes has been spreading rapidly across the western hemisphere where more than 60 countries and territories reported autochthonous transmission in addition to mosquitoborne transmission nonvector transmission routes especially sexual ones have also been described but their impact during an epidemic and in nonepidemic settings remains largely unknown 1 most infections are asymptomatic however people with zikv disease can have symptoms that include mild fever skin rash conjunctivitis muscle and joint pain malaise or headache and certain less common serious neurological sequela 2 of particular concern is the association between zikv infection and adverse pregnancy and fetal outcomes including microcephaly

introduction quality extension programs depend on properly prepared staff just as effective dissemination of educational content is central to the extension model so is the preparation of staff to accomplish their roles through access to highquality professional development professional development opportunities change at a rapid pace with innovative strategies that include communities of practice blogs personal learning environments and massive open online courses as noted by bass a growing appreciation for the porous boundaries between classroom and life experience…has created not only promising changes in learning but also disruptive moments in teaching in an era of increasing expectations competing priorities and limited resources meeting the professional development needs of extension professionals is paramount furthermore to remain relevant extension professionals need to be prepared to deliver educational content to individuals and communities using contemporary methods and strategies examining both traditional and contemporary professional development practices of youthserving organizations can inform practices across extension particularly in light of the barriers that have been noted for effectively developing the professional competencies of extension educators many of these organizations adopted a positive youth development approach to serving youtha model that stresses assets over deficits as the field evolved from a focus on problem behaviors to a holistic approach emphasizing assets and healthy development there has been an increase in professional development opportunities offered at local regional and national levels for youth workers research supports the relationship between a properly prepared workforce and improved youth outcomes for almost 20 years youth worker professional development has focused on identifying competencies for youth workers and addressing those competencies through specific learning opportunities these competency models provide a framework for content knowledge and skills needed across positions to properly serve youth national organizations such as 4h the american camp association national collaboration for youth boys girls clubs of america girl scouts and the national afterschool association have developed competencies for youth workers researchers find that determining professional development needs can be challenging particularly across large organizations with personnel across multiple sites these researchers have called for professional developmental models to apply across organizations and states efforts have focused on establishing the relationship between professional development practices with promising programs or promising practices this article examines the current state of knowledge about professional development practices of youthserving organizations addresses the need for cotemporary benchmarking of professional development and offers recommendations for improving extension professional development practices professional development terms a review of the literature reveals a variety of terms and approaches to professional growth opportunities across disciplines for example human resource scholars and human resource textbooks call this effort training workplace learning employee development and development the business literature describes professional development as growth and learning training and executive education the education professions also use a variety of terms and approaches to professional growth adult educators used training for many years as an approach to professional development but the term has fallen out of favor and instead this work is referred to as continuing professional education higher education training and transformative learning teacher education uses the terms professional development and professional learning for this work ©2014 extension journal inc roschelle et al 2010sparks 2002 cooperative extension scholars and practitioners use the term professional development for their approach to growth and development finally youth development educators including outofschooltime program providers such as camps refer to professional growth as professional development and specific learning opportunities as training in this article we have chosen to use the term professional development when referring to educational opportunities meant to enhance the competences of youth program providers professional development significance as outofschool time program providers advance implementation of evidencebased practices more providers are offering professional development opportunities to enhance staff competence in implementing programs and services research supports the multiple benefits of employee professional development including staff retention improved health and safety reduced stress leadership succession better use of resources improved program quality reduced hiring and orientation costs improved job satisfaction and more rapid and successful organizational change all disciplines describe professional and personal growth as an outcome of professional development in addition the human resource and business literature documents increased innovation improved work outcomes improved ethics and professionalism skill development improved teamwork increased networks and adaptation to changing environments as impacts of employee professional development researchers have also found professional development leads to better content expertise reduces barriers to achieving outcomes develops particular skills in employees transforms individual and team perceptions of the world that improves decision making and improves practice through licensure and certification in particular competencies as youth workers are exposed to promising or best practices the growth they experience in knowledge and skills becomes incorporated at the program level and eventually benefits entire organizations as better prepared youth workers serve as a conduit for networking and crossagency collaboration professional development delivery professional development and staff training opportunities vary across organizations and sectors the content format and delivery strategies of professional development may differ depending on an organizations needs developmental stage management structure program characteristics staffing model target population resources or service model delivery professional development takes many forms from traditional to contemporary education discussion boards communities of practice blogging moocs personal learning environments and a variety of video chat platforms online education is now commonly used as a delivery method for professional development from synchronous live webinars to asynchronous online course and recorded webinars communities of practice have become a popular professional development strategy these groups are also referred to as learning circles learning communities study circles or affinity groups cops emerge around areas of common interest are often informal and often take place online to reduce geographic time financial and other barriers to participating in professional development opportunities one example of professional development through cops is extension which is comprised of faculty from landgrant universities working in communities of practice on specific topic areas currently 76 extension cops offer professional development for members through a combination of webinars moodle courses social media and wikis blended learning a set of professional development activities including both facetoface and technologydriven activities is another promising trend within professional development the benefits of blended learning include providing for the needs of youth workers while balancing their busy schedules reducing overall travel costs associated with professional development and enabling learning to happen anytime anywhere although this approach has been used for a decade the method has not been documented extensively in the extension literature lobley and ouellette found a combination of webbased and facetoface training provided greater flexibility when training afterschool providers the flipped classroom approach is a blended pedagogic model in which the learning elements are reversed or flipped a common example of a flipped classroom is short video lectures viewed by learners before facetoface time is spent on discussion exercises and other applied activities while traditional professional development activities have most often been managed by a host organization a more innovative approach for managing professional development activities can be found in use of a personal learning environment a ple which is conceptually based on lifelong learning includes a webbased hub for personal and professional development for learners to set learning goals summarize and manage learning content and communicate with others in the learning process ples are dynamic open and unique to each person ples often integrate of a variety of learning components including online courses and webinars communities of practices blogs and artifacts of traditional courses and trainings credentialing is also evolving a new form of professional development credentialing has emerged called badging when used in a professional development context a badge is a digital graphic credential that recognizes a specific accomplishment such as completion of an online course badges give learners a stamp of credibility within the variety of learning activities they can now engage in online badges also provide a learning map of skills that matter to an individual and are easily added and shared through a persons web page social network or personal learning environment professional development practices the professional development practices of youthserving organizations can inform extension practices cooperative extension educators extension educators credentials vary by state however all states require a minimum of a bachelors or a masters degree professional development within extension is typically conducted at the state and local levels with additional opportunities available at professional conferences and through the extension learn system a comprehensive inventory of extension educators professional development opportunities was conducted by senyurekli dworkin and dickinson through an online survey of 157 extension educators across 14 states they found the most common forms of professional development included workshopsseminars traditional classroom courses video conferences online classes and interactive television to determine the professional development needs of extension educators nationwide the national association of extension program and staff development professionals and extension surveyed extension professionals to determine educator needs for professional development a total 1316 educators from 69 institutions responded to the survey this was the first national level assessment of educator professional development needs across all extension programmatic areas 4h educators represented 27 of respondents and indicated their most important need was learning to evaluate and report program effectiveness 4h educators expressed the least need for developing effective programs these findings give some indication of professional development topics to guide national benchmarking american camp association day and resident camps the american camp association surveyed a representative sample of 1350 day and resident acaaccredited andor affiliated camps in 2012 to establish industry benchmarks around professional development practices a total of 423 camps responded because of their aca affiliation these camps were likely following quality standards established by aca the survey indicated that 61 of responding resident camps required professional development for fulltime staff with an average of 2 hours required for fulltime staff annually aca also found that responding camps required specialty seasonal frontline staff to complete an average of 12 hours of professional development each year before arrival at camp with 20 of camps requiring 20 hours or more of professional development before arrival and responding camps required other seasonal frontline staff to complete an average of 6 hours of professional development each year before arrival at camp with 22 of camps requiring 10 hours or more of professional development before arrival with regards to methods used to complete professional development for fulltime staff 46 of responding camps used offsite opportunities 21 used onsite opportunities provided by internal staff 19 used onsite opportunities provided by external trainersconsultants and 12 used online education opportunities for seasonal staff 73 of responding camps used onsite opportunities provided by internal staff 16 used onsite opportunities provided by external trainersconsultants 7 used online education opportunities and 5 used offsite opportunities commonly used online education systems by day and resident camp staff included the american camp associations professional development center and an online education system called expertonlinetrainingorg the american camp association survey also revealed incentives andor benefits provided by camps for staff members who completed professional development with 23 of camps indicating some type of incentive was provided to fulltime staff this question was not asked for seasonal staff 21st century community service learning centers in a 2007 study khashu and dougherty examined staffing and other organizational practices that distinguish higher quality afterschool programs at twenty 21st century community service learning centers in new york they found across all programs staff members reported high levels of participation in professional development activities however they also found that higherquality program staff received more training and participated in training on a wider variety of topics than staff from lower quality programs higher quality programs were more likely to purchase professional development for their staff in fact there was a significant difference between higher and lower quality programs in ways program administrators supported staff participation in professional development sixty percent of staff from higher quality programs reported administrators paid for training 50 said administrators made staff aware of training opportunities and 19 of staff said that administrators rewarded participation in professional development some organizations encourage staff to create professional development plans to guide their learning needs and opportunities garst improving professional development practices

examining traditional and contemporary professional development practices of youthserving organizations can inform practices across extension particularly in light of the barriers that have been noted for effectively developing the professional competencies of extension educators with professional development systems changing quickly particularly through online education and blended learning opportunities benchmarks need to guide new research around best practices in professional development although many program providers have not established benchmarks for professional development a few cases exist this article examines the current state of professional development practices of youthserving organizations and offers recommendations for improving extension professional development practices

introduction mental a sports approach has a contribution to a persons social and personal development one of which is to provide meaningful developmental experiences for adolescents and participates in programs relevant to positive youth development perspectives such as increased self control goal setting and leadership skills in addition research results generally believe that through the participation in sports children and youth learn values and skills that would serve them to prepare for the rest of their lives and have the potential to facilitate positive development outcomes one of the research results shows a relationship between a highperformance sports environment and pyd the increase in selfconfidence evidenced the cognitive abilities possessed by athletes at highperformance levels a strong coachathlete relationship and a higher level of prosocial behavior compared to antisocial behavior the study results prove that sport is important for youth development in various aspects especially in the social aspect even sports intervention is sometimes seen as a solution for social problems related to adolescents basically pyd is a developmental concept considering the strengths because children and adolescents are believed to have resources to develop themselves based on the problems they solve to encourage the acquisition of life skills in adolescents through the activities and sports programs they carry out therefore the pyd concept has been widely implemented to study the involvement of children and adolescents in various sports program activities based on the inductive metadata analysis results there are three categories of pyd climate including relationships with adults relationships with peers and parental involvement the three pyd climate categories illustrate what happens in sports because sports participation positively impacts physical fitness at a practical level the most significant impact on the development of social skills and life skills as the variables that become the focus of assessing the pyd program pyd is a picture of a paradigm shift from the development of the sport to development through sport in a sociopolitical context therefore development through sports is one of the indicators of becoming a developed country in the field of sports in the positive youth development context many studies related to the importance of sport have been carried out however the results of these studies still emphasize the general impact of the research results therefore this study would strengthen the conceptual study of the importance of sports activities in evoking cognitive affective psychomotor and social aspects especially for adolescent development through sports activities global issues of the importance of youth potential development the importance of developing the youth potential in the current era has become one of the topics discussed globally especially the shift from the development of sports paradigm to development through sports paradigm in the field of sports in some developed countries one of the countries that have received international recognition in recent decades in south korea south korea has gained maximum achievements in various international sports competitions and hosted various sports mega event events in recent years the south korean government policy has begun to show interest in development through a sports approach to become a truly developed sports country several studies regarding pyd have been conducted one of which is the research conducted by o connor et al which proves a positive relationship between a highperformance sports environment and positive youth development it was evidenced by the level of selfconfidence and cognitive skills positive youth experiences of the athletes at highperformance levels a strong relationship between coaches and athletes and a higher level of prosocial behavior than anti social behavior in addition the results of research conducted by armour et al indicated that positive youth development and physical activity interventions lead to sustainable impacts after carrying out these activities the study shows that the six main features inculcated in the physical activity design are positive youth development programs it means that physical activity instilled in children adolescents and students becomes one of the impacts of pyd development the global issues previously explained become exciting issues that we need to study because the paradigm shift in thinking from development of the sport to development through sport must be based on relevant studies supported by existing research results therefore conducting this study is essential to convince academics and practitioners of the importance of development through sports especially the development of pyd through sports participation positive youth development through sports pyd is an integrative framework considering the cognitive social emotional and intellectual skills needed by youth to play an active role in society from a sports perspective petitpas applies a conceptual framework to arrange a sportsspecific framework the framework distinguishes youth development through sports and youth development in general youth development focuses on the process of teaching youth life skills and their physical competencies while youth sports development explicitly refers to the acquisition of sports skills as discussed earlier sport plays an important role as a social and human personality builder hence pyd program can be one of the programs implemented by the government to promote sports in a country the primary literature on positive developments concerns how sports programs are implemented based on two main approaches namely explicit and implicit approaches theoretically there are three pyd climate categories the relationship with adults the relationship with peers and parental involvement one of the variables becoming the focus in assessing the pyd program is life skills the literature review of research results describes that the formulation of the pyd program can refer to the model shown in figure 1 figure 1 explains how pyd conceptual framework relates to social context through sports participation specifically the pyd climate is defined as a social environment that allows young people to gain experiences that contribute to three categories first the climates refer to an implicit approach that leads directly to pyd outcomes and an explicit approach by first implementing a focused life skills program it becomes a moderator variable that affects pyd outcomes the formulation in figure 1 is one of the formulations having a significant impact if it is carried out as a figure 1 conceptual framework of pyd through sports media for positive youth development through sports in a country therefore government policy is important for realizing the program the sports policy process can be understood as a chain of interrelated legitimacy actions where six elements of legitimacy action that are interrelated and intertwined in the process are identified as sports policy namely 1 legitimacyseeking organizations 2 subjects 3 sources 4 strategies 5 the base upon the legitimacy and 6 the scenario each of the six elements must be carried out according to the correct phase or stage methods the method used in this study was a literature review method using a narrative review type in addition this research tried to map the development of research fields related to pyd from time to time and to strengthen the results of previous studies related to pyd in the sports context the literature search was conducted from february to december 2021 to identify studies of positive youth development through sports the publication period of the cited articles was from 2000 to 2019 the article search database included google scholar tailor and francis elsevier science direct and sage the keywords involved positive youth development and development through sport which was also used as the criteria set in the article search because the authors wanted to examine the role of sport in the pyd context all articles found as primary data sources were used as references for analysis and synthesis using critical appraisal analysis techniques namely analyzing relevant articles related to the theoretical basis to be studied result from the data search 190 articles were found as sources that became the reference for analysis and synthesis pyd through sports and development through sport was used as criteria set in the article search it was because the authors tried to examine the role of sport in the pyd context based on the study results of the 190 articles 27 articles were identified for analysis and synthesis the analysis and synthesis results showed that the sports approach contributed to developing cognitive affective psychomotor social and life skills the concept of pyd emphasizes how to develop youth through sports in this case the coaching process focused on the process of teaching life skills along with their physical competencies to prepare their life and apply the skills in real life the analysis and synthesis results showed that the sports approach contributed to developing cognitive affective psychomotor social and life skills the concept of pyd emphasizes how to develop youth through sports in this case the coaching process focused on the process of teaching life skills along with their physical competencies to prepare discussion this study aimed to examine the important role of sport in forming pyd several reference sources state that pyd is a picture of a paradigm shift from the development of the sport to development through sport in a sociopolitical context in a country in this case pyd is one of the programs that can be implemented to develop positive youth through sports activities pyd leads to the important role of sports activities in building supportive relationships obtained by adolescents through their sports activities so that it can be implemented in real life for example cognitive skills emotional skills or social skills in addition pyd programs through sports can contribute to the ability to cope with stress communicate receive feedback set goals solve problems and deal with success and failure to be successful in encouraging youth to develop positive behavior the sports program must be defined in a clear strategy so that the aspects contained in sports activities can be carried out in real life although the program to gain an impact on the aspects of skills that can be implemented in real life is still in a topic of discussion in addition research results show that exercise impacts many aspects such as increasing motivation and selfconcept in addition people who participate in regular physical activity are more effective in maintaining body function and psychosocial health the national research council and medical institutions suggests four main areas in adolescent development including physical intellectual psychologicalemotional and social areas of these four areas the nrcim outlines eight regulatory features to promote positive development for positive youth development the eight of which are presented in table 1 table 1 explains that many assets contribute to adolescents psychological and emotional development including mental health positive selfesteem problemsolving skills conflict resolution skills mastery of motivation character and selfconfidence therefore this indicator becomes one of the assets to facilitate the social development of adolescents in undergoing relationships with parents peers adults and places of association the paradigm shift from the development of the sport to development through sport is one of the indicators of the development of the sport in a country another term is called sport for development referring to sportbased interventions designed to support and achieve goals other than sports such as gender empowerment health promotion peace and conflict resolution and positive youth development the role of the government is needed to make a policy the sports policy process can be understood as a series of interrelated legitimacy actions involving six interrelated legitimacy elements in the identification process of sports policy namely 1 legitimacyseeking organizations 2 subjects 3 sources 4 strategies 5 the base upon the legitimacy and 6 the scenario the research results conducted by macintosh parent culver showed that the participation of young athletes in the youth olympic games had a significant influence especially in terms of gaining competitive experience in sports and social skills both planned and unplanned during these activities in addition young athletes developed their confidence in the more prominent olympic movement in principle sports development is related to the development or improvement of the sports system through improving the skills of athletes to support achievements while development through sports is related to attractive social outcomes such as education social development and good public relations sport development focuses on the intrinsic value of sport while sport for development focuses on the instrumental value of sport in a broader sense to pursue social and political goals positive youth development and social development are the most widely used theories within the sports for development framework there is a new trend in youth sports participation particularly the growing popularity of noncompetitive informal and noninstitutionalized action sports the study proves that participation in the activity can make a valuable contribution to the sport for the development context and peace the sdp conceptualization suggests two phases involving children and youth to influence the contextual system the first phase requires the athlete to be influenced by the sport while the second phase implies that the positively impacted athlete is an agent of change another finding showed a positive relationship between the sports environment and adolescent development in the gender and sports performance context the results showed that males scored significantly higher than females in terms of confidence selfefficacy selfcompetence antisocial behavior towards friends and foes relationships with their coaches and cognitive skills besides the results of pyd research in sports environments comparable results were found in pyd research in the education and school contexts one of the most significant impacts was found in student leadership and socialemotional learning the results of the literature review on the impact according to studies in various literature development through sports is considered an indicator of becoming a truly developed sports country therefore a country needs to make the sport a vehicle for positive youth development through sports the pyd perspective is a theoretical framework that can improve understanding of the youth sports experience it is assumed that the youth has great potential to develop positively where youth is seen as a resource to be nurtured rather than a problem to be solved in addition the main goal of this approach is to engage the younger generation in more productive activities to build their strengths and abilities although pydoriented program guidelines have been proven to provide benefits in terms of knowledge attitudes skills and social aspects at the implementation level it is not yet in line with the stakeholder conceptions in preparing and implementing the program in some countries the results of this study strengthen the assumption that pyd through sports activities positively impacts adolescent development physical fitness and social and cognitive aspects are also obtained in these activities therefore one of the main focuses of research on pyd is to examine how sports activities contribute to the development of social emotional and behavioral skills in social life this study hopes that it can give a theoretical contribution related to the importance of sport to increase the positive youth not only in terms of sports achievement but also a significant impact on the country conclusion fostering positive youth through sports is a must in a country therefore the development of pyd is the primary key to the countrys progress specifically in the field of sports the research results proved that sport could contribute to developing cognitive affective psychomotor social and emotional aspects of community life therefore it is expected to be a benchmark for the success of a country where youth becomes the agent of change in the future through sports activities conflict of interest the authors declared no conflict of interest

the global issue of the importance of positive youth development has become an interesting topic to be studied more deeply this is evidenced by the number of research results discussing positive youth development pyd in the sports context this research generally aimed to examine the critical role of sport in forming pyd through the study on the research result development from time to time and strengthen the results of previous studies the research was conducted using a literature review method with the narrative type the article search was conducted to identify pyd through sports research results the publication period of articles was quoted from 2000 to 2019 database search was conducted through google scholar tailor and francis elsevier science direct and sage using positive youth development and development through sports keywords all articles found as primary data were analyzed using critical appraisal analysis techniques namely the process of analyzing relevant articles related to the results and theoretical basis being studied the analysis and synthesis results show that sports in general can develop positive youth development such as physical fitness development social development and life skill development as the benchmarks for the countrys success with youth as agents of change in the future therefore it is important for a country to use sport to develop positive youth through sports activities

background globally over 700 million women alive today entered a formal union before age 18 1 in developing countries one in nine girls marries before age 15 while one in three girls marries before age 18 2 girl child marriage defined as a female in a formal union before age 18 violates rights guaranteed in international and regional human right instruments and has been associated with adverse health behaviors and outcomes girl child marriage has been associated with increased fertility and reduced modern family planning reduced antenatal care and less safe delivery 3 4 5 literature has also documented significant associations between girl child marriage and mental health disorder diagnoses 6 suicide attempt and ideation 7 and items in measures of posttraumatic stress disorder social reactions abuse attributions and selfesteem 8 though both ending child marriage and improving nutritional status are key items in achieving sustainable development goals 2 and 5 by 2030 much less is known regarding empirical associations between girl child marriage and undernutrition 910 globally undernutrition is identified as the main cause for 35 million deaths in mothers and children and for 11 of disabilityadjusted life years 11 among adolescent girls being underweight or too thin for age and height ranges from 1 to 10 across subsaharan africa 12 more than 10 of adult women are underweight in subsaharan africa and despite improvement from 1980 to 1995 where the rate dropped from 18 to 11 the proportion of women underweight is more than double to that of the americas caribbean and europe 11 subsaharan africa also has the highest proportion of countries with women married as children as 18 of the 20 countries with the highest percentages of girl child marriage worldwide are found in the region 13 if current trends in marriage and population growth continue subsaharan africa will account for the largest number of girl child brides by 2050 14 the relationship between girl child marriage and undernutrition is not conceptually obvious as illustrated in fig 1 girl child marriage may influence nutritional status through direct and indirect pathways marrying at earlier ages is often associated with early and multiple childbearing 15 leading to biological consequences for womens nutritional status yet early pregnancy has been associated with both increased and decreased maternal weight in different contexts 1617 influenced by a number of previous childbirths fatstoring patterns and dietary intake the hypothesis for nutritional depletion following adolescent pregnancy has not been consistently observed revealing that the direction of the relationship between early childbearing and weight change is unclear girl child marriage may also affect nutrition through social pathways 18 marrying at earlier ages has been associated with lower educational attainment 19 leading to more limited labor opportunities and income 20 weakening womens socioeconomic status and reducing autonomy both lower socioeconomic status and reduced autonomy will affect womens decisions surrounding diet composition physical activity and healthseeking behavior 9 a transition to marriage additionally can directly influence womens physical activity levels as they take on new social roles in their contexts 21 yet it is unclear in what direction these subsequent changes in womens behavior would affect their nutritional status these mechanismsearly and multiple childbearing lower socioeconomic status and reduced autonomymay further lead to adverse health and developmental outcomes for children born to women who marry early 1518 using data from 103 demographic and health surveys from 1991 to 2014 representing 35 out of 48 african countries the aim of this study was to estimate associations between girl child marriage adult socioeconomic status and the likelihood of being underweight as a measure of undernutrition among women in subsaharan africa methods data source this study used data from the demographic and health surveys program implemented since 1984 by a private company called icf under funding of the united states agency for international development dhs are crosssectional householdbased surveys administered by national statistical offices and designed to be representative at national residence and regional levels 22 dhs typically use a stratified twostage cluster sampling design randomly sampling from clusters or enumeration areas followed by households within each ea 22 all women aged 15 to 49 within selected households are invited to complete the womens fig 1 conceptual model of how girl child marriage can impact health and nutritional status model was developed through extensive review of existing literature on girl child marriage human development and nutrition questionnaire in this study we focused on dhs that collected height and weight data for women in subsaharan africa measures girl child marriage girl child marriage the exposure of interest was defined as a selfreported formal union before the age of 18 based on international human rights guidelines 26 in dhs women were asked if they were currently married or if they had ever been married women were then asked for the month and year they started living with their husband or how old they were when they first started living with their husband if year could not be provided we ran additional analyses using an alternative categorical variable comparing women married at age 18 years and above with three child marriage age groupsbelow age 14 14 to 15 years 16 to 17 yearsto test for differences by early and very early marital ages underweight underweight status was the primary outcome of interest for this study the body mass index or the ratio of weight to square height in meters is an objective measure of womens nutritional status weight and height of women were collected in dhs by a trained measurer 27 underweight was defined as having a bmi of less than 185 we also created a binary variable for being severely underweight for additional analyses secondary outcomes we analyzed several secondary outcomes including age at first birth number of children born completion of secondary education and wealth index secondary education was defined as an educational attainment of secondary school or higher wealth index was defined using asset quintiles as proxies for household relative socioeconomic status within a country and asset scores were computed using principal component analysis of six key household assets following the methodology outlined by filmer and pritchett 28 we compared wealth quintiles to the richest wealth quintile other covariates to reduce confounding we controlled for selfreported completion of primary education or higher and cluster fixedeffects in adjusted analyses in the second set of empirical models we also controlled for age at time of interview age gap and education level gap to further reduce confounding concerns there were no concerns of high correlations between girl child marriage and all covariates thus we included all variables in our final model statistical analysis to assess the associations between girl child marriage and being underweight a series of multivariable logistic regression models were estimated in all models we included ea fixedeffects to control for local differences in infrastructure norms and labor market opportunities that are likely to be correlated with both outcomes and predictors and thus could potentially cause confounding biases for our main analyses we estimated the basic association between girl child marriage and underweight conditional on ea fixedeffects and primary education completion we included primary education in the base model because based on existing literature we expect females in african contexts would have had the opportunity to complete primary schooling prior to their marriage although secondary schooling would likely overlap for some with marriage we thus conceptualized primary education as a predetermined confounding factor influencing the timing of a girls marriage 1929 and secondary schooling as often disrupted by early marriage instead 30 in the second set of models we estimated the same associations conditional on early and multiple childbearing womens completion of secondary education wealth index and partner characteristics that may influence womens autonomy and decisionmaking power the estimated coefficients on girl child marriage in this second set of models should be interpreted as direct effects outside of the three mechanisms directly accounted for not all covariates were applicable to all participants thus we also included dummy variables for ever given birth and currently married at the time of the survey these coefficients were not reported and were instead used to prevent dropping of censored data the missing data for age at first birth and age gap with partner variables were imputed using the mean value we estimated associations for the pooled data and by country as well as accounting for different age at marriage categories subsequently we estimated the associations between girl child marriage and secondary outcomes early and multiple childbearing educational attainment and poverty these variables used to proxy socioeconomic status were identified as the most likely mechanisms from girl child marriage to undernutrition through an extensive literature review resulting in the conceptual framework represented in fig 1 finally we ran several sensitivity analyses and additional analyses for countryspecific models to further examine findings we estimated additional models with severely underweight as an alternative outcome to examine a more extreme measure of undernutrition we ran analyses restricting the sample to women age 20 to 24 to examine results for younger generations in the sample we also ran analyses restricting data to only the most recent wave of data collection from 2011 to 2014 to examine if results were consistent in recent years we ran analyses controlling for womens work status within the survey year in a subsample to explore the effect of one proxy for womens autonomy to check for measurement error we ran analyses excluding women married at ages 18 and 19 to see if associations were present when accounting for more extreme child and adult marriage age categories we also measured associations between girl child marriage and being anemic to see if the same relationship held for another measure of undernutrition results are presented as risk differences with 95 confidence intervals and p values hubers clusterrobust standard errors which assume that clusters are independent were used to account for withingroup correlation due to the complex survey design used in the dhs 31 since we include ea fixedeffects in all models our empirical models exclusively explore withinea variation comparing women married at different ages within given eas from each ea the dhs samples approximately 20 women who live in close proximity typically a village in rural areas and a neighborhood in urban areas our empirical estimates should thus be interpreted as relative outcome differences of women marrying earlier in a community compared to other women from the same community marrying later analyses were conducted using statamp 15 software ethical approval this study was determined exempt by the harvard longwood medical area institutional review board permission to use dhs data was obtained from the icf dhs program results the final sample included 249269 women across 35 african countries fiftyfive percent of women married before age 18 with variation in marital age across the sample the percentage of women marrying before age 18 ranged from 19 in namibia to 80 in niger the median age at marriage for women who married as children was 15 years compared to 20 years for women who married as adults overall 18 of women in the sample were underweight while 2 were severely underweight 22 of women were overweight and 4 were obese sao tome and principe had the smallest proportion of women underweight while ethiopia had the highest proportion table 1 shows differences in the outcome and sociodemographic characteristics comparing women who married as adults and as children table 2 shows the estimated risk differences for being underweight conditional on primary education and ea fixedeffects women who married before age 18 had two percentage points lower probability of being underweight as compared to women who married at age 18 or above the estimated association remained largely unchanged when we additionally adjusted for childbearing womens relative status and socioeconomic outcomes additional file 6 table s6 shows that similar results are observed when estimating associations among early and very early ages at marriage compared to women who married at age 18 or above models adjusting for childbearing womens relative status and socioeconomic status revealed that the probability of being underweight was two percentage points less for women married before age 14 just over two percentage points less for women married between ages 14 and 15 and three percentage points less for women married between 16 and 17 years results were not significant for the earliest marital age category by the final model figure 3 shows underweight risk differences for girl child marriage by country conditional on primary education and eafixed effects eight countries across central eastern and southern africa showed marginally significant associations between girl child marriage and reduced risk of being underweight similar results were found for models adjusting for birth history womens relative status and socioeconomic outcomes with only comoros gabon kenya lesotho madagascar malawi tanzania and zambia showing marginally significant and negative associations we found similar results when countryspecific models were run using the categorical specification of girl child marriage table 3 shows associations between girl child marriage and secondary outcomes conditional on primary education and eafixed effects women who married before age 18 had 38 percentage points increased probability of giving birth before age 18 and 27 percentage points increased probability of having at least four children compared to women who married as adults among women who completed primary school girl child marriage was associated with a 27 percentage point reduction in the likelihood of completing secondary education compared to those who married as adults women who married before age 18 also had increased risk of being in the poorest quintile sensitivity analyses confirmed study results displaying reduced risk of being underweight in very few countries and suggesting that associations were not overall significant at the country level girl child marriage was significantly associated with reduced risk of being severely underweight in only one country democratic republic of congo no countries showed significant associations with anemia when restricting data to the youngest generation of participants only one country malawi showed significant and negative associations in the most recent wave of data collection associations showed a significant and reduced risk of being underweight in four countries and increased risk of being underweight in one country restricting to more extreme ages of child and adult marriages also confirmed the main study results and revealed that our models may slightly underestimate risk by including women married at 18 and 19 years old discussion interpretation the aim of this study was to estimate the empirical associations between girl child marriage adult socioeconomic status and the likelihood of being underweight in subsaharan africa while results suggest that women who married before age 18 had substantially increased risk of early and multiple childbearing lower educational attainment and living in poverty analyses revealed that girl child marriage was associated with a slightly reduced risk of being underweight with variation by country to our knowledge this is the first study to explore associations between girl child marriage socioeconomic status and underweight status in subsaharan africa while the socioeconomic associations found in this study highlight important negative longterm consequences of girl child marriage the observed small negative association with being underweight contradicts a recent study that found that the percentage of women underweight was significantly higher among those who married or gave birth before age 18 in two states of india 9 while the authors of that study do not offer a direct explanation for their findings they allude to roles of early childbearing rural environments illiteracy and poverty in their discussion these broad patterns are also visible in the dhs data used in this paper when women from different communities and districts are compared to each other however once we controlled for clusterlevel confounding using ea fixedeffects these associations reversed yielding the small negative associations presented here the pronounced difference between traditional crosssectional estimates and models focusing on withincommunity comparisons only like the ones presented here suggests that the general crosssectional relationship between girl child marriage and underweight is severely biased by local contextual factors that jointly determine marriage and nutritional outcomes our findings additionally point toward differential experiences within marriage particularly in the subsaharan african context an analysis of gender differentials of undernutrition in subsaharan africa found unique differences from south asia and cautioned comparisons between the two contexts 32 svedeg posits that existing social customs including womens participation in farming and marital practices such as early marriage polygamy and bride price paid by a grooms family to his bride are more common across subsaharan africa and are distinctly different than asian contexts possibly leading to more favorable nutritional status among women in subsaharan africa these differences moreover may lead to a differential impact of the potential pathways outlined in fig 1 by context one possible explanation for our study results is that marriage provides an opportunity for a woman to have access to more food of different nutritional content women who marry earlier may more quickly access these nutritional outcomes and do not present as undernourished additionally women who marry earlier on average give birth earlier which has been associated with weight gain in some contexts 33 early and repeated pregnancies in adolescent mothers in a longterm prospective us study gained more weight than adult mother counterparts 16 similarly weight change in childbearing and marriage may be associated with poorer nutritional status prior to marriage a study in pakistan found that women with increased levels of reproductive stress gained more weight and that those who were malnourished at baseline gained more than marginally nourished women 34 in our analysis the relationship between childbearing and underweight was rather weak overall further analysis of possible mediators of the association between girl child marriage and underweight may help to illuminate pathways our results may also point toward the influence of contextual factors on marriage that further connect with a womans nutritional status as identified in fig 1 for age gap between partner and woman 000043 education gap between partner and woman 0027 coefficients presented are risk difference estimates from logistic regression models ninetyfive percent cis in parentheses are based on cluster standard errors underweight is defined as body mass index less than 185 model 1 adjusts for sampling cluster and womans primary education model 2 adjusts for womans primary education womans age age at first birth number of children born secondary education wealth quintile and partner characteristics asterisks denote level of significance p 001 p 005 example social and cultural norms in some african contexts point toward a preference for larger body size among women 3536 which may extend into bride preference evidence from developed countries further shows that married individuals are more likely to gain weight than unmarried counterparts possibly explained by marital lifestyle changes 2137 this study thus may capture the consequences of changing marital practices and family patterns in african contexts in an increasingly globalized world some participants from an ongoing qualitative study on child marriage in guinea similarly describe how their early marriages and the security provided have supported good eating sleeping health and access to healthcare 38 as such it would be important to look at associations between girl child marriage and overnutrition outcomes such as obesity which has been positively associated with marriage in the us and is on the rise across the african continent the double burden of malnutrition another consequence of globalization may mask negative nutritional and health outcomes in this study we will explore these associations in a followup paper beyond subsaharan africa investigating the associations between girl child marriage and nutritional status fig 3 countryspecific associations between girl child marriage and female underweight all models control for primary education and ea fixedeffects based on risk differences for 35 independent countryspecific models would be important in any contexts where girl child marriage and undernutrition are prevalent including south asia where this association has yet to be thoroughly explored it is also important to note that the estimated associations between girl child marriage and undernutrition in our modelswhich adjust for the most likely mediators of childbearing autonomy and socioeconomic statuscapture unobserved factors like nutrition intake physical activity or other unmeasured behavioral changes associated with girl child marriage additional research will strengthen an understanding on the potential consequences of girl child marriage or the drivers of undernutrition and could provide evidence for integrated or alternative programmatic and policy response limitations this study used crosssectional data and thus cannot claim causality though we control for several variables identified in the literature residual confounding is possible we were unable to control for other variables including premarital factors such as anthropometry diet and nutritional intake and physical activity given that our data does not allow us to observe nutritional status prior to girl child marriage it is possible that differential preferences for betternourished brides or other contextual and sociocultural factors could be confounding factors in the observed relationships we were also unable to control for childhood factors such as earlylife socioeconomic status and earlylife nutrition which likely impact women later in life there may be variability in how data were collected across settings and timepoints the analysis is also limited by our empirical approach which relies on ea fixedeffects and does not include dhs sampling weights the main disadvantage of using ea fixedeffects is that only clusters with variation in both girl child marriage and underweight status are observed the main disadvantage of not accounting for sampling weights is that results cannot be generalized to each country represented if the sample itself was not representative importantly this study does not measure the shortterm effects of nutritional changes immediately following childbirth and may consequently only capture longterm effects following adolescence this study does not conduct mediation analysis but rather reports associations with secondary outcomes of interest formal mediation analysis in this setting could be an important area for further research additionally dhs data did not permit us to more thoroughly investigate countryspecific sociocultural and historical contexts that may have contributed to marginally significant outcomes presenting opportunities for future research strengths despite these limitations this study has several strengths we used a large dataset with nationally representative data from 35 african countries greatly increasing generalizability and external validity compared to existing singlecountry or small sample studies on health consequences of girl child marriage the fig 4 map and countryspecific associations between girl child marriage and underweight conditional on full set of covariates based on risk differences for 35 independent countryspecific models controlling for primary education age age at first birth number of children ever born secondary education wealth quintile age gap education gap and ea fixedeffects outcome of underweight was calculated using measurements externally measured by trained individuals rather than selfreported by participants which could reduce bias data collection was standardized across countries and timepoints under the leadership of the dhs program and in combination with the caution we exercised in pooling data we are not overly concerned about data collection variability our analytical strategy using ea fixedeffects also addressed concerns of residual confounding as we control for observed and unobserved differences within narrow geographic settings which may affect both girl child marriage and underweight status by focusing on withinea variation we eliminated potential biases due to differences in observable and unobservable factors common to all women in these geographic areas including local population density infectious disease environment poverty levels availability of food and nutrients differences in enforcement or presence of laws cultural and social norms fragility or effects of conflict and other environmental factors conclusions girl child marriage remains a prevalent practice that threatens womens socioeconomic status and rights more broadly it continues to affect millions of women from adolescence a time where rapid development takes place that has a lasting impact our findings suggest that girl child marriage is likely not a major driver of female underweight emphasizing the importance of using empirical data to guide program and policy decisionmaking further research is needed to understand the determinants of undernutrition in this context as well as the broader relationship between socioeconomic status and nutritional outcomes coefficients presented are risk difference estimates from logistic regression models estimating associations between girl child marriage and secondary outcomes with 95 cis in parentheses controlling for ea fixedeffects and primary education and clustering standard errors at sample cluster level for each secondary outcome only women belonging to clusters in which there is variation in the outcome are included girl child marriage is defined as marriage before age 18 all variables are selfreported by participants secondary education estimates restrict to women who completed at least primary education wealth index was based on principal component analysis of household ownership of 6 core items p 001 p 005 additional files additional file 1 table s1 s6 risk difference of girl child marriage and underweight for pooled analysis note coefficients presented are risk difference estimates from logistic regression models 95 cis in parentheses are based on cluster standard errors underweight is defined as body mass index less than 185 model 1 adjusts for sampling cluster and womans primary education model additional file 13 figure s13 countryspecific associations between girl child marriage and underweight controlling for work status of woman conditional on full set of covariates note all models control for primary education age age at first birth number of children ever born secondary education wealth quintile age gap education gap and ea fixedeffects we additionally control for whether or not the woman worked in the past year based on 35 independent countryspecific models additional file 14 table s14 risk difference of girl child marriage and underweight for pooled analysis excluding women married at age 18 or 19 note coefficients presented are risk difference estimates from logistic regression models ninetyfive percent cis in parentheses are based on cluster standard errors underweight is defined as body mass index less than 185 model 1 adjusts for sampling cluster and womans primary education model 2 adjusts for womans primary education womans age age at first birth number of children born secondary education wealth quintile and partner characteristics bolded values are significant at the p 005 level p 001 p 005 additional file 15 table s15 regression results of unadjusted associations between girl child marriage and underweight by country note coefficients presented are from unadjusted linear regression models with 95 cis in parentheses underweight is defined as body mass index less than 18 authors contributions ye conceptualized the project reviewed the literature created the detailed research strategy conducted the statistical analyses led manuscript revisions and was the primary author of the manuscript jb contributed to the conceptual development of the project and reviewed the manuscript pf contributed to the conceptual development of the project and reviewed the manuscript gf contributed to the conceptual development of the project created the initial database advised on the research strategy and analyses and edited multiple versions of the manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background girl child marriage a formal union of a female before age 18 and undernutrition remain common in subsaharan africa the aim of this study is to establish the extent to which girl child marriage contributes to socioeconomic status and underweight a measure of undernutrition among adult women methods we used data from 103 demographic and health surveys dhs representing 35 african countries from 1991 to 2014 girl child marriage was coded both as a binary variable before 18 years and categorical variable before 14 14 to 15 years 16 to 17 years the primary outcome was underweight body mass index less than 18·5 secondary outcomes were early and multiple childbearing secondary education completion and wealth index logistic regression models were used to estimate associations results fiftyfive percent of women married before age 18 girl child marriage was associated with reduced risk of being underweight both in models adjusted for basic confounders risk difference 0020 95 ci 0026 0 014 p 001 and in models adjusted for childbearing womens relative status and socioeconomic outcomes risk difference 0018 95 ci 0024 0011 p 001 conditional on completing primary education and community fixedeffects women married before 18 years had an increased risk of early motherhood risk difference 038 95 ci 038 038 p 001 and of being in the poorest quintile risk difference 0024 95 ci 0012 0036 p 001 and were 27 percentage points less likely to complete secondary education risk difference 027 95 ci 028 026 p 001 compared to women married as adults conclusions though associated with substantially reduced socioeconomic status girl child marriage appears to be associated with slightly reduced risk of being underweight in the population studied further research is needed to understand the determinants of undernutrition in this context as well as the broader relationship between socioeconomic status and nutritional outcomes

introduction one of the most widely studied questions in contemporary political science is why terrorism occurs in certain places and times but not others since the year 2000 an article on this topic has appeared in on average every fourth issue of the american political science review every fifth issue of international organization and every third issue of the journal of conflict resolution there are currently at least nine peerreviewed journals dedicated exclusively to the study of this phenomenon and dozens of terrorism databases and datasets have been constructed for associated analysis despite the scale of this combined research effort scholars have reached little consensus on the empirical determinants of terrorism in the analysis of political economic and social factors studies have recorded contradictory findings in signs size and significance in their findings why do studies on the same topic report such divergent results are these differences driven by some underlying heterogeneities and causal complexities or by differences in scope conditions the usage of disparate datasets or other some other elements of research design this article outlines a systematic approach for researchers to conduct crossdataset comparisons isolate sources of variation in empirical findings and determine the robustness or uniqueness of determinants in the context of terrorism and other forms of political violence to demonstrate the utility of this process the author assembles three of the largest and most widely used terrorism datasets and applies the crossnational data on subnational violence data integration protocols to process event data into a common event typology with consistent categories and units by space time and target after processing the events onto a common typology these standardized measures are combined with data for economic conditions regime type demographics and weather and fit empirical models across a common set of spatialtemporal coverage and scales once these data are harmonized onto a standardized event typology with consistent categories and the analysis is confined to shared spatiotemporal dimensions the findings exhibit greater consistency past divergences observed in crossnational studies may in part reflect that relationships between common correlates of terrorism are contextspecific and vary across different time periods and geographical locations examined in individual studies terrorism research would also benefit from a process by which scholars can more confidently compare findings between terrorism datasets and general conflict event datasets that capture other forms of political violence often perpetrated by the same actors our understanding of terrorism remains incomplete when studied in isolation as most uses of terror actually occur as complements or as byproducts of struggles in which participants…are engaging simultaneously or successively in other more routine varieties of political claim making in fact many hypothesized determinants of terrorism are shared with other forms of violent contention therefore a framework such as that presented in this article which facilitates such a comparison has the potential to provide additional insight into whether certain correlates explain the occurrence of terrorism or simply rebellion in general consider recent events in afghanistan the taliban an entity that has oscillated between status of an incumbent government and an insurgent organization has employed a spectrum of political violence some of these actions particularly indiscriminate attacks on civilians align with most scholarly definitions of terrorism consequently these events are likely to be reflected in terrorism event databases however what about other forms of violence in which the taliban is engaged such as skirmishes with pakistani border guards or the former afghan army what about the violence they pursue now that they have regained control in afghanistan most terrorism databases exclude acts carried out by state forces therefore if we exclusively consider events involving the taliban using only terrorism event databases we are likely to obtain an incomplete picture regarding the determinants of when they use terrorism or other forms of violence as such this article compares findings from the terrorism event databases with some of the general conflict datasets already available in the xsub repository 1 additionally the author demonstrates how this protocol facilitates the integration of the databases using the merging event data by location time and type software package which can help account for missingness and provide more comprehensive coverage of violence for researchers the contributions of this exercise are threefold first this type of metaanalysis helps identify factors driving the heterogeneity of results adopting a consistent set of data aggregation standards allows us to isolate the role of specific research design decisions such as sampling variation across datasets or differences driven by model specification second by carrying out hypotheses testing in the broadest of empirical settings at different levels of analysis it allows scholars to systematically assess whether their geographic and temporal scope conditions are valid and whether the types of empirical phenomena to which a given theory applies are narrower than initially specified finally this process can reduce barriers to conducting comparative research of different forms of political violence facilitating discovery of previously unknown heterogeneities or phenomenon while opening new lines of inquiry while the xsub protocol has been applied to 22 different conflict databases this is the first time it has been applied to terrorism event datasets scholars can find replication code online which can be customized to align with variation in researchers definitions of terrorism or to account for specific research questions 2 background terrorism event databases were constructed for different purposes by distinct organizations and research teams with diverse definitions and original sources of varying consistency and quality over time and inherently face biases due to their reliance on news sources these descriptive differences and limitations of terrorism event databases are well documented but an understanding of how these differences affect empirical findings remains incomplete due to challenges in conducting a systematic comparison across datasets with variation in scope and coverage such an undertaking requires classifying events into a common typology and geolocating events to assign them to appropriate levels of spatial and temporal specification previous efforts aggregated events to countryyear level in search of robust correlates across datasets however without consistent units and common coverage across time and space it remains unclear whether the convergence and divergence in findings was due to some peculiarity of a dataset the research design or a reflection of how the relationship of determinants are unique in different time periods and locations with the occurrence of terrorism absent from the terrorism literature is a metaanalysis that evaluates why there is heterogeneity in findings across and within datasets not just which correlates appear robust determinants of terrorism economic political and societal characteristics and grievances encompass the most explored structural explanations of terrorism in extant research however this literature has produced wildly divergent results and yielded little consensus on the nature of their relationships with terrorism for example consider the literature that analyzes the relationship between economic wealth and the occurrence of terrorism one prominent argument revealed in this body of research is that economic hardships and underdevelopment aggravate grievances create sanctuaries for terrorists alter opportunity costs that affect recruitment influence the quality of terrorism and are accompanied by a general instability that promotes the likelihood of violence alternatively other scholars have posited that more economically endowed countries should experience a greater number of terrorist events by posing as a more attractive target in which to garner press coverage and attention to causes wealthy countries are expected to have a higher power ratio relative to any wouldbe challenger making terrorism a potentially lucrative violent strategy for disadvantaged militants finally others contend that once accounting for other factors like political grievances liberties or population there is no direct relationship between levels of national wealth or income inequality and the likelihood of terrorism competing theories on the causes of terrorism are not unique to measures of economic wealth terrorism research concerning political and social determinants suffers from a similar divergence in theory and findings failing to reach a consensus and advance our understanding of why terrorism occurs in certain places and times but not others a survey of 24 influential articles presented in table 1 offers some insight on this discontinuity each study adopts a slightly different research design using disparate datasets while focused on different types of terrorism using various empirical methods covering different countries levels of analysis or historical periods 3 as such it is not surprising that this work has failed to converge in some sort of consensus this effort to uncover a relationship between terrorism economic and political determinants remains ongoing in terrorism research for example in a 2023 study biglaiser et al employed a crossnational analysis encompassing 114 countries spanning from 1991 to 2017 to assess the impact of foreign direct investment on terrorism additionally jetter et al conducted a subnational examination in 75 countries from 1970 to 2014 of the relationship between gdp and the onset of terrorism in a separate investigation conducted by hand and saiya spanning data from 1972 to 2016 across 200 countries the authors explored the impact of democracy on the incidence of terrorism while accounting for the goals of different terrorist organizations as terrorism scholars continue to seek to identify important determinants of terrorism across and within nations a process by which to consider how dataset selection and variation in temporal and spatial coverage may be driving findings could enhance and contribute to this effort placed on uncovering a relationship between terrorism economic and political determinants data management and processing to investigate potential drivers of discontinuity event data is assembled from the largest and most widely utilized datasets in the empirical study of terrorism the national consortium for the study of terrorism responses to terrorism s 2019 global terrorism database the 2009 note iv independent variable dv dependent variable ∅ no relationship identified ∩ invertedu shape relationship ols ordinary least squares abadie uses the world market research centers global terrorism index for terrorism risk in 20032004 as the dependent variable global terrorism database international terrorism attributes of terrorist events memorial institute for the prevention of terrorism and the rand database of worldwide terrorism incidents memorial institute for the prevention of terrorism s rand database of worldwide terrorism incidents and international terrorism attributes of terrorist events then to consider the generalizability of findings results are compared with data from two of the largest general conflict event databases already available in xsub the uppsala conflict data program s georeferenced event dataset and the armed conflict location event data project types of terrorism importantly variation exists in the types of terrorism each dataset catalogs iterate only records internationaltransnational terrorism events mipt limits collection to transnational incidents for the first 30 years over coverage but started cataloging domestic incidents beginning in 1998 and gtd records both internationaltransnational and domestic terrorism incidents for the entirety of its holdings 4 given this variation events are first organized by type international terrorism andor events that are state sponsored are omitted in the empirical models in this article events coded in gtd as doubt terrorism are similarly omitted table 2 details the number of events and years of coverage available at the time of analysis 5 next events are categorized into common perpetratortarget dyads using the xsub actor types government opposition civilian and unaffiliated given that each dataset has a unique typology individual actor dictionaries are generated to map events onto the common classification depicted in table 3 actor and event type dictionaries for each dataset are available through online replication material 3 an example of how the targetvictim coding is used to map gtd events onto this typology is depicted in table 4 as terrorism definitions often differ by dataset and scholar the researcher can match targets to the definition being operationalized in respective studies and evaluate whether certain determinants uniquely effect attacks against different target types for example the researcher could omit attacks against other terrorist groups if it did not match with their definition of terrorism spatial and temporal levels of analysis drawing from the respective geographic precision codes for each event in each terrorism dataset aggregates are constructed at the appropriate units across space see table 5 i then generate event counts within each spatial unit at different time intervals 4 common support to explore whether variation in geographic and historical coverage drives heterogeneity of results common support datasets are generated which are limited to overlapping spatial and temporal units priogrid grid cell of analysis across all three terrorism datasets in models that compare findings from the terrorism datasets to those from acled and ged this process is repeated to generate common support across all five datasets specifically as mipt ceased collection in 2009 common support datasets in this article also end in 2009 similarly when acled is included in the common support analysis datasets only start in 1997 this is repeated at each level of spatiotemporal specification dependent variable the dependent variable used in this article is counts of terrorist attacks for this analysis attacks against any targets are included again if a scholar has a more restricted definition for their respective theory or research question they could limit events to match those requirements metaanalysis of determinants of terror for illustrative purposes this article considers the sensitivity of some of the common explanatory variables found in terrorism and conflict literature models are initially fit without common support to consider the relationships one might observe if relying on a single dataset for their analysis subsequently models are fit only where there is overlapping geographic and temporal coverage across all datasets this stepbystep method can help determine whether divergence in results is driven in part by any peculiarities of the datasets or the result of variation in the relationship with predictors over time and in different geographic contexts the models here cannot nor are they intended to identify causal effects researchers applying this protocol and seeking to make causal claims will still need to account for any issues of endogeneity and sources of bias in their research design as this metaanalysis is intended to help researchers isolate and understand drivers in the variation in f indings the author f irst f its the following core linear f ixedeffects model terrorism z u it it i t it α γ where terrorism it is the number of terrorism events in locality i at time t and z it represents a vector of the determinants of interest locality fixed effects a i are used to help account for unobserved timeconstant factors that affect terrorism it and g t to account for shocks over time the fixedeffects model helps us consider how the variables of interest perform across datasets while reducing some concern of omitted variable bias subsequently models are repeated with a negative binomial regression model common for terrorism analysis given overdispersion in the data crossnational analysis and common support to consider why previous studies have yielded little consensus this article uses measures of economic productivity ubiquitous in extant researchgross domestic product per capita from the world bank the author begins at the most prevalent level of analysis in terrorism research before conducting subnational analysis the models also show control for population density regime type using polity scores from marshall and jaggers and standard deviations in temperature and precipitation all covariates are lagged one unit of time results from the base fixedeffects model mirror the discord in the literature estimates vary in sign size and significance by dataset even when analysis is limited to common support overlapping countryyears results still vary across datasets variation in model specification some scholars have posited an invertedu relationship exists between economic wealth and polity scores with terrorism to assess whether disparate findings might be a function of forced linearity quadratic terms for gdp and polity scores are incorporated there is general agreement of an invertedu relationship for gdp across datasets although there remains variation in whether this relationship is statistically significant alternative estimation methods the process is repeated with a negative binomial model to account for overdispersion when using terrorism count data the findings at each stage follow the fixedeffects linear models the base model without quadratic terms varies with sign size and significance across datasets even when analysis is limited to common support there is more congruency among findings with the inclusion of quadratic terms for both gdp and polity scores disparity in effect sizes is further reduced when analysis is limited to overlapping countryyears all tables are reported in the online appendix 5 and table 9 is included here for negative binomial model using quadradic covariates and common support again there is general agreement of a tendency toward the invertedu relationship for gdp but this finding is significant only considering domestic terrorism events reflections these findings do not invalidate theories or previous findings not supported here but this illustrative example demonstrates how processing data into consistent units and generating a common support dataset can help isolate some of the drivers of findings the results for economic wealth and regime type are sensitive to dataset selection differences in geographic and temporal coverage and model specifications subnational analysis and general conflict event datasets applying the xsub protocol to the terrorism event databases also leverages geoprecision and temporalprecision codes in datasets to aggregate events at different levels for subnational and subannual analysis at times terrorism research has underutilized the tremendous amount of georeferenced data admittedly this is due in part to scarcity of key explanatory variables at levels below the countryyear however when determinants are available at more microlevels of analysis applying the xsub protocol facilitates efforts to compare findings from datasets at more granular levels of spatial and temporal precision to illustrate the utility of this feature the author considers a variable that is easily scalable across different spatial units and where concerns of potential reverse causality are reducedtemperature mean changes in climate and the number of extreme weather events such as heat waves and droughts are increasing extreme temperatures may exacerbate violence through a relative deprivation mechanism by decreasing income in agrarian societies or physiologically though a heataggression effect although this relationship has been examined in the study of rebellion the relationship if any between climate measures and terrorism is still an area that is understudied then standard deviations of temperature are generated using data from the national oceanic and atmospheric administration at each level of geographic specification the models continue to control for population regime type and economic wealth however for subnational models an aggregate of gross cellular product from the gecon v40 dataset aggregated to the same levels of analysis is used it should be noted again that due to the limitations of common support the findings presented in this section are based on analysis of events in 27 african countries between 1997 and 2009 as acled data was initially limited to countries in africa when it began in 1997 and mipt ended in 2009 figure 1 reports the predicted shape of the temperatureviolence relationship at the countryyear level no clear pattern emerges even when analysis restricted to common support however at the subnational level there emerges a consistent positive linear relationship between standard deviations in temperature and the occurrence of violent events this effect is not exclusive to terrorism databases a similar relationship is found when using events from ged and acled this example highlights two additional benefits of this protocol first new patterns can emerge when analysis is conducted at the subnational level which is useful when determinants are theorized to have local effects and there is significant variation within countries second comparing findings from specialty terrorism datasets with general political violence datasets at the same units of analysis can help researchers evaluate whether findings are distinct to terrorism or more generalizable to rebellion an integrated picture of terrorism in 2008 the department of justice funded a rand effort to integrate the gtd and mipt datasets from 1970 to 2006 after accounting for differences in inclusion criteria a rand computer program spent 10 days running to identify matches and recorded a 28 match rate the analysts manually reviewed each record and found a high rate of false negatives the process was repeated leaving the computer program to run for 30 days followed by another manual review in dugan et al the final match rate was 335 the resulting integrated dataset was touted as the most extensive set of opensource data on both international and domestic global terrorist attacks ever assembled and the authors demonstrated some of the ways the new dataset could identify unique trends associated with terrorism figure 1 reports the predicted shape of the temperatureviolence relationship figure 1 analysis of temperature and terrorism integrating data from conflict event datasets has the potential to improve the measurement and understanding of different patterns and causes of violence by accounting for missingness inherit with the use of a single event dataset and allow researchers to analyze terrorism alongside other forms of conflict there is an interest in the terrorism research community in obtaining integrated datasets but efforts have been stymied as integration and validation have historically been cumbersome timeconsuming and difficult to replicate even with the assistance of computer programmers and funding from the federal government it took 30 days for rand to integrate mipt and gtd datasets in 2008 and this does not account for the time spent by analysts manually reviewing results additionally researchers today do not have access to the program used and cannot independently validate or replace this effort the xsub protocol facilitates the integration of terrorism datasets using the meltt automated software integration now takes minutes on a standard personal computer and builtin functions in meltt allow the researcher to validate matches and nonmatches most importantly this process is transparent and replicable if scholars disagree with some of the decisions made in the preprocessing or coding of taxonomies or contend that the parameters are misspecified they can adjust the process accordingly as an example this section integrates events from gtd mipt acled and ged in somalia for years in which there is common support in keeping with recent work by dunford et al a spatiotemporal window of 25 kilometers and two days is set when integrating gtd with mipt a taxonomy that draws on the target types and weapon systems is used to identify candidate matches and consolidate entries that are deemed duplicates these duplicates are then validated using meltts builtin functions to randomly sample and review potential candidates as an additional validation measure the author also manually validates each candidate match for gtd and mipt in somalia table 10 summarizes the results of the integration including matching and unique entries across each dataset a match rate of 248 is found between gtd andmipt in somalia for 19972009 this is comparable to the 2008 study that also finds incompleteness when relying on solely gtd or mipt to account for terrorism using the meltt builtin function to randomly sample and review potential matches a 95 accuracy rate is recorded and when each candidate match is manually validated the author finds there is a 919 accurate match rate figure 2 shows the number of unique and duplicate entries by dataset for each year figure 2 shows the number of unique and duplicate entries by dataset for each year the author repeats the process with general conflict event datasets acled and ged however as ged provides less details about events the taxonomy here is limited to target types using the same spatial and temporal window results are presented in table 12 there is significant overlap between acled and the two terrorism datasets which is not surprising as aceld attempts to cover a broad range of conflict event types including acts of terrorism still despite this broad scope there remain potentially hundreds of events acled did not record in somalia during this period percent reduction in the size of the pooled dataset 205 figure 3 shows the number of unique and duplicate entries by dataset for each year and table 13 shows the match accuracy rate the yaxis is negative in the bottom panel to denotate these are identified as duplicate events all databases show events increase substantially beginning in 2007 most likely due to an increase in media coverage of alshabaab as it came to prominence and subsequently designated a foreign terrorist organization by the us department of state in 2008 again the intent of this illustration is not to critique any dataset over the other but to highlight the potential value in integrating datasets to measure and analyze different forms of political violence in the same location and time researchers interested in political violence broadly defined would benefit from a more complete picture of violence and related metrics that this process provides 6 in each case relying upon a single dataset would potentially result in an underestimation of the level of violence in somalia additionally deconflicting matches between terrorism and nonterrorism event databases could help terrorism scholars put the rates of terrorism into greater context for researchers policymakers and partitioners in comparison to other forms of violence questions like are nonstate actors increasingly relying upon terrorism could be better addressed with this process as an example of the utility of this process consider a recent retrospective look at terrorism in subsaharan africa from 1970 to 2020 published by the world association for disaster and emergency the study sought to understand how counterterrorism medicine initiatives might improve health care outcomes through an analysis of types of terrorism that occurred in the region over the last 50 years using the global terrorism database however as we just demonstrated any conflict event database alone may underestimate the number of attacks and related deaths that may be pertinent to the studys conclusions and recommendations figure 3 shows the number of unique and duplicate entries by dataset conclusion an understanding of how the selection of different data sources at different times influences empirical findings in terrorism has been limited due to challenges in conducting a systematic comparison across datasets with variations in scope and coverage the intent of this analysis is to illustrate how applying xsub protocols to existing terrorism event databases can improve the ability of terrorism researchers to assess the relationship between variables of interest across data sources and different levels of analysis and facilitate comparative analysis with other forms of political violence just as geddes observes that the cases one selects affect the answers they get in smalln studies the author finds that the dataset one selects affects the answers they get when conducting largen terrorism research heterogeneity in findings appears to be driven by differences in coverage and model specification rather than differences in inclusion standards or original sources across datasets as such discrepancies may be reduced when conducting analysis across common support and units scholars of terrorism and other forms of political violence might consider this process as part of a robustness check if findings are consistent across various specifications datasets locations and time periods it can enhance researcher confidence in the validity of their theories and results if the same empirical regularities are identified in multiple datasets assembled by different research teams and during different time periods levels of analysis and using different methodologies it bolsters the understanding of causes of political violence conversely when findings are not generalizable it still provides researchers with valuable means by which to articulate the scope of any conclusions this article also reinforces that new patterns may emerge when analysis is conducted at the subnational level and processing terrorism event data using the xsub protocol facilitates analysis of microfoundations of terrorism to build upon this study future research should also assess the generalizability of empirical results at different levels of temporal specification particularly if explanatory variables are available at more finite temporal units for example there may be unique relationships between climate measures that emerge when analysis is conducted at the month or week level moreover using this protocol to process events into common units and then pool events from disparate datasets can also offset underreporting and missingness by facilitating the use of automated integration software available to scholars finally the ability to conduct crossdata comparisons could improve research that asks whether terrorism is an effective strategy there are a range of strategies that challengers can employ concurrently and sequentially by adopting the data integration protocols put forth here and conducting crossdataset comparison with general political violence datasets terrorism scholars can evaluate political violence more holistically and employ a systematic means by which to identify variables that explain a groups choice to privilege a certain violent strategy over another this would also free researchers to exert energy towards uncovering determinants that resolve the use of terrorism post rebellion for additional details on how geoprecision codes from each dataset are used to aggregate data to different levels of spatial specification see zhukov ym et al op cit pp 609 and replication code for how this is implemented at xsubreplicationcode 5 additional tables can be found at 6 a 5 sample of the matched pairs from the integrated data were manually reviewed using meltts validation function using the candidate match and two control events randomly drawn from the pool of events in a similar spatial and temporal proximity for each match a true positive rate of 941 and false positive rate of 59 were identified in the sample conflict of interest the author declares that they have no conflict of interests authors note data is available on request

why do terrorist attacks occur in certain places and times but not others despite advances in collection and empirical methods the literature has produced divergent results and reached little consensus for common hypotheses about the economic political and social causes of terrorism it is hard to know what to make disagreements as studies adopt disparate research designs using different datasets covering different locations and times this article applies the xsub data protocol to conduct a metaanalysis of terrorism event datasets and isolate explanations for variations in findings although the datasets are constructed for different purposes by different research teams with different inclusion standards processing data onto a common event typology and conducting analysis across common coverage reduces heterogeneity in findings this protocol also facilitates comparisons with general conflict event datasets providing researchers policymakers and practitioners with a broader context for understanding terrorism in relation to other forms of violence

introduction as of march 2020 most european countries have adopted a range of public health measures to lower the transmission of sarscov2 coronavirus physical distancing and quarantine have been among the most important nonpharmacological measures to reduce infection rates of coronavirus disease 2019 these preventive measures however may have a profound impact on public mental health studies investigating the psychosocial impact of earlier pandemics have shown that physical distancing and quarantine have immediate as well as prolonged effects on individuals mental health including depression anxiety psychosis and perceived stress 1 2 3 4 5 furthermore it has been found that these safety measures are associated with an increase of more distal risk factors for poor mental health such as social isolation risk behaviors and lowered physical activity 1 in line with findings on earlier outbreaks accumulating evidence suggests negative psychosocial consequences of the current covid19 pandemic on public mental health including increased levels of depression anxiety selfharm and loneliness although the increasing number of approved vaccines and potential breakthroughs in the pharmacological treatment of covid19 are reasons for optimism healthrelated outcomes may worsen at any time due to new virus variants as well as economic uncertainties and recession which may occur secondary to the pandemic there is also evidence that the detrimental effects of pandemics are disproportionally distributed across communities societal inequalities have been found to increase the risk of covid19 on various health domains those with inferior social position for instance have been found to have increased disease fatality and hospital admission rates as well as to experience more severe psychosocial and economic consequences 28 and initial findings from the united kingdom suggest inequalities in adverse experiences during the early weeks of the lockdown 29 other studies have found that individuals with histories of migration and unemployment experience more severe depressive and anxiety symptoms especially in youth 30 information and communication technologies may be particularly important in alleviating covid19related psychosocial consequences 31 for instance smartphone applications help individuals to remotely interact with others and digital interventions which do not require facetoface contact may help to increase public mental health during health crises 31 previous studies have shown that digital tools available in major app stores especially mhealth apps are already frequently being used although most developers do not provide information on their evidence base safety and effectiveness 32 33 34 while in contrast ehealth and mhealth interventions that have been developed and evaluated by research groups signal great promise on their safety acceptability and effectiveness across the whole spectrum of public mental health provision especially if embedded in social and therapeutic contexts 3135 thus although mhealth apps available in app stores should be used with caution digital interventions may be used to mitigate the negative impact of the covid19 pandemic 31 if used purposefully these tools may help to provide lowthreshold timely and personalized public mental health care and can be tailored to the individual needseven under the restrictive conditions of the covid19 pandemic and without the risk of viral infection 31 36 37 38 however to the best of our knowledge there has been no study to date which has specifically investigated the role of publicly available mhealth apps during public health crises including the current covid19 pandemic and the available evidence on the occurrence of psychological distress in young individuals and important correlates remain very limited in the current study we aimed to investigate the associations between social isolation covid19related cognitive preoccupation worries and anxiety objective social risk indicators and psychological distress as well as use of and attitude toward digital mhealth apps in a representative sample of youth aged 1625 from the general population data collection took place in may 2020 and during active lockdown in germany specifically we sought to test the following hypotheses first social isolation and lack of company covid19related cognitive preoccupation worries and anxiety and objective indicators of social risk are associated with occurrence of psychological distress second these associations are consistent with a doseresponse pattern third current use of and positive attitudes toward mhealth apps are more common in those who experience psychological distress more frequent social isolation and lack of company covid19related preoccupation worries and anxiety and who are exposed to more objective indicators of social risk methods design and participants data were drawn from the mental health and innovation during covid19 surveya crosssectional panel study this study was conducted as part of a living lab entitled ai4uartificial intelligence for personalized digital mental health promotion and prevention in youth which aims to develop optimize evaluate and implement digital artificial intelligencebased interventions in routine public mental health provision by adopting a transdisciplinary approach involving users from the target population and relevant stakeholders in all stages of the research process we recruited a representative sample of youth aged 1625 from the german general population the study commenced on may 7 2020 and was completed on may 16 2020 thus data were collected at times of active lockdown measures to lower transmission rates more specifically during this time period regionspecific measures were enacted to prevent the spread of sarscov2 including the closure of schools kindergartens playgrounds zoos churches sports clubs services that require close physical contact and nonessential shops in addition it was forbidden to leave the house without a good reason and it was only allowed to have contact with one other person not living in the same household furthermore keeping a physical distance of 15 m and wearing face masks in public places as well as in public transportation was obligatory also in order to reduce the effects of these measures on the population and the economy many companies received state aid to be able to pay for running costs for data collection we used the norstatpanel by norstat deutschland gmbh 39 which consists of a group of registered internet users who have agreed to take part in surveys and opinion polls and is certified according to iso 26362 and iso 9001 standards to ensure the high quality of the panel various quality assurance measures have been implemented and are frequently evaluated such as random selection representativeness diversified sources and active recruitment of panelists as well as the absence of a public registration page profile validation plausibility testing and cheater detection the online panel operates in accordance with the applicable data protection laws prior to assessments informed consent was obtained from participants in this general population sample participants were registered members of the norstatpanel and selected at random selected individuals were invited by email to participate in the online survey to ensure representativeness of the sample individuals were stratified by gender education and population density data published by the federal statistical office of germany participation was incentivized through payments and other benefits all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional andor national research committee and with the 1964 helsinki declaration and its latter amendments or comparable ethical standards the study was approved by the medical ethics review committee ii of heidelberg university medical faculty mannheim ref measures social isolationlack of company social isolation and lack of company were assessed using two items of the threeitem loneliness scale which has been developed based on the 20item revised ucla loneliness scale 40 and was specifically developed to assess loneliness in largescale surveys 41 however as we were interested in measuring social isolation and lack of company we excluded one item assessing the feeling of being left out subjective experiences of social isolation and lack of company were both rated on a 6point likert scale ranging from 1 to 6 a high internal consistency has been demonstrated for different versions of the ucla loneliness scale including the threeitem loneliness scale 4142 covid19related cognitive preoccupation worries and anxiety covid19related cognitive preoccupation worries and anxiety were assessed using modified items from the covid19 snapshot monitoring 30 survey in germany first worries were assessed using 10 items introduced by the following sentence on a scale from 1 to 7 how often did you worry last week that… which was followed by differing types of worries for current analyses we computed the overall mean score we also dichotomized the continuous score using median split of the continuous variable 50th percentile was coded as 0 and ≥50th percentile was coded as 1 second preoccupation and anxiety with the covid19 pandemic were assessed using three separate items rated on a 5point scale objective social risk indicators data on objective indicators of individuals social circumstances and migrantethnic minority group position were assessed using a modified version of the medical research council sociodemographic schedule 43 in total six domains of social risk were included in the current study employment education relationship status living arrangements parental educational level as a proxy for lower socioeconomic status and migrant or ethnic minority group position to investigate the impact of social risk we built on the work by morgan et al 44 and created an index by dichotomizing variables from each of the six domains to define the presence or absence of wellestablished indicators of social risk this generated an index ranging from 0 to 6 current use of and attitudes toward mhealth apps after providing a definition of mhealth apps participants were asked whether they are already using mhealth apps by asking the following question do you already use mhealth apps this item was rated on a 6point likert scale and dichotomized this item was followed by an item assessing the positive negative or neutral attitude toward the use of mhealth apps to help cope with the covid19 pandemic this item was rated on a 5point likert scale and dichotomized psychological distress the kessler10 45 a wellestablished screening instrument for mental disorder in the general population was used to assess psychological distress the questionnaire was modified to assess psychological distress during the covid19 pandemic that is instead of asking about psychological distress experienced in the past 30 days psychological distress experienced since the beginning of the pandemic was assessed the 10 items were rated on a 5point scale yielding a minimum score of 10 and a maximum score of 50 for analyses including psychological distress as dependent variable we dichotomized continuous distress scores based on an established cutoff score good psychometric properties have been reported for this measure 46 for analyses in which psychological distress was used as independent variable we used a categorical variable with four levels likely to be well mild mental disorder moderate mental disorder and severe mental disorder again based on established and validated cutoff scores 4547 analysis descriptive statistics were used to report on basic sample characteristics logistic regression was used to first quantify the association of social isolationlack of company covid19related cognitive preoccupation worrying and anxiety and objective indicators of social risk as independent variables with psychological distress as outcome variable this approach allows for examining doseresponse relationships second we investigated whether psychological distress social isolation lack of company covid19related preoccupation worries and anxiety and the objective indicators of social risk as well as the social risk index are associated with the current use of and attitude toward mhealth apps in all analyses we adjusted for potential confounders except in models that included social risk indicators as independent variable here we adjusted for age and gender we adjusted significance levels for type1 error proliferation using familywise errorcorrected pvalues by multiplying the unadjusted pvalue by the total number of independent variables all analyses were performed using stata version 151 results sample characteristics in total 1006 individuals were invited by email to participate of these 685 youths completed the online survey and 19 individuals had to be excluded after completion of quality control checks thus abbreviation sd standard deviation a educational levels were defined as follows low middle high b the following k10 cutoffs were used to categorize severity levels of psychological distress none mild moderate severe c based on 10 items asking for potential worries related to the covid19 pandemic during the last week rated on a 7point likert scale items were dichotomized d defined as the number of objective indicators of social risk e based on the following item do you already use mhealth apps binary outcome variable answering never was coded as 0 whereas answering very rarely rarely occasionally often or very often was coded as 1 f based on the following item do you think that an mhealth app could help you deal better with the corona situation this item was rated on a 5point likert scale and dichotomized 1 social risk indicators by psychological distress we next investigated whether objective indicators of social risk were associated with psychological distress in young individuals during the covid19 pandemic first we investigated associations of all individual indicators of social risk and migrantethnic minority group position with psychological distress we found that individuals from migrant and ethnic minority groups were more likely to experience psychological distress compared to those from the ethnic majority group however after adjustment for multiple testing there was no evidence that unemployment being single lower educational level parental educational level or living arrangements were associated with psychological distress in testing associations between the social risk index and psychological distress we found that compared to individuals in whom objective social risk indicators were absent individuals with two objective indicators were at an increased risk to experience psychological distress during the covid19 pandemic by contrast there was no strong evidence that after adjustment for multiple testing those exposed to only one social risk indicator or three or more indicators were at an increased risk for psychological distress there was also no evidence of a doseresponse relationship psychological distress covid19related preoccupation worries anxiety and social isolation by current mhealth app use there was some evidence that psychological distress perceived social isolation and lack of company as well as covid19related cognitive preoccupation worries and anxiety were associated with current use of mhealth apps for example those with severe levels of psychological distress were two times more likely to use mhealth apps compared to those without psychological distress however those with mild and moderate levels of psychological distress were as likely to use mhealth apps as those without psychological distress after adjustments for multiple testing furthermore youth who perceived a lack of company were more likely to use mhealth apps as compared to those who reported to never experience a lack of company during the covid19 pandemic although some inconsistencies were found in contrast there was no evidence that objective indicators of social risk were associated with the use of mhealth apps psychological distress covid19related worries anxiety and social isolation by attitude toward mhealth apps as shown in table 5 and figure 2 individuals who experienced psychological distress were across all levels of severity more likely to report a positive attitude toward the use of mhealth apps mild psychological distress aor 2 discussion this study investigated whether social isolation lack of company covid19related worries and anxiety as well as objective social risk indicators were associated with psychological distress during the covid19 pandemic in a representative sample of adolescents and young adults during active lockdown in germany in addition associations with current use of and attitude toward mhealth apps were investigated first there was evidence that social isolation lack of company and covid19related cognitive preoccupation worries and anxiety were associated with psychological distress second we found evidence of doseresponse relationships as psychological distress was progressively more likely to occur as the level of reported social isolation lack of company and covid19related preoccupation anxiety and worrying increasedalthough some inconsistencies were observed third an association between migrantethnic minority group position and psychological distress was found while other objective indicators of social risk were not associated with psychological distress similarly associations of levels of the social risk index and psychological distress were inconsistent fourth there was evidence that psychological distress and high levels of covid19related cognitive preoccupation worries and anxiety were associated with a more positive attitude toward the use of mhealth apps to help overcome negative consequences of the covid19 pandemic finally the actual use of mhealth apps was more likely to be evident in those with severe psychological distress frequent social isolation and lack of company as well as covid19related preoccupation anxiety and worries although some inconsistencies were found by levels of respective variables e based on 10 items asking for potential worries related to the covid19 pandemic during the last week rated on a 7point likert scale items were dichotomized an important strength of this study is that findings are based on a representative sample of adolescents and young adults who participated in this survey during active lockdown in germany however several limitations should be taken into account before interpreting reported findings first the crosssectional design of the study did not allow us to investigate temporal order and thus we cannot rule out that reverse causality may have operated on our findings and importantly the complex nature of investigated constructs and the study design exclude any form of causal inference 48 also as we have not assessed variables before the pandemic we are not able to disentangle the unique additive effects of the pandemic on reported associations however longitudinal cohort studies have found that the prevalence of psychological distress and various mental health conditions was considerably higher during the pandemic as compared to time periods before the pandemic 182023262745 although some inconsistencies were reported 21 also participants were explicitly asked to report levels of psychological distress during the covid19 pandemic second the very dynamic development of the pandemic may limit the generalizability of findings to latter stages of the ongoing pandemic or subsequent pandemics although strong evidence was found that social isolation worrying and other psychosocial factors related to public health measures for minimizing transmission rates were strongly associated with psychological distress it is possible that the withdrawal of restrictions quickly decreases subjective feelings of social isolation and worrying and thus may contribute to a reduction of psychological distress for most individuals 20 however the survey was conducted after the peak of new cases per day had occurred during the first wave of the pandemic in germany and some infection control measures were already beginning to be lifted thus our findings may also underestimate prevalence of psychological distress as compared to moments of strict lockdown and high rates of new cases that said mental health outcomes may worsen due to ongoing and expected economic uncertainties and hence it may be argued that further negative psychosocial consequences are yet to come furthermore we used a conservative method to minimize type i error rate inflation which further supports robustness of our findings third some of the indicators used to conceptualize social risk mayalthough frequently being used in social epidemiological studies apply to young people only to a limited extent for instance living alone may not be perceived as indexing social adversity also some social risk indicators may only be contributing to poor mental health later in life fourth we used a short screening measure to assess psychological distress as the k10 is arguably largely focusing on depressive symptoms other potentially important psychopathological domains have been largely neglected finally due to time constraints the study was not preregistered before data collection and data on the psychometric properties of covid19related measures are very limited however we tested a priori defined hypotheses and findings on internal consistency are reported overall there is accumulating evidence on the negative consequences of the covid19 pandemic on public mental health a number of crosssectional and longitudinal cohort studies have found detrimental effects of the pandemic on various mental health domains including psychological distress depression anxiety and an increase of more distal risk factors such as cannabis and alcohol misuse and loneliness 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 these findings are largely in line with findings from this nationally representative survey ie high levels of social isolation lack of company covid19related worrying and anxiety have been reported and found to impact psychological distress in youth during active lockdown in germany although migrantethnic minority group position was found to be associated with psychological distress we found no evidence that an increased number of social risk indicators was associated with increased levels of psychological distress thus our findings partly differ from other studies which have found that psychosocial consequences of the current pandemic are disproportionally distributed in the society and may especially affect those with more inferior social positions or minority status however our findings are in line with findings demonstrating more pronounced effects in youth 2324 and one study has shown associations between loneliness and covid19related distress 25 furthermore positive attitudes toward the use of mhealth apps to help alleviate the psychosocial consequences of the pandemic were highly prevalent and associated with an objective need there have been also other studies which have reported that individuals have a positive attitude toward and 36 37 38 4950 and alterations of telemedicine regulations have been reported 51 however mhealth apps provide the opportunity of delivering lowthreshold personalized mental health care in daily life the present findings suggest that there is a pressing demand for evidencebased public mental health interventions that aim to specifically target the negative consequences of the covid19 pandemic 1 digital interventions including ehealth interventions and mhealth apps may help to mitigate the negative psychosocial consequences by providing evidencebased information reliably monitoring symptoms or delivering intervention components in individuals daily lives 3136375253 furthermore digital interventions may be used to ensure continuity of care in the provision of mental health services in case of repeated outbreaks and lockdowns during the pandemic and for providing and extending digital interventions to the area of mental health promotion and prevention to mitigate the negative impact of the pandemic especially in youth digital mhealth interventions may be particularly suited to help achieve this goal as they have the potential once developed and evaluated to be scaled up and broadly offered at the population level model adjusted for age and gender and social risk indicators e binary variable defined as unemployment unable to work early retirement vs other f binary variable defined as low education level that is secondary school qualification as well as no schoolleaving qualification vs other g binary variable defined as being foreign born or secondgeneration migrant vs other h binary variable defined as low educational level of both parents as a proxy for low socioeconomic status vs other i binary variable defined as living alone or alone with children vs other j binary variable defined as being single vs other k defined as the number of objective indicators of social risk abbreviations ci confidence interval or odds ratio sd standard deviation pfwe familywise errorcorrected pvalues were computed by multiplying the unadjusted pvalue by the total number of independent variables to adjust significance levels na not applicable a based on the following item do you already use mhealth apps binary outcome variable answering never was coded as 0 whereas answering very rarely rarely occasionally often or very often was coded as 1 the following k10 cutoffs were used to categorize severity levels of psychological distress none mild moderate severe f based on 10 items asking for potential worries related to the covid19 pandemic during the last week rated on a 7point likert scale items were dichotomized g defined as the number of objective indicators of social risk abbreviations ci confidence interval or odds ratio sd standard deviation pfwe familywise errorcorrected pvalues were computed by multiplying the unadjusted pvalue by the total number of independent variables to adjust significance levels na not applicable a based on the following item do you think that an mhealth app could help you deal better with the corona situation binary variable answering strongly disagree disagree or neithernor was coded as 0 whereas answering agree or strongly agree was coded as 1 thus individuals who had a negative or neutral attitude toward using an mhealth app were compared to those with a positive attitude model adjusted for age and gender and objective indicators of social risk e the following k10 cutoffs were used to categorize severity levels of psychological distress none mild moderate severe f based on 10 items asking for potential worries related to the covid19 pandemic during the last week rated on a 7point likert scale items were dichotomized g defined as the number of objective indicators of social risk to conclude digital interventions may help to mitigate the negative impact of the covid19 pandemic on youth mental health as there is a subjective demand and objective need smartphonebased mhealth apps are particularly suited to provide lowthreshold and timely public mental health care in times of physical distancing and quarantine as the quality of evidence of currently available apps in major app stores is often unknown or very limited 54 55 56 57 58 59 there is an urgent need to develop and evaluate digital interventions specifically designed to address social isolation and poor mental health to actively prepare for a potential worsening of the current pandemic as well as future health crises make these evidencebased digital interventions publicly available to improve public mental health and develop digital strategies for continued mental health care as well as mental health promotion and prevention of mental disorders finally decisionmakers and stakeholders in the area of public mental health should work on systematically evaluating currently available digital interventions to support young users to find evidencedbased digital tools which are most helpful for their individual preferences and current needs 60 61 62 financial support this work was supported by a dfg heisenberg professorship to ur and a living lab grant by the federal ministry of science education and culture of the state of badenwürttemberg germany to ur dd gk and sk the funders of the study had no role in the collection analysis and interpretation of data in the writing of the report and in the decision to submit the paper for publication the corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication conflict of interest all authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this manuscript data availability statement the data that support the findings of this study are available from the corresponding author ur upon reasonable request

background public health measures to curb sarscov2 transmission rates may have negative psychosocial consequences in youth digital interventions may help to mitigate these effects we investigated the associations between social isolation covid19related cognitive preoccupation worries and anxiety objective social risk indicators and psychological distress as well as use of and attitude toward mobile health mhealth interventions in youth methods data were collected as part of the mental health and innovation during covid19 surveya crosssectional panel study including a representative sample of individuals aged 1625 years n 666 m age 213 assessment period may 5 2020 to may 16 2020 results overall 38 of youth met criteria for moderate or severe psychological distress social isolation worries and anxiety and objective risk indicators were associated with psychological distress with evidence of doseresponse relationships for some of these associations for instance psychological distress was progressively more likely to occur as levels of social isolation increased reporting never as reference group occasionally adjusted odds ratio aor 91 95 confidence interval ci 43191 p 0001 often aor 222 ci 98502 p 0001 very often aor 423 ci 1411268 p 0001 there was evidence that psychological distress worries and anxiety were associated with a positive attitude toward using mhealth interventions whereas psychological distress worries and anxiety were associated with actual use conclusions public health measures during pandemics may be associated with poor mental health outcomes in youth evidencebased digital interventions may help mitigate the negative psychosocial impact without risk of viral infection given there is an objective need and subjective demand

background stigma and discrimination based on sex gender identity and sexual orientation significantly impact all aspects of the lives of sexual and gender diverse people 1 including people who identify as lesbian gay bisexual transgender queer or questioning and other sexual sexand genderdiverse people and people with intersex traits 2 3 4 5 under international human rights law discrimination on the basis of sexual orientation is a human rights violation 6 the firstever united nations resolution on sexual orientation and gender identity was published in november 2011 it requested a report by the office of the high commissioner for human rights which stated homophobic and transphobic violence has been recorded in all regions such violence may be physical or psychological these attacks constitute a form of genderbased violence driven by a desire to punish those seen as defying gender norms 7 in this study we adopted t 8 he definition of stigma from link and phelan who conceptualise stigma as the cooccurrence of labelling stereotyping separation status loss and discrimination 9 in which power is exercised 10 discrimination happens at an individual level where one faces unequal treatment 1112 and at the structural level where societies constrain a persons opportunities resources and wellbeing 4 homophobic reactions entail emotional intellectual and behavioural reactions 13 towards sexual and gender diverse people in this study we consider homophobia as a particular case of stigma or discrimination based on sexual orientation and gender identity 14 discrimination based on sexual orientation intersects with other forms of discrimination towards various groups including those related to race 1516 gender identity 17 age 18 hiv status 19 disability and socioeconomic status 2021 evidence suggests that stigma and discrimination impede the health and wellbeing of sexual and gender diverse people 22 according to the joint united nations programme on hivaids national commitments and policy instrument 70 countries have discriminatory and punitive laws that criminalise people who engage in samesex sexual relations and 20 countries criminalise or prosecute transgender people 23 consequently they are less likely to access health services due to stigma and discrimination 24 and bear a disproportionate burden of adverse physical and mental health outcomes 25 evidence suggests that factors such as stigma discrimination and violence based on sexual orientation and gender identity and the criminalisation of samesex sexual behaviour lead to elevated rates of emotional distress and adverse mental health conditions 18 hindering the availability access and uptake of prevention testing treatment and care for hiv sexually transmitted infections and mental health services 19 the criminalisation of samesex sexual behaviour in africa was found to be correlated with lower rates of hiv testing and higher hiv prevalence among gay men and other men who have sex with men 26 a study of transgender women in argentina showed that those who had experienced discrimination in healthcare settings were three times more likely to avoid healthcare settings than those who had not 27 sexual and gender diverse people face overlapping forms of vulnerabilities related to mental health conditions 28 they are at higher risk of anxiety depression suicidal ideation substance misuse and deliberate selfharm than heterosexual people 29 mental health conditions further increase the risk of hiv infection and people living with and affected by hiv have an increased risk of these conditions which are in turn associated with lower retention in hiv care increased risk behaviours and lower engagement with hiv prevention 6 evidence suggests that sexual and gender diverse adolescents and young people experience higher rates of depression and anxiety and are disproportionately at risk of selfharm and suicide than other adolescents and young people 30 the prevalence of depression across surveys of people living with hiv in subsaharan africa is estimated at 24 compared with less than 3 for the general population 3132 efforts to improve data collection in sexual and gender diverse people are important for monitoring healthcare outcomes and designing healthcare services and programmes while sex disparities are well documented in public health through nationally notifiable surveillance data population studies and sentinel surveillance they stratify by binary sex and only include male or female sex as assigned at birth which leads to an incomplete understanding of the burden of disease in sexual and gender diverse communities and limits the effectiveness of health and hiv prevention and care programmes 33 moreover the quantitative evidence of the factors driving mental health disparities in sexual and gender diverse people is particularly deficient in lowand middleincome countries this study aims to examine the association between the severity of the symptoms of anxiety and depression and factors affecting the wellbeing and livelihood of sexual and gender diverse people using quantitative methods and the data from a global lgbt survey the study assesses this relationship for specific factors such as homophobic reactions stigma or discrimination at the workplace and in healthcare facilities economic vulnerability lack of social support and hiv status among people who selfidentify as gay men bisexual men transfeminine and queer or questioning men the study explores two questions is there a link between the mental health distress measured by the severity of anxiety and depression symptoms in sexual and gender diverse people and the above socioecological factors if there is a link does it differ between selected lgbt communities methods the analysis presented here draws on the results of the lgbt happiness survey which collected data from sexual and gender diverse people aged 18 years and older without geographical restrictions the survey aimed to generate data for sexual and gender diverse people across countries providing a snapshot of the populations characteristics of interest and outcomes it captured information on demographics economic situation factors influencing happiness wellbeing health hiv stigma or discrimination the survey also considered challenges faced by sexual and gender diverse populations across countries such as symptoms of depression and anxiety and experiences of or apprehension about hivrelated discrimination including in healthcare or the workplace the survey design was developed collaboratively by unaids the lgbt foundation the university of aixmarseille the medical school of the university of minnesota and representatives of the lgbt community consenting sexual and gender diverse participants were recruited between may 2019 and january 2020 through social networks lgbt activists more than 300 global regional and national lgbt communitybased organisations and development partners participation was through an anonymous selfadministered and encrypted internetbased questionnaire in 32 languages questions could be answered using a computer mobile phone tablet or another internetlinked device communitybased organisations provided access to the internet in several african and caribbean countries where access to the internet was limited the survey purposefully did not use cookies geographic or other identifiers thus ensuring anonymous and safe participation this was important for participants who fall within socially marginalised or stigmatised groups in their country and for people who wish to exercise their right to privacy participants were provided with five options for sexual orientation attracted to men or who identify as gay attracted to women or who identify as lesbian attracted to both women and men or who identify as bisexual those who identify straight or heterosexual those who do not know or identify as questioning regarding gender identity options were man woman transmasculine transfeminine or nonbinary options for sex at birth were male female or person with intersex traits more than 115000 participants from more than 200 countries and territories responded to the survey over the may to december 2019 study period the attrition rate was 22 following a review of completed questionnairesfor example removing participants under the age of 18 the studys final sample was 197 countries with 112053 sexual and gender diverse participants including those who identify themselves as lesbian gay bisexual transgender queer or questioning other sexuality sexand genderdiverse people and people with intersex traits a small proportion of the sample indicated they were living with intersex traits the detailed research protocol and the questionnaire are available in the supplementary material description of variables dependent variable we explored the predictors of symptoms of anxiety and depression among sexual and gender diverse people depression and anxiety are the most common mental disorders and frequently occur together we used the patient health questionnaire a crosscultural validated 31 34 35 36 37 38 39 40 41 fouritem questionnaire set up to detect symptoms of depression and anxiety manifestations among our subsamples sexual and gender diverse groups 4243 it comprises two items on depression feeling down depressed or hopeless having little interest or pleasure in doing things and two items on anxiety feeling nervous anxious or on edge not being able to stop or control worrying possible answers follow a 4item likert scale ranging from 0 1 2 and 3 the possible scores ranged from 0 to 12 the index was categorised into none mild moderate and severe we tested the robustness of the index using the cronbach alpha coefficient the value of the scale reliability coefficient was 086 which validates the internal consistency of our index independent variables a set of socioeconomic control variables were first included for each of the sexual and gender identities included in this study such as age education economic vulnerability and the recency of hiv test as a proxy of possible risk exposure to hiv 44 respondents had to choose between the following options within the last 6 or 12 months more than 12 months or never thus two dichotomous variables related to discrimination and stigmatisation of sexual and gender diverse people the experience of homophobic or transphobic reactions considered whether the respondent had ever been intimidatedstared at andor verbally insulted andor physically assaulted during the last 12 months or more or not stigma and discrimination at the workplace considered whether in the last 12 months the respondent had their application refused was harassed or ridiculed at the workplace was not promoted was told not to show them being a member of the sexual and gender diverse people or was denied certain workrelated benefits because of who they are stigma and discrimination in healthcare considered whether in the last 12 months the respondent experienced verbal or physical abuse was given a condition to change their sexual behaviour or gender identity or was refused services finally models included two sources of perceived social support 45 family and friend support these variables were assessed with the following questions my family accepts me as i am and there is someone i can count on if things go wrong possible answers followed a 4item likert the variables were dichotomised between those who agree or strongly agree and those who disagree or strongly disagree statistical model the intuitive model to address the research question would be the ordered logistic model however such model is conditional on the proportional odds assumption this key assumption says that the slope of the logistic function is the same for all category cutoffs of the outcome variable 46 in the present case the brant test 47 concluded that the parallel regression assumption was not met ie the slopes of the four stages of the patient health questionnaire are not parallel in other words the differences between each stage were not identical the test results are presented in supplementary material s2 therefore we developed a multinomial logistic model to adequately reflect the variable characteristics 48 this technical choice further enabled us to capture the evolution of the independent variables at different severity scores for depression and anxiety symptoms the base category was no symptoms of anxiety or depression the multinomial logistic regression model detects determinants that increase or decrease the relative risk for a participant to suffer from symptoms of anxiety or depression considering the possible biases inherent to conveniencebased online sampling methods where participants tend to be younger and more educated 4950 we included variables age education and geographicalcontinental as covariates in the regressions we applied a conservative approach to the sample size using the criteria of total completion ie the regression models only considered participants who informed all variables in the models we did not impute missing variables in addition we successfully tested whether the participants who did not inform their hiv status could create a systematic bias on the dependent variable see supplement s3 we performed the model for the four sexual and gender diverse groups studied for each model we assess the validity of the results the likelihood ratio showed that the independent variables contribute significantly to the predictions of the model all statistical regressions and tests were performed on stata 17 and the results were considered significant at p 005 ethical approval the design of the global lgbt happiness survey used in this study was developed collaboratively by unaids the lgbt foundation the university of aixmarseille the medical school of the university of minnesota representatives of the lgbt community and other stakeholders the survey was approved by the research board of ethics of aixmarseille university and the research ethics review committee of the world health organization all study methods followed the guidelines and principles of the declaration of helsinki and the sex and gender equity in research participants had to provide their informed consent prior to accessing the survey the survey protocol fully complied with the european unions general data protection regulation participation was voluntary and no monetary incentive was given to complete the questionnaire participants could skip questions or exit at any stage of the questionnaire participants who did not provide a numeric value for age or below 18 were excluded from the study the survey did not collect any identifier or geolocation data although participants could selfreport their country of residence role of the funding source the funders of this study had no role in study design data collection data analysis or data interpretation all authors had full access to the data in the study el and bv had final responsibility for the decision to submit for publication results descriptive statistics table 1 presents the sociodemographic characteristics of the sample among the 108389 participants more than two third identified as gay bisexual and queer or questioning participants represent about a seventh of the sample and transfeminine people account for four per cent of the participants the proportion of participants suffering from moderate or severe symptoms of anxiety and depression represents almost a third of the whole sample we noticed that transgender women are the most affected with 39 reporting moderate to severe symptoms of anxiety and depression participants who identified as queer or questioning are the second most affected group with 348 reporting moderate to severe symptoms of anxiety and depression over a third of the participants are adults aged 25 to 34 the highest proportion among young the selfreported hiv prevalence among all participants is 98 with the highest hiv prevalence being reported among gay men and the lowest among bisexual men these figures should be considered together with the high proportion of participants unaware of their hiv status gay men have the lowest rate of unknown hiv status in comparison more than a fifth of bisexual transfeminine and queer or questioning participants are unaware of their hiv serostatus homophobic stigmatising or discriminatory reactions are largely prevalent among all sexual and gender diverse groups with seven in ten participants reporting having faced such reactions bisexual men are the community reporting the lowest percentage of such reactions while more than threequarters of transfeminine participants reported facing such reactions more than one in seven participants declared facing stigma or discrimination at the workplace the transfeminine persons reported the highest proportion of stigma or discrimination at the workplace with a quarter of them facing such stigma or discrimination in the last 12 months almost one in five queer or questioning participants declared facing stigma or discrimination at the workplace overall 68 of participants indicated they had suffered from stigma or discrimination at health facilities transfeminine persons are the community declaring the highest proportion of stigma or discrimination at a healthcare facility with 153 confronted with it followed by queer or questioning participants gay men reported the highest perceived social support with more than half having their family supporting them and nearly three quarter benefiting from the support of their friends transfeminine reported the lowest level of support from their family and friends statistical models on the severity of anxiety and depressive symptoms figures 1 2 3 and 4 below present the results of the multinomial regressions for respectively gay cisgender men or living with intersex traits bisexual cisgender men or living with intersex traits people transfeminine people and queer or questioning cisgender men or living with intersex traits people the complete regressions tables can be found in supplement s4 for gay men the risk of having severe symptoms of anxiety and depression is 11 higher for those living with hiv it increases to 27 for those who do not know their hiv status regarding economic vulnerability the risk of having severe symptoms of anxiety and depression for gay men struggling with present income is 318 times that of those living neither comfortably nor struggling on present income the risk of having severe symptoms is reduced by 48 for those living comfortably on their present income in other terms economic empowerment is associated with lower symptoms of anxiety and depression whereas poverty is associated with increased symptoms of anxiety and depression access to social support whether through family or friend support decreases the relative risk of having symptoms of anxiety and depression for each 1unit increase in family support the risk of having severe symptoms of anxiety and depression decreases by 255 similarly for each 1unit increase in support from friends the risk of having severe symptoms decreases by 462 facing homophobic reactions is strongly associated with increased symptoms of anxiety and depression among gay men the risk of having severe symptoms is 220 times higher for gay men who have faced homophobic reactions facing homophobia at the workplace increase the risk of suffering of severe symptoms of anxiety and depression as well with a rrr of 187 figure 2 shows that most results for bisexual men are similar to those of gay men with one notable exception the risk of having severe symptoms of anxiety and depression is 42 higher for those unaware of their hiv status figure 3 shows that transfeminine people facing economic hardship are 287 times higher risk of having severe symptoms of anxiety and depression relative to those with no symptoms the risk of having severe symptoms of anxiety and depression is 67 higher for those living with hiv transfeminine people who do not know their hiv status have a 41 higher risk of severe symptoms than those with no symptoms as the stigmatising and discriminatory reactions faced by transfeminine people increase by one unit the risk of having severe symptoms of anxiety and depression increases by a factor of 347 relative to those with no symptoms figure 4 shows that the relative risk of queer or questioning participants having severe symptoms of anxiety and depression is 242 times that of those living neither comfortably nor struggling on present income the risk for queer or questioning people having severe symptoms of anxiety and depression is 31 higher for those who do not know their hiv status compared to those who are hivnegative like transfeminine people queer or questioning people facing homophobic stigmatising and discriminatory reactions have a high risk of reporting severe symptoms of anxiety and depression relative to those with no symptoms their risk of severe symptoms is multiplied by a factor of 272 for those who faced homophobic reactions and by 191 for those facing stigma or discrimination at the workplace we conducted two postestimation tests to assess the robustness of our results first we have investigated potential multicollinearity issues between the independent variables the variance inflation factor was 122 showing that multicollinearity did not threaten our model we conducted a likelihood ratio test using mlogtest a user command 51 for stata results have shown that every independent variable contributes significantly to the models predictions discussion this study explored the role of stigma discrimination economic vulnerability and hiv status in the severity of depression and anxiety symptoms among 108329 participants including those living with intersex traits from 161 countries who identify as transfeminine people gay bisexual and queer or questioning men four multinomial logistic regressions enabled us to study the evolution of each predictor on the symptoms of anxiety and depression for each sexual and gender diverse group we found that almost a third of the sexual and genderdiverse participants reported suffering from moderate to severe symptoms of anxiety and depression this proportion rose to almost four in ten among fig 1 gay cisgender men or living with intersex traits association between the severity of symptoms of anxiety and depression and socioeconomic factors transfeminine people and more than a third for queer or questioning men these scores of the severity of anxiety and depression are substantially higher than the ones for the general population which is around 4 52 overall we found that for each sexual and gender diverse population group younger age low education and income level seropositivity homophobic experiences and stigma or discrimination at the workplace and healthcare are associated with a greater risk of suffering from or experiencing severe symptoms of anxiety and depression in contrast respondents who have a comfortable income high levels of family and friends support and who are older tend to have a lesser risk of suffering from severe symptoms of anxiety and depression the findings demonstrate the strong association between the severity of depression and anxiety symptoms and economic hardship in all four categories of sexual and gender diverse people this finding is corroborated by other studies among sexual and gender diverse populations 5354 and the general population 5556 this association is particularly acute for gay and bisexual men than for transfeminine people and queer or questioning participants keeping in mind that participants from the latter two communities are also skewed in the lowest socioeconomic tercile the relationship between mental health and hiv risk behaviours has been documented 57 including among sexual and genderdiverse people 58 59 60 the study found that the likelihood of reporting severe symptoms of anxiety and depression is significantly higher for those living with hiv 61 transfeminine people are the most exposed group with more than 80 higher likelihood for those living with hiv to suffer from severe symptoms of anxiety and depression the study further found that gay and bisexual men with severe symptoms of anxiety and depression are statistically more likely to ignore their hiv status these findings matter as poor mental health is associated with increased hiv risk behaviours such as unprotected anal intercourse increased number of sex partners poor hiv continuum of care 62 and negative physical health decisions 63 it highlights the importance of including mental health support in hiv programmes 61 this is essential for countries health systems to reach the sustainable development goal 3 ensure healthy lives and promote wellbeing for all at all ages the survey demonstrated that the social support provided by family and friends are two essential components associated with no or low symptoms of anxiety and depression these findings confirm earlier studies 4557586465 lower symptoms of anxiety and depression are associated with support from friends among all sexual and gender categories studied the relation between the two is particularly strong among transfeminine people lower symptoms of anxiety and depression among bisexual queer or questioning men are also strongly associated with support from family these findings suggest that public health interventions on mental health with sexual and gender diverse people should increasingly consider the importance of social support from family and friends the study examined three forms of stigma and discrimination i homophobic reactions such as being stared at or intimidated verbally insulted or physically assaulted because someone knew or presumed ones sexual orientation or gender identity ii stigma or discrimination at the workplace and iii stigma at healthcare facilities we found that the severity of the symptoms of anxiety and depression was strongly associated with stigma or discrimination based on sexual and gender diversity corroborating findings from other studies 226667 considering that homophobia is also associated with a reduction in life expectancy of sexual and gender diverse people 68 these findings call for effective measures and legislation to eliminate homophobia stigma or discrimination at the workplace and in healthcare services as it contributes to better health outcomes and economic growth 14 the study has several limitations the first one relates to representativeness the participants were recruited through online social networks and communitybased organisations at global and countrylevel it is based on a nonprobabilistic convenience sampling method that is not meant to represent the sexual and gender diverse population of the countries participating in the study it is generally acknowledged that convenience sampling methods are subject to selection biases compared to probabilistic samples 6970 the degree and direction in which the selection bias of internet convenience sampling may under or overestimate the relationship between sample characteristics and measured outcomes are difficult to predict and control 371 we identified and included demographic covariates associated with the potential bias described above to reduce but not eliminate the fig 3 transfeminine people association between the severity of symptoms of anxiety and depression and socioeconomic factors potential bias 72 73 74 the survey intended to include the different sexual and gender diverse people to our knowledge it is the first time a global survey has tried to reflect this diversity nonetheless the study had to merge population groups into larger categories for the analysis this is the case for example for the queer or questioning category following consultations with sexual and gender diverse representatives this category included participants who identified themselves as gender and sexual diverse people but not as gay and men who have sex with men bisexual or transgender people additional studies on specific population groups are required to reflect the extraordinary diversity and the cultural differences of the large spectrum of sexual and gender diverse people to that effect data are available to researchers upon request a second limitation relates to the fact that the survey questionnaire was selfadministered making it impossible to assess the accuracy of the information provided by participants this includes the selfdeclared hiv status amongst others nevertheless the participation was voluntary anonymous and without any incentive therefore we assume participants had little motive to conceal their preference and hiv serostatus third it is worth noting that some instruments used in the study refer to different periods for example the last homophobic reaction is measured in months and the phq4 for symptoms of anxiety and depression refers to the last two weeks these validated instruments are built based on the expected frequency of the occurrences of the different events they intend to measure finally the statistical model has an underlying limitation the current model analysed the compounding effect of independent factors on symptoms of anxiety and depression the size of the effect of each factor reflects its role considering the existence of the other factors this is a contribution to the research question it does not address how these factors intersect and overlap future studies could explore the intersectionality of hiv homophobia and economic precarity on the levels of anxiety and depression of lgbt communities conclusions this study found that severe anxiety symptoms and depression among sexual and gender diverse people were associated with factors such as low education economic vulnerability and socioeconomic status more importantly the study also identified a strong relationship fig 4 queer or questioning cisgender men or living with intersex traits association between the severity of symptoms of anxiety and depression and socioeconomic factors between hivpositive status and the severity of symptoms of anxiety and depression moreover the association between severe symptoms of anxiety and depression is the highest among those who ignore their hiv status these two findings call for urgent and concrete actions to meet the united nations global targets to end hiv end inequality both findings are particularly acute among transfeminine queer and questioning people three communities that are often under the radar of national hiv programmes the findings also argue for better more integrated mental health and hiv services finally the association between stigma and discrimination and the severity of symptoms of anxiety and depression among sexual and gender diverse people is alarming and pushes for bold structural public health interventions incorporating communitylevel interventions alongside health care provision decisionmakers and practitioners must pursue and intensify their efforts for inclusive public health policies that promote wellbeing without discrimination abbreviations ci confidence interval covid 19 written informed consent was obtained for all study participants prior to accessing the survey participants below 18 years old or who did not provide a numerical value for their age were not included in the study participation in the survey was voluntary and no monetary incentive was given to complete the questionnaire participants could interrupt the survey at any moment with an exit button on every questionnaire page and data were immediately and permanently deleted participants could skip questions they did not feel comfortable with or did not want to answer no trackers identifiers or geolocation data were collected from respondents competing interests the authors declare no competing interests

background sexual and gender diverse people face intersecting factors affecting their wellbeing and livelihood these include homophobic reactions stigma or discrimination at the workplace and in healthcare facilities economic vulnerability lack of social support and hiv this study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse peoplethis study is based on a sample of 108389 gay bisexual queer and questioning men and transfeminine people from 161 countries collected through a crosssectional internet survey we developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptomsalmost a third 303 of the participants reported experiencing moderate to severe symptoms of anxiety and depression higher severity scores were found for transfeminine people 39 and queer or questioning people 348 severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups compared to those who are hivnegative those living with hiv were more likely to report severe symptoms of anxiety and depression and the highest score was among those who do not know their hiv status transfeminine people were the most exposed group with more than 80 higher risk for those living with hiv suffering from anxiety and depression finally homophobic reactions were strongly associated with anxiety and depression the relative risk of severe anxiety and depression was 347 times higher for transfeminine people facing transphobic reactions than those with no symptoms moreover anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilitiesthe strong association between the severity of anxiety and depression and socioeconomic inequality and hiv status highlights the need for concrete actions to meet the united nations pledge to end inequalities faced by communities and people affected by hiv moreover the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming there is a need for bold structural public

coupling human behavior urbanization and flood risk urbanization occurs as a result of two processes urban dynamics inside the city boundary and urban dynamics at the city boundary each of which is influenced by individuals behavior some individuals who seek housing prefer to live within the city boundary while others select newly developed housing in the suburbs therefore modeling these two processes is essential in understanding the role of human behavior in urbanization herein we develop a behavioral urban growth model that employs abm as a class of computational models for simulating the interactions between autonomous entities in the form of agents to investigate their consequences on complex systems and networks 28 our behavioral urban growth model consists of two submodels the relocating model which simulates the dynamics within the city boundary and the growth model which mimics the dynamics at the city boundary as illustrated in fig 1 these two submodels are connected through the supply and demand of the real estate market further information is given in material and methods section of the paper and in supplementary information as the interaction of sellers and buyers in the real estate market shapes the dynamic inside the city boundary the relocating model consists of three agents real estate agent seller agent and buyer agent the real estate agent provides an estimation of housing price using a hedonic price model 29 and assists the negotiation process between sellers and buyers this agent can capture the effect of flood risk on the real estate market by modifying the hedonic price model the seller agent is the other effective entity in the relocating model that participates in this process by providing housing options within the current city limit and adding them to the real estate market as available choices the seller decides to relocate or leave the study region with the aim to maximize its profit in this study we have not evaluated the effect of flood risk on the decision of the seller to relocate therefore the seller agent adds its housing unit to the market regardless of its intention the buyer agent is the third component of the relocating model accordingly buyers represent the households who seek housing that can maximize its expediency whether or not buyers consider the flood risk on their decision they decide where to locate according to two behaviors risknegligence and expected utility 30 individuals with risknegligence behavior do not consider flood risk in their decision as they may or may not be aware of such risk on the other hand individuals who take the expected utility attitude aim at maximizing their utility while considering future flood risk the information regarding modeling the behavior of real estate agent seller agent and buyer agent is provided in material and methods section the growth model on the other hand simulates the process of converting undeveloped lands at the city boundary to developed lands which causes the expansion of the community over time this process occurs as a result of interaction between developers and buyers in the real estate market hence this submodel implemented using cellular automata also consists of three main agents real estate agent developer agent and buyer agent each of which has been described in detail in material and methods section and supplementary information the developer agent can also show two types of behaviors developing under risk and developing without risk based on the flood risk and the expected return from buying undeveloped lands these behaviors are also comprehensively described in material and methods section using the aforementioned urban growth model we propose a framework that accounts for the role of urbanization influenced by human behavior on future flood risk the overall framework consists of fully integrated models behavioral urban growth flood hazard and policy implementation in this study we defined two potential nonstructural flood mitigation measures in terms of socioeconomic incentives these measures include policy i building new educational facilitates and shopping centers in the northern part of the city and policy ii creating green spaces and water bodies in the southern part of the city the details of each model and the aforementioned policies can be found in material and methods section using this framework effective nonstructural flood risk mitigation policies in terms of socioeconomic incentives can be devised that take human behavior into account such policies are more likely to be accepted by the community and will be more effective in shaping urbanization toward safer and less vulnerable areas to floods to the best of our knowledge this is the first framework that incorporates the urbanization dynamics both inside and at a city boundary this point will assist us in evaluating the role of human behavior in shaping urban growth explicitly and at a very high resolution model application the city of boulder shown in fig 2 was selected as the testbed of this study boulder is located in colorado which is among the states that have experienced a high rate of population growth from 2010 to 2020 boulder is an upper middleclass community with approximately 100000 inhabitants 31 home to a worldclass research university a mix of key industry clusters major government research facilities visionary entrepreneurs and a highly educated population boulder has experienced a significant urban expansion in the past halfcentury due to population and economic growth boulder is susceptible to flooding due to its geographical location on the eastern front range of the rocky mountains which contains many streams and creeks the citys assessment of exposure to flood risk reveals that there are about 10000 people and 3600 structures with an assessed valuation of 1 billion within boulders 100year floodplain 31 the city has imposed restrictive regulations in new development and redevelopment activities however the city is still expected to continue to grow as the population estimate for the year 2040 is about 123000 inhabitants if this growth occurs within floodplains it poses further potential risks by adding more exposure to floods and changing the floodplains current regulations do not restrict the redevelopment of properties within floodplains but do require suitable structural and or nonstructural flood protection however these properties would still be subject to flood damage from larger flood events that appear plausible under the effects of climate change in this study we estimated urban growth using the ca model according to the steps outlined in figure s4 in supplementary information effect of flood risk on behavior of driving agents in urbanization using the proposed behavioral development framework summarized above we seek to evaluate the changes in urbanization caused by changes in the behavior of the key actors as influenced by flood risk we first assess the effect of floods on the real estate agent to investigate how flood risk can change the housing prices in the market next we examine how vulnerabilities to floods influence buyers decisions on where to locate we perform statistical analysis to identify the factors that most influence buyers decisions on their locational choices finally we employ this information to identify policies that promote urbanization toward less vulnerable areas to floods in the community using socioeconomic incentives and effect of flood risk on the real estate agent as a first step we performed two sets of analysis examination of historical sale transactions from 2010 to 2020 to train the abm model prediction of the sale prices for 20202040 as illustrated in fig 3 these analyses were calculated by the real estate agent using the hedonic price model introduced in material and methods section the historical data revealed that the housing prices inside both 100year and 500year floodplains are lower than the housing prices outside the floodplains since the real estate agent behavior was trained based on the historical data future projections inside 100year floodplain are expected to reveal the same trend as shown in fig 3 the results of the historical analysis and the projection of sale transactions from 2020 to 2040 for housing inside the 500year floodplain are presented in supplementary information this fact raises a question whether these lower prices will ultimately promote settlement in the floodprone areas compared to less vulnerable regions which will result in rising flood risk this question will be answered in the upcoming sections effect of flood risk on the buyer agent we next performed analyses to assess how individuals decisions are influenced by flood risk with this aim we analyzed the buyers choices on a historical basis for the period of 20102017 under the two behaviors risknegligence and expected utility we calibrated the model for this period by comparing the actual sale transactions to the results from the model for this historical period to validate the model the buyers decisions for the year 2020 were estimated and compared to the actual sale transactions in 2020 the results of historical analysis of the buyer choices under these two behaviors are presented in supplementary information finally we calculated the projections of sale transactions for 2020 to 2040 illustrated in fig 4 to investigate how these interactions between buyer seller and real estate agents would affect the vulnerability to future floods as shown in fig 4 eastern boulder is more vulnerable to floods and this area is selected the most by risknegligence buyers due to lower housing prices inside the floodplains however the northern part of boulder is less susceptible to floods and this area is selected by most expected utility buyers even though housing prices tend to be higher table 1 summarizes the percentages of sales within 100year and 500year floodplains under these two behavior scenarios for the historical records and future projections these results show that when the individual decision is simply based on price implying risknegligence behavior it will result in more choices in floodplains and an increase in future flood risk because the housing prices in the floodplains are less than housing prices outside the floodplains this fact will increase the popularity of such housing within the floodplain policies such as buyout and acquisition would be more challenging for policymakers and local authorities to implement as shown in table 1 the projections of housing choice by buyers reveal that nearly 17 and 29 of the sale transactions under risknegligence behavior are inside the 100year and 500year floodplains respectively while these numbers decrease to 2 and 15 if the choices are made based on the expected utility behavior this means that if the individuals seeking housing are aware of the risk and make a fully informed decision having full knowledge about their choices and their consequences future flood risk can be mitigated since exposure will be reduced this information can be beneficial for policymakers to plan for enhancing the resilience of communities in floods as will be explained in the next section policy implementation as the previous analysis has indicated individuals make more informed decisions in their housing choices regarding future risks when they consider flooding consequences on their locational choices this will reduce the attraction of housing in those regions susceptible to floods therefore the local authority can perform buyout and acquisition with less social and economic consequences thus as a first policy toward enhancing the resilience of communities to floods buyers seeking housing should be informed about potential future flood events and the social and economic consequences that they may incur in the future this information can be provided through the real estate market or other educational programs there have been some initiatives that prove the effectiveness of such programs for example first street foundation a nonprofit organization that provides flood risk at us national level has collaborated with realtorcom a website that provides housing information to buyers this work has resulted in revealing housing information along with their susceptibility to flood risk to buyers 32 such initiatives could gradually increase the knowledge of people about the flood risk and its consequences in a buildings lifetime on the other hand when individuals adopt a risknegligence attitude toward flood risk they decide to purchase a home solely based on the housing price which simply represents a bundle of building and environmental characteristics acreage building age square footage number of bedrooms and neighborhood quality in this study neighborhood quality is defined as the accessibility of the area to highways education facilities city center water bodies and lakes parks and green spaces one may ask which of these features have a higher impact on the decision of individuals the answer can help planners to impose policies that are compatible with peoples behavior resulting in enhancing resilience in a community and using a bottomup policymaking process to protect future generations in flooding events the subsequent section will help to answer this question driving factors in buyers decisions to adopt policies that are compatible with human behavior we should have information about the factors that most influence buyers decisions on where to locate assuming that the buyers are not fully informed about the vulnerability of a property to flood risk they decide their housing location solely based on housing price using a risknegligence behavior explained in material and methods section the housing price is a bundle of bedroom numbers square footage acreage building age and neighborhood quality here we investigate the importance of each of these characteristics on housing price and consequently the buyers decision on their locational choices such information can help to adopt suitable socioeconomic incentives in less susceptible regions to shape the urbanization on creating sustainable communities and cities in floods accordingly we performed three statistical tests to find the relative importance of the aforementioned housing characteristics on the housing price the first statistical test is an analysis of variance to investigate the different weights that the critical featuresbedroom number square footage acreage building age and neighborhood qualityhave over the housing prices using eq explained in material and methods section and trained for the buyer agent the independent variables in this equation are excluded from the housing price model one by one and the change in the coefficient of determination which is a statistical measure indicating how much variation of a dependent variable is explained by the independent variable is determined the results presented in table 2 indicate that the neighborhood quality term has the highest impact on r 2 in other words the neighborhood quality term is more responsible for the housing price variation in comparison to the other factors considered above the second statistical test involves a 2d heatmap shown in fig 5 that indicates the correlation between the features influencing the risknegligence behavior of the buyer agent and housing prices as fig 5 illustrates there is a strong positive correlation between the housing price and neighborhood quality as found previously the next most influential variable is building age which has a negative correlation with the housing price it is interesting to note that square footage and acreage are only weakly correlated to housing prices the third and final statistical test is a principal component analysis a dimensional reduction technique used to reveal strong patterns in a dataset 33 in simple words pca is a method of extracting the most influential parameters in a dataset first the dataset needs to be standardized for overcoming scaling impacts and other features that may inaccurately affect the analysis second the number of principal components is calculated by drawing a horizontal line at an eigenvalue equal to one the number of components with an eigenvalue larger than one equals the number of main principal components the pca reveals that housing prices consist of two main principal components which are responsible for about 40 and 30 respectively of the variation in housing prices the results of this analysis are provided in supplementary information the pca analysis was used to construct the biplot graph illustrated in fig 6 in which the size of each vector represents the importance of that variable on the housing prices while the angles between the vectors describe the effect of each variable on the others smaller angles indicate a stronger dependence moreover the angle of each vector to the xand yaxes represents the importance of that feature on the main principal components figure 6a shows that neighborhood qualitydefined as accessibility to highways education facilities city center water bodies and green spacesis the characteristic among housing features that is most important to identify the dominant contributor to neighborhood quality among these terms we construct the second biplot graph illustrated in fig 6b using pca figure 6b shows that in rank order accessibility to education centers highways city center water bodies and green spaces are the most critical features impacting neighborhood quality effect of flood risk on the developer agent our next step is to assess how flood risk affects the behavior of the developer agent and how the policies extracted from the previous step can be applied in the future urban expansion of the community by the developer agent at the city boundaries to achieve sustainable development we evaluate the projected growth of boulder for the year 2040 under the four different development scenarios identified in table 3 and fig 7ad these scenarios are explained in detail in material and methods section these figures show that if the developer agent makes a riskinformed decision for buying undeveloped lands and converting them to developed lands she selects northern boulder instead of eastern boulder for future development due to a higher expected return since the lands adjacent to eastern boulder are more susceptible to floods moreover as the previous analysis of policy implementation has shown the most important factor governing household decisions as to where to locate is the neighborhood quality accordingly we define two policies to increase the neighborhood quality on northern and southern lands adjacent to the current city boundary that are less vulnerable to flood events based on policy i we build educational facilities as well as shopping centers in northern boulder policy ii focuses on building parks and water bodies in southern boulder projections for policies i and ii are illustrated in fig 7cd revealing that adopting these policies will direct the future development toward the northern and southern regions at boulder where are less susceptible to future flood scenarios table 3 also summarizes the percentage of each development scenario falling within the 500year floodplain these results show that if the developer does not consider the risk on the initial analysis it will result in the highest percentage of future development in floodplains and consequently increases the flood risk in the future discussion the framework developed in this study enables planners to investigate the role of human behavior in achieving resilient communities susceptible to floods through sustainable development this framework is a holistic toolset that helps a community to adopt risk mitigation policies that are compatible with human behavior such policies will be more acceptable to people than other nonstructural flood mitigation measures such as acquisition and buyout that require large social and economic investments the core strength of the proposed framework is the behavioral urban growth model which is the integration of the relocating model that simulates the dynamics of urbanization within the city boundaries and the growth model that mimics the urban expansion at the city boundaries this feature helps us to understand household locational choices table 3 percentage of future residential buildings that are inside the 500year floodplain scenarios percentage of growth inside the floodplains normal behavior 16 riskinformed behavior 7 policy i 5 policy ii 13 the analysis of the real estate agent has revealed that for the testbed used in this study the housing prices are lower inside the floodplains compared to the prices outside the floodplains leading to more sale transactions in the floodplains if the buyer agents exhibit risknegligence behavior such behavior increases housing choices inside the 100year and 500year floodplains to 17 and 29 respectively up to 2040 on the other hand if the buyers exhibit expected utility behavior to make riskinformed locational choices housing choices inside the 100year and 500year floodplains will decrease as much as 2 and 15 respectively this result emphasizes the need for educating individuals who are seeking housing about flood risk to different properties over time this will reduce the popularity of properties in areas susceptible to floods and allow policymakers and stakeholders to implement measures such as buyout and acquisition with less social and economic costs and political resistance neighborhood quality defined as the accessibility to green spaces water bodies highways education facilities and the city center favors areas leading to more choices by the risknegligent buyers in such locations neighborhood quality is most influenced by accessibility to education centers highways the city center water bodies and green spaces these findings encourage planners to adopt socioeconomic incentives according to this rank that promote urbanization in less vulnerable areas in floods leading to reducing future flood risk to the community one point to note is that this rank order may be different for other cities and the detailed proposed framework in this paper can be used to extract the most influential variables in people decisions on their locational choices and be imposed on the community as socioeconomic incentives to shape urbanization toward building resilient communities in floods finally the developer behavior at the city boundary itself can result in safer communities if flood risk is included in their estimation of their expected return all models have limitations and this model is no exception for example in this study we have not considered the geomorphological and hydrological changes in the region brought about by the combined effect of urbanization and climate change which could increase the extent of the floodplains 34 also to model the decision under risk we have assumed that the agents behavior is rational and make a fully informed decision about their locational choices future work will expand the current behavioral study to that of decisionmaking under limited information another avenue of further work could include the role of climate change and how repetitive floodinglearning by experiencemay affect the decision of households under risk finally the current study has been performed for the case of flooding as the dominant hazard in the region but we see no reason the current framework could not be expanded to other hazards as well conclusions in this study we have focused on investigating the effect of human behavior as one of the underlying factors that affects urbanization over time we also examined how perceptions of flood risk can change the decisions of individuals as to where to locate and what characteristics of a neighborhood entice households to make such decisions this information was used to weigh the merits of various nonstructural mitigation measures for flooding in terms of socioeconomic incentives to move urbanization toward creating sustainable communities that are resilient to flooding our proposed framework employs a behavioral urban growth model that uses abm to evaluate the effect of human behavior as influenced by urbanization on community vulnerability to floods the observations from our analysis addressed some of the longstated challenges in considering the human behavior factors that add nonstationarity in future flood risk and render employed disaster risk reduction measures less effective the results demonstrated when individuals make an informed decision about their housing choices housing choices inside the 100year and 500year floodplains are reduced by 2 and 15 respectively moreover under the proper socioeconomic incentives derived from the preferences of individuals on their housing choices the percentage of future urban growth of the community inside the 100year and 500year floodplains can be reduced from 16 to 5 by the year 2040 for the selected testbed in this study we aim that this study will initiate a dialogue in a new direction of quantifying the role of human behavior in flood risk assessment of communities our framework enables policymakers and local authorities to achieve a more accurate picture of the future of their communities to employ mitigation measures for protecting cities from flood hazard and to perform tradeoffs between costs and benefits of future land development in investing in sustainable and resilient communities material and methods behavioral urban growth model urbanization is the process of landuse change that is affected by the interaction of social biophysical economic and political entities 35 individuals behaviorsellers buyers real estate and developersand their interactions affect urbanization over time these behaviors can be influenced by perceptions of flood risk modeling human behavior and its effect on the built environment is a complex endeavor as individuals do not make decisions randomly but decide based on their knowledge characteristics and resources 36 the question that may arise here is that how we can model human behavior abm is a technique that can be used to simulate behaviors of autonomous entities and has applications in geographic and urban systems such as pedestrian modeling traffic simulation residential dynamics and urban growth models of cities and regions this modeling technique provides an opportunity to study the behavior of entities and their heterogeneity on urban systems and their role in shaping their environment 36 the employed behavioral urban growth model in this study uses abm to capture human behavior and its impact influenced by flood risk on urbanization over time this model consists of two parts relocating model which is responsible for simulating the dynamic of urbanization inside the current city limit and the growth model that mimics urban expansion at the city boundary over time these two models are connected through the supply and demand of the real estate market some buyers may prefer to live within the city boundary while others select new housing in suburban areas thus the presence of these two submodels is essential in simulating the urbanization process over time accurately relocating model this model simulates the interaction of real estate seller and buyer agents to assess how the interactions of these agents shape the dynamic of urbanization inside the city boundary to do so the real estate agent provides an estimation of housing prices using a hedonic price model 29 which is a function of the structural neighborhood and environmental characteristics as below the function h trans is assumed to be a linear function of different variables that range from housing charac teristics to proximity to amenities to hazard level the coefficients β are determined by ordinary regression analysis this function is trained using historical datasets from 2010 to 2020 the structural variables used in this model are building age bedroom number bathroom number and square footage the neighborhood and environmental variables considered are accessibility to highways green spaces water bodies city center educational facilities the sale transaction year and the existence within 100year or 500year floodplains as the simulation proceeds the successful transaction will be added to retrain the regression and reassess the coefficients to account for the dynamic of the land market and changes in the housing prices through the years the last two variables in table s1 fld 100 and fld 500 have been added to the hedonic price model to evaluate how the floodplain presence affects the real estate market after training the model with the historical dataset the real estate agent predicts the housing prices in every time step of the analysis this agent estimates housing prices with and without considering flood risk due to the housing location if it is within or outside the floodplains more details of the real estate agent can be found in supplementary information section 111 the seller agent is the other effective entity in the relocating model that participates in this process by providing the housing options and adding them to the real estate market the seller decides to relocate or leave the study region regardless of the incentives she aims to maximize profit for modeling the sellers behavior we need to calculate the number of sellers and the location of sale within each time step the number of sellers is calculated using the yearly number of historical sale transactions within the study region from 2010 to 2020 these numbers are used to determine the mean and standard deviation of a normal distribution then using the distribution characteristics we generate random numbers as the available housings within the market at any time step the location of sale is also calculated randomly from the available housing in the study region more details regarding the seller agent can be found in supplementary information section 112 the buyer agent is one of the most critical components of the relocating model accordingly a buyer is a household that seeks housing that can maximize its utility whether the buyer considers the flood risk on their decision or not she decides where to locate according to two behaviors risknegligence and expected utility these two behaviors are considered to account for a full range of possible actions from the buyer within the market risknegligence happens when a household does not consider risk when she searches for a property to buy this point does not mean that she is unaware of the risk in fact flood risk is not considered as a substantial factor when she wants to offer a bid price therefore their decision about the locational choices is limited to housing prices she forms a utility for a property based on hedonic analysis of sale price that is a bundle of structural and neighborhood characteristics 30 in this scenario the buyer utility function is calculated as below where x i is a vector consisting of housing characteristics that play a role in locational choices by buyers in this study this set includes bedroom number square footage building age and neighborhood quality neighborhood quality is the residual of the hedonic price model for each housing and is defined as accessibility to highways education facilities city center water bodies and lakes and parks and green spaces also a i is the coefficient of such characteristics that shows heterogeneity in the preferences of different people on housing features the summation of a i should be 100 indicating that variation in the sale price is considered in this way we can consider the heterogeneity in agent behaviors that can make the modeling approach more realistic the other behavior representative of household decisions under risk is expected utility initially this is based on the assumption that the economic actorshouseholdsmake a fully informed decision based on the perfect information they have for all of the available housing options in the region in other words expected utility is based on the assumption that households are fully rational agents then based on this theory it is assumed that the households form a utility expectation for each housing unit and they select the unit with the highest utility to reach their ideal preferences to consider the flood risk and decision under a risky situation the utility for a property in floodprone areas is calculated based on eq as below in this equation the coefficient of 025 accounts for the average insurance damage claims which is equal to 25 of the property values 37 this value serves as a benchmark for the average property loss in the case of flooding which households decide on their choice in buying the property moreover u 0l represents the utility of a property without considering the risk to consider the probability of the flooding in the average length of residence which is equal to 10 years in this study eq are used as below h trans h lnh trans β 0 n i1 β i x i u 0l a i x inorm u l 025 u 0l where p is the annual flood probability and n is the number of flooding that can occur within the residence length in this study we assume that each property can experience only three flooding events at most in their life then the utility for properties under flood risk is calculated based on eq as follows where in eq u nloss is a utility gain for a property for a specific number of flood events some details of the buyer agent have been represented in supplementary information section 113 the real estate seller and buyer agents in the relocating model interact through the negotiation process buyers and sellers set an expectation of their bid and ask prices to register a successful sale transaction these expectations should be within a specific threshold using the actual housing prices in the market the real estate agent will provide feedbacks for both buyers and sellers and help to achieve a successful sale transaction if the buyers and sellers stay in the market and experience unsuccessful sale transactions they adjust the expectations of their bid and ask prices to maximize their utility and their profit respectively comprehensive details of the negotiation process are explained in supplementary information section 114 growth model this model mimics the dynamic of urbanization at the city boundary resulting from converting the undeveloped to the developed lands and expanding the city boundary this process occurs because of interaction between the developer real estate and buyer agents the real estate and buyer agents are identical to the relocating agent model on the other hand the developer agent is responsible for providing the housing options as a result of buying undeveloped lands and covert them to developed areas to maximize its profit for modeling the developer agent behavior we use a cellular automata described in detail in supplementary information section 121 cellular automata is a powerful geosimulation tool that has been previously used to model complex geographical systems with nonlinear and evolving characteristics it uses a set of mapssuitability accessibility zoning and neighborhood mapsin a 2d spatial rectangular grid to calculate the transition potential as the probability that defines the evolution in time a transition probability vector is determined within each time step for each cell using the probabilistic function presented in eq 38 in which a t k is accessibility to the transportation network s t k is intrinsic suitability z t k is the zoning status and n t k is the neighborhood effect of the interested cell for landuse k at time t the parameter ϑ is the scalable ran dom perturbation number at time t calculations for these terms can be found in supplementary information section 121 here we modified eq to account for the role of developer agent as shown in eq in this equation the developer preferences are considered as a map adding to the set of suitability z accessibility zoning and neighborhood maps to examine the role of the developer agent and its preferences both in a normal situation and by considering flood hazard if the developer agent considers flood risk in its expected return where d t k is the developer map for landuse k at time t the process of assessing the developer map with and without considering flood risk and the model implementation is thoroughly explained within supplementary information sections 122 and 13 respectively flood hazard module the flood hazard in this study is measured by its frequency intensity and the extent of flooding known as the floodplain we use the coupled hydrologichydraulic analysis in the flood module of hazusmh 39 a loss estimation platform developed by the federal emergency management agency to calculate the floodplain characteristics for various flooding scenarios including 100and 500year return periods based on a review by banks et al 40 hazusmh was identified as the best tool for the flood damage assessment compared to other available tools such as mike flood water ride hydrologic engineering center flood impact analysis in addition tate et al 41 suggested that the results obtained from the default hydraulic analysis in hazusmh are suitable for regional analysis which further confirmed the suitability of using hazsumh in our study since we focused on regional analysis as well it should be noted that uncertainties in the floodplain characteristics calculated by hazusmh are large due to the simplifications in the model moreover changes in surficial geology and hydrology due to urbanization are not considered 11 some studies have quantified these changes by coupling more detailed hydrologichydraulic software such as hechms 42 and hecras 43 to landuse projection models however since the objective of this study is to investigate the effect of human behavior on urbanization and exposure to risk and to introduce a methodology for evaluating different nonstructural strategies in terms of socioeconomic incentives and landuse policies hazusmh is sufficient for our purposes p t k ϑ × a t k × s t k × z t k × n t k p t k ϑ × a t k × s t k × z t k × n t k × d t k policy implementation module in this study we focus on nonstructural flood mitigation measures in terms of socioeconomic incentives that are designed to be compatible with human behavior the behavioral urban growth model reveals information about the critical factors in peoples decisions on their locational choices this information is used to design socioeconomic strategies encouraging households to the safer location gradually with time as the developer agent is responsible for simulating the growth of the community over time the first two scenarios normal behavior and riskinformed behavior are considered to investigate the behavior of the developer agent behavior on urbanization additionally we define the policy i and policy ii scenarios according to the information revealed in the statistical analysis to be applied as the future development plans by the developer agent to shape the communities moving toward resilience each of the development scenarios is explained below • normal behavior this policy is designed to evaluate the developers behavior when the agent does not con sider the flood risk on their decision accordingly the developer preferences are considered using a map calculated by equations s6 and s7 this scenario simulates the situation where the developer agent does not consider the flood risk on how the city expands through years and how the developed areas are selected by buyers • riskinformed behavior this policy is defined to evaluate how the consideration of flood risk by developer agent will change the city expansion over time equations s6 and s9 are used to assess the developer map and expected return based on this scenario • policy i as the statistical analysis has revealed accessibility to educational facilities is the most influential aspect of buyers decision on where to locate after that commercial facilities highways parks and water bodies are important the most based on policy i we build educational facilities as well as shopping centers in northern boulder to promote urbanization in this direction these incentives will affect the suitability term of eq • policy ii policy ii focuses on encouraging urbanization in the southern part of boulder by constructing parks and lakes this will also impact this process by increasing the suitability of southern boulder where is less susceptible to flood events compared to eastern boulder again these incentives will affect the suitability term of eq data availability the data that supports the findings of this study are available from the corresponding author upon request the digital elevation model input for hazusmh software can be obtained from the landuse maps and geospatial information were obtained from the city of boulder and openstreetmap that are already provided in this study code availability the model components have been described in the paper and supplementary information the code required for analysis are available from the first author and corresponding author on request competing interests the authors declare no competing interests additional information

floods are among the costliest natural hazards and their consequences are expected to increase further in the future due to urbanization in floodprone areas it is essential that policymakers understand the factors governing the dynamics of urbanization to adopt proper disaster risk reduction techniques peoples relocation preferences and their perception of flood risk collectively called human behavior are among the most important factors that influence urbanization in floodprone areas current studies focusing on flood risk assessment do not consider the effect of human behavior on urbanization and how it may change the nature of the risk moreover flood mitigation policies are implemented without considering the role of human behavior and how the community will cope with measures such as buyout land acquisition and relocation that are often adopted to minimize development in floodprone regions therefore such policies may either be resisted by the community or result in severe socioeconomic consequences in this study we present a new agentbased model abm to investigate the complex interaction between human behavior and urbanization and its role in creating future communities vulnerable to flood events we identify critical factors in the decisions of households to locate or relocate and adopt policies compatible with human behavior the results show that when people are informed about the flood risk and proper incentives are provided the demand for housing within 500year floodplain may be reduced as much as 15 by 2040 for the case study considered on the contrary if people are not informed of the risk 29 of the housing choices will reside in floodplains the analyses also demonstrate that neighborhood qualityinfluenced by accessibility to highways education facilities the city center water bodies and green spaces respectivelyis the most influential factor in peoples decisions on where to locate these results provide new insights that may be used to assist city planners and stakeholders in examining tradeoffs between costs and benefits of future land development in achieving sustainable and resilient cities floods are among the costliest natural hazards and threaten the lives and livelihoods of millions of people worldwide 1 2 3 4 5 the annual cumulative losses due to various types of flooding are higher than those from largescale disasters such as earthquakes 6 the consequences of flooding are intensified by climate change and socioeconomic development urbanization as a direct result of socioeconomic development exposes more people and their livelihoods to risk 7 8 9 10 11 12 the united nations has projected that 68 of the worlds population will live in urban areas in 2050 compared to 50 in 2020 13 urbanization occurs mainly in lowlying floodprone areas due to accessibility to recreational facilities and agricultural development 14 therefore the interaction of more intense and frequent flooding events due to climate change with the increased exposure brought by urbanization may lead to catastrophic social and economic consequences in the future if not addressed 121516 as a result the united nations has emphasized the importance of sustainable development by building resilient cities and communities subjected to natural hazards including floods as its 11th sustainable development goals sdgs 17 people and their perception of flood riskcollectively human behavioris one of the most significant factors influencing urbanization therefore achieving sustainable development requires a comprehensive understanding of human behavior and its impact on flood risk 18 households real estate developers government and their interactions can create favorable or unfavorable socioeconomic conditions and consequently encourage

introduction selfperception of oral healthrelated quality of life and normative measures are essential for planning of public health policies with prioritization of services as well as for evaluation of the effect of oral health strategies ohrqol is described as a multidimensional construct and refers to the impact of oral health conditions on the daily functions wellbeing and quality of life of individuals environmental and individual factors such as socioeconomic status social capital dental behaviors and clinical status influence subjective oral health outcomes this perspective suggest that clinical factors alone cannot explain the effect of oral health on everyday life social capital has been highlighted as one of the key determinants of health in the whos social determinants conceptual framework this concept has been defined as the features of social organization such as participation in social activities and voluntary organizations norms of reciprocity and trust in others the social interactions within the structure of social allow the discussion about community issues and help participants to act together on objectives and mutual benefits in this context participation in religious groups can be a specific measure of social capital where there is reciprocal exchange of social support among members religiosity have been linked to protective effects against chronic diseases and mortality in children and adults data from nhanes iii epidemiology followup study highlighted the association between church attendance and allcause mortality in middleaged sample of 5449 adults religiosity was also inversely associated with health risk behavior such smoking and alcohol consumption in a crosssectional study with 3674 adolescents moreover high levels of the practice of religion are associated with psychological wellbeing and life satisfaction among young people and related to better selfrated health status among the elderly however some negative associations between religion and health have been reported measures of religiosity were associated with worse selfreported health and obesity risk some studies have been reported the association of religiosity with oral health in children and adults families with religious beliefs showed lower levels of caries and periodontal diseases in addition to clinical findings the association between religiosity practice and selfrated oral health demonstrating that frequent religious practice was a protective factor against fair or poor perception of oral health mirghafourv et al showed that received religious support and religious practice may act as a powerful facilitator for improving the healthrelated quality of life in iranian adolescents girls there are some pathways by which religiosity might lead to better subjective health outcomes religiosity provides adherence to a social network and support from participants which may affect the individuals health by improving health related behavior through the more rapid diffusion of health information and increased access to local services and additional external resources for managing stress furthermore attending religious practice may assist in coping with stressful life events providing greater social support and a source of selfesteem and mutual respect although religiosity have been associated with better dental condition and positive selfperception of health there are no studies regarding the relationship between religious practice and ohrqol especially among schoolchildren thus the aim of this crosssectional study was to evaluate the association between family religiosity and ohrqol in 12yearsold schoolchildren we hypothesized that children with higher family religiosity are more likely to have higher ohrqol material and methods sample we conducted a crosssectional study to assess the oral health status in a representative sample of 12yearold schoolchildren from santa maria a city in southern brazil data was gathered from may to november 2012 santa maria has an estimated population of 261 thousand inhabitants and 85 of these children were enroll in public schools this study was part of a major project including other outcomes thus the sample size calculation was performed to assess the association between cpq1114 scores and different oral health outcomes the final number of the sample was 1134 schoolchildren achieving a power of 70 to detect a significant difference on the frequency of going to the church between those who rated their oral health as goodexcellent and those who rated their oral health as fairpoor a twostage sampling was adopted the primary sampling units were 20 of 39 public schools that were considered representative of all schools in santa maria the secondary sampling units were all 12yearold children who were enrolled in the 20 selected schools all 12yearold children enrolled in the 20 selected schools were invited to participate in the study children with cognitive impairment or those who were not able to read and understand brazilian portuguese were excluded from the study ethical considerations the study protocol was approved by the committee of ethics in research of the federal university of santa maria all children consented to participate and their parents or guardians signed an informed consent form data collection the gathering of data used dental examinations and structured interviews four examiners and three interviewers participated in the study the children oral health relatedquality of life was measured by the short version of the brazilian child perceptions questionnaire the questionnaire was completed at school through facetoface interviews by three trained interviewers the cpq1114 comprises 16 questions and four domains 1 oral symptoms 2 functional limitations 3 emotional wellbeing and 4 social wellbeing each question has five possible answers on a likert scale from 0 to 4 and higher values corresponded to a poorer ohrqol the cpq1114 scores were computed by summing up all scores for each domain and the overall scores ranged from 0 to 64 socioeconomic demographic and religious practice characteristics were collected using a selfadministered questionnaire that was given to the childrens parents and guardians the questionnaire included information regarding sex race parents education household income use of dental service parentsperception of the childs oral health and family religiosity race was classified according to the criteria established by the agency for demographic analysis the brazilian institute of geography and statistics the parents educational level was classified as the completion or failure to complete 8 years of formal instruction monthly household income was measured in terms of the brazilian minimum wage a standard for this type of assessment data regarding the parents health perceptions of their childrens oral health were measured using the following question would you say that your childs oral health is 1 excellent 2 very good 3 good 4 fair or 5 poor religiosity was assessed according to frequency of going to church and time of religious practice by the following questions respectively how often do you go to a church temple or other religious meeting 1 more than once a week 2 about once a week 3two or three times on a month 4 once a year or less or 5 never and how often do you devote your time to religious activities such as prayer meditation bible reading or to read other religious texts 1 more than once a day 2 daily 3 two or more times on a week 4 about once a week 5 a few times on a month or 6 neveralmost never these questions have been used in previous study the feasibility of these questionnaire was previously assessed in a sample of 20 parents during the calibration process these parents were not part of the final sample international criteria standardized by the world health organization for oral health surveys were used for all dental examinations by four examiners children were examined in a room at school with natural light using periodontal the cpi probe and dental mirrors severity of dental caries was assessed by the score of decayed missing and filled teeth index gingival bleeding was assessed by cpi in all six sites per tooth these examiners were trained to assess dental caries and gingival bleeding the data were also calibrated for assessment of dental caries the calibration process was performed prior to the survey by a benchmark dental examiner who had previous experience in epidemiological surveys theoretical and clinical training and calibration exercises were arranged for a total of 36 hours for this purpose a total of 20 children were examined twice by the same examiner with an interval of two weeks between each examination to assess intra and interexaminer reliability statistical analysis data were analyzed using stata 140 software outcomes were overall and domainspecific cpq1114 scores predictor was considered the family religiosity the frequency of going to the church was dichotomized into often and neveralmost never the time of religious practice was dichotomized in once a weekmore than once a week and less than once a week gingivitis was dichotomized as either without or with other independent variables were categorized according to their distribution in the sample all descriptive analyses considered the sample weight using statas svy command for complex data samples unadjusted analyses were conducted to provide summary statistics and preliminary assessments of the associations between the independent variables and the outcomes models were fitted using multilevel poisson regression analysis to assess the association of religiosity and ohrqol the multilevel model considered children as the firstlevel unit and schools as the secondlevel unit the rate ratios and their respective 95 confidence intervals were used to assess the predictors of ohrqol and it corresponded to the mean of cpq1114 scores between the exposed and unexposed groups models building was carried out using statistical and epidemiologic criteria initially a preliminary analysis was carried out using unadjusted models and all variables showing associations with p 025 were considered for the adjusted models monthly household income was maintained following an epidemiological criterion the model excluded the variable fathers level of education and use of dental services from the analysis to prevent multicollinearity with the variable mothers level of education and reason visit to the dentist respectively all final models were adjusted by sex race monthly household income mothers education parents health perception untreated dental caries gingivitis reason visit to the dentist frequency of going to the church and time of religious practice the quality of the fit was measured using deviance and significant changes in the fitting of the models were assessed using the likelihood ratio test results in a total 1134 children were enrolled with a response rate of 93 nonparticipation was typically attributable to the absence of children from school on the day of the examination or a failure of the children to return the signed consent form interand intraexaminer agreement for dental caries ranged from 079 to 085 and from 077 to 082 respectively table 1 summarizes the distribution of the sample according to demographic socioeconomic religious practice and clinical status in relation to the family religiosity characteristics the majority of the families gone to the church frequently and had high religious practice the mean cpq1114 scores ranged from 0 to 43 with a mean of 102 domainspecific scores did not have a large variation scores in the emotional wellbeing and oral symptoms domains had the largest variations family religiosity was associated with mean cpq1114 scores and domainspecific scores in the unadjusted models children whose family reported never or almost never went to church and had less than once a week of religious practice showed higher mean symptom cpq1114 domain scores moreover lower time of religious practice was associated with higher mean overall cpq1114 scores in children the results of the multilevel adjusted analysis of the dental clinical socioeconomic and religious variables for cpq 1114 scores are shown in table 4 religious practice less than once a week was associated with 110 higher mean symptoms cpq 1114 domain scores and 101 higher mean cpq 1114 overall scores in schoolchildren this study identified other clinical conditions that associate with ohrqol a fair or poor parental perception of their oral health and reported toothache had a higher mean cpq1114 scores and domainspecific scores the means of the cpq1114 also was higher for females nonwhite children children whose mothers have not completed primary education and children with gingivitis discussion this study assessed the association between family religiosity and ohrqol in brazilian schoolchildren the time spending in religious practices such as prayers meditations bible reading or reading of others religious texts was associated with better ohrqol in addition parents perception oral health of children mothers education visit to the dentist by pain female nonwhite race and gingivitis also had negatively impacts to ohrqol nonpractice of religious activities or less frequent practice was associated with worst ohrqol only one study assessed the impact of religiosity on health relatedquality of life and its findings showed that religious activities may be considered a powerful facilitator to improving the quality of life in adolescents however there are no studies that link the quality of life regarding oral health participation on religious activities have been described as important features of bounding coping with stress and also encouragement of health behavior therefore practicing religious activities is a feature that facilitates the action of members within a social group thus benefiting health and influencing behaviors that lead to an improvement in ohrqol additionally worse oral symptoms related to quality of life were report by schoolchildren who engage in fewer religious activities in their lives these results are in accordance to previous studies that showed the association between clinical outcomes and psychosocial factors focusing on the best dental conditions presented by people who have higher rates of religiosity these results highlight that religiosity may affect the individuals health by improving health related behavior through the rapid diffusion of health information and increased access to local services and amenities sociodemographic characteristics as nonwhite children and females and parents perception of childrens oral health were negatively associated with orhqol in schoolchildren which corroborates the findings of previous studies clinical conditions as dental caries gingivitis and seek dental care due to pain were also associated with negative impact on ohrqol in accordance with literature some plausible pathways link religiosity to health outcomes religiosity can act as an important social network through the dissemination of health promotion by promoting greater access to health and would promote greater social support acting as a source of selfesteem and mutual respect thus in more active communities people would be better able to solve their own problems or possess better infrastructure to facilitate their involvement community and its actions related to health recent studies reported that religious support and religious practice were positively associated with healthrelated quality of life this pathway appears to provide a plausible mechanism regarding the protective effect of family religiosity on ohrqol thus we propose that as observed for healthrelated quality of life religiosity may affect children ohrqol through a psychosocial pathway our study has some limitations the crosssectional design prevents the establishment of causality between religiosity and ohrqol in addition parents reported religiosity experience through two questions which may not capture the full extension of the impact of religiousness on oral health nevertheless no validated instruments were available to assess religiosity in brazilian population when the present study was conduct the study also evaluated only schoolchildren from public schools finally there is limitation of using religiosity as aspect of social capital it is possible that religious practice may not reflect the differences in individual social capital and we did assess other indicators such trust and social support the strengths of this study are the sample size and its representativeness because 85 of the children are enrolled in public schools of the city in addition previous studies have been used religious practice as a valid measurement to evaluate the social capital and its impact in oral health in conclusion our findings demonstrate that family religiosity was associated with schoolchildrens ohrqol the association may be important to highlighted the participation in communities social movements associations trade unions councils of class and health may favor the creation of social capital and consequently stimulate the adoption of behaviors more consistent with health and better quality of life the implication of this study is that the religiosity assists in coping with stressor circumstances of life for improving the individual social capital therefore religious affiliation provides social network and support from others which may lead to better normative and subjective oral health we suggest that strategies to improve social capital should be considered in the future studies resumo a religiosidade tem sido associada a uma melhor condição dentária e autopercepção positiva de saúde mas não há estudos sobre a relação entre a prática religiosa e qualidade de vida relacionada à saúde bucal especialmente entre escolares assim o objetivo deste estudo foi avaliar a associação entre religiosidade da família e a qvrsb em escolares de 12 anos de idade nós realizamos um estudo transversal em uma amostra representativa de escolares de 12 anos de idade de santa maria uma cidade no sul do brasil um total de 1134 escolares foram avaliados em uma seleção aleatória em 20 escolas públicas da cidade os participantes

religiosity has been associated with a better dental condition and positive selfperception of health but there are no studies on the relationship between religious practice and oral healthrelated quality of life ohrqol especially among schoolchildren thus the aim of this study was to evaluate the association between family religiosity and ohrqol in 12yearold schoolchildren we conducted a crosssectional study in a representative sample of 12yearold schoolchildren from santa maria a city in southern brazil a total of 1134 schoolchildren were assessed in a randomly selected in 20 public schools in the city participants were examined by 4 calibrated dentists minimum kappavalue for intra and interexaminer agreement were 079 and 077 respectively according to dental caries decayed missed filled teeth index and gingival bleeding community periodontal index criteria ohrqol was assessed by the brazilian short version of child perceptions for questionnaire cpq1114 parents or guardians answered a structured questionnaire regarding their socioeconomic status and religious practice data were analyzed using multilevel poisson regression analysis to assess the association of religiosity and overall and domainspecific cpq 1114 scores religious practice less than once a week was associated with higher mean symptoms domain scores and higher mean cpq 1114 overall scores in schoolchildren in conclusion our findings demonstrate that family religiosity was positively associated with schoolchildrens ohrqol

introduction of the estimated 44 million informal caregivers in the united states 35 million are thought to care for cancer survivors 1 as cancer care shifts from the inpatient to the outpatient setting 2 and as individuals with cancer in both early and chronic stages live longer the number of cancer caregivers will grow and their contributions will increase while some may assume that caregiving responsibilities are necessary only in the advanced terminal stages of the disease the importance of this service is evident throughout the disease process 34 similar to caregivers of individuals with other health conditions cancer caregivers experience a range of emotional and psychological reactions as well as physical symptoms 5 6 7 for those engaged in this activity changes in appearance physical needs functional ability social and employment status and family roles and responsibilities combined with the emotional reactions of patients to the disease the treatment process and the higher risk for premature death create emotional psychological and physical distress 8 9 10 adding to the strain is the fact that caregivers commonly take on responsibilities for navigating the health care system managing patient symptoms and sharing or making treatment decisions on behalf of patients 11 12 oncology nurses are wellpositioned to address the needs of cancer caregivers for them to do so however they should have an understanding of the multidimensional aspects of this role in developing interventions consideration should be given to how the experience varies with various factors including the stages of the disease and provision of services by those with different racial and ethnic backgrounds the cancer caregiving experience varies by race white caregivers who care for advanced cancer patients and who report poor relationships with the patients healthcare provider are more distressed than african american caregivers who perceive the relationships similarly 13 in another domain however african american cancer caregivers fare less well compared to whites african americans report more difficulty negotiating time away from work to attend to the new responsibilities that develop from being a caregiver 14 an understanding of how different racial groups negotiate the caregiving experience will provide insight into why some interventions aimed at supporting caregivers have not had substantial effects that is the interventions may not have reflected the needs of diverse populations since only a few studies have explored caregiving by racially diverse populations the present study addressed this gap in knowledge in this effort we examined care given by black and white caregivers caring for lung and colorectal cancer patients the challenges of coping with these cancers are many lung cancer patients report high levels of depression fatigue anxiety pain lung cancer symptoms and poor overall wellbeing 15 among colorectal cancer survivors compromises in quality of life include less strength feelings of tiredness depression and anxiety concern about cancer recurrence and less participation in activities that make access to toilets difficult 16 given the experiences of these patients their caregivers face intense and complex situations while the present study was not designed to test a specific theory we included constructs identified as important to assess when exploring the caregiving process pearlins 1990 stress process model 17 provides a useful framework for understanding cancer caregiving according to this model contextual factors objective stressors and resources contribute to outcomes we sought to determine if race has an independent effect on caregiver objective burden and caregiver resources after controlling for other contextual factors we hypothesized that after adjusting for relevant factors associated with the caregiving experience in both the early and late phases of the disease african american caregivers compared to white caregivers would report greater objective burdens and fewer resources methods caregivers were identified by cancer patients who participated in the share thoughts on care survey 12 conducted by the cancer care outcomes research and surveillance consortium 18 in 2001 the national cancer institute established cancors the consortium which includes five large geographically based sites five cancer research network integrated health systems and 15 veteran hospitals was formed to identify and better understand the reasons that underlie variations in cancer treatment and cancer outcomes the recruitment of newly diagnosed lung and colorectal cancer patients began in 2003 patients were identified through state cancer registries using rapid case ascertainment or identified from medical records minority patients were oversampled institutional review board approval from each study site was obtained and patients provided informed consent the cancors patient survey asked a consecutive sample of patients to name and provide contact information for the person who was most likely to care for you should you need it nominated caregivers were eligible to participate if the caregiver had provided care that was related to the patients current cancer diagnosis two independent samples of caregivers were drawn for the survey one sample consisted of caregivers identified within the first year of patient diagnosis the other sample consisted of caregivers identified after the 1 st year of the patients diagnosis we sent caregivers information about the study a postagepaid return envelope a 20 incentive and a survey a modified dillman method was used to maximize response rates 19 of the 1430 caregivers who were identified within the first year of the patients diagnosis and sent questionnaires and of the 1626 caregivers who were identified after the first year of the patients diagnosis we excluded those that provided information indicating that either the patient did not need care or that the identified caregiver did not provide care those that returned incomplete questionnaires or if the caregivers were not of black or white race also excluded were those whose care recipients were not eligible for cancors based on information provided by the cancors statistical coordinating center these included care recipients who died before the caregiver completed the survey this resulted in a final sample size of 1249 caregivers of which 193 were african american and 1056 were white measuresthe study survey was developed by an interdisciplinary team across study sties measures assessing constructs in the studys conceptual framework based on pearlins model were included a longer description of the measures appears in our previous paper 12 contextual factors caregivers reported their gender age household income from all sources educational level marital status current employment status and their relationship to the patient caregivers reported their current health status using the single selfreported health status item from the sf12 20 additional contextual factors included clinical and health status variables collected by medical record abstraction from the patients record these variables included type of cancer cancer stage at diagnosis and a comorbidity score none mild moderate and severe according to the highest ranked single ailment of the 25 ailments in the adult comorbidity evaluation27 a comorbidity index for patients with cancer to assess other caregiving responsibilities and paid help caregivers were asked do you provide unpaid care to any other adults in addition to your care recipient and do you provide unpaid care for children and asked have you had any paid helpers assisting you or your care recipient as a result of his or her illness mastery was measured with 8 items collectively from the pearlin mastery scale 21 the rosenberg selfesteem scale 22 and the national survey of families and households all of which loaded to a common factor respondents indicated agreement on a fourpoint scale to statements such as on the whole i am satisfied with myself and i have little control over the things that happen to me a single mastery variable was created that consisted of an average of responses to all 8 items objective caregiver burden objective burden included standard and validated measures including number of adls iadls and disease specific measures for crc and lung cancer we collected time spent caregiving number of clinical care tasks performed and number of activities of daily living was based on previous work 23 performed and number of times the caregiver assisted with instrumental activities of daily living for clinical care tasks adls and iadls caregivers responded in reference to the past 2 weeks caregiver resources caregivers indicated whether they received training to help their care recipient manage nausea pain fatigue side effectssymptoms administer medicine or change bandages response options were yes no and not needed with yes responses coded to one and summed to create a training score caregiver preparednessself efficacy was assessed using four items from the preparedness subscale of the family caregiving inventory 24 that measures how confident the respondent feels regarding caring for the patients emotional needs physical needs finding needed services and coping with the stress of caregiving response options ranged from not at all confident to extremely confident on a fivepoint scale a preparedness variable was calculated by averaging the responses across the four items perceived social support was measured with the mos social support scale 24 25 26 27 scale items assess the frequency of receiving specific types of support from none of the time to all of the time exploratory factor analysis identified three subscales of support in this sample emotional informational and instrumental the global social support scale also showed good internal consistency statistical analysessas software was used to perform all statistical analyses descriptive statistics were used to summarize study variables differences in caregiver demographics health status objective burden other caregiving responsibilities and paid help resources available to care for the patient and care recipient health status by race were calculated using the usual twogroup test or the twogroup ttest for unequal variances when needed for continuous variables and the twogroup chisquare test or fishers exact test when needed for categorical variables comparisons were performed separately for each phase of caregiving however these comparisons were not performed separately for care recipient cancer type the two cancer types were combined in order to increase the sample sizes of caregivers in these analyses particularly for the african american caregivers cancer type was considered as one of the clinical characteristics in the univariate analyses and as one of the key covariates in the multivariate analyses analysis of covariance was used to compare racial groups by objective burden and caregiving resources while controlling for key covariates because african americans tend to be diagnosed at a later stage of disease and have higher mortality we controlled for cancer stage and the patients comorbidity score when examining racial disparities in the caregiving experience since caregiving preparedness might be influenced by the caregivers general levels of mastery mastery was included in the caregiver preparedness model pvalues obtained from the ancovas were based on the type iii sum of squares a separate model was examined for each outcome of interest for each model an overall pvalue and a pvalue for the race effect is reported all statistical tests were twosided and were performed using a 5 significance level results african american caregivers returned a lower proportion of mailed surveys than did white caregivers for the earlier and for the later phase of caregiving overall the majority of caregivers were female had at least some college education worked for pay and had sf12 scores that indicated that their health status was slightly below population norms there were notable racial differences in caregiver characteristics in both the early and later phases of caregiving african american caregivers were less likely to be the spouse of the care recipient less likely to be 65 years and older less likely to be male and less likely to be married in the early phase african american caregivers were less likely to be unemployed and their care recipient less likely to have severe comorbidities than whites in the later phase african americans were less likely to have incomes of 80000 or more african american caregivers reported greater objective burden african americans reported more hours per week caregiving for both the early and the later phase of caregiving no significant race differences on other indicators of objective burden were found for the early cancer caregiving phase african americans were more likely to have child care responsibilities a finding that approached significance for caregivers in the later phase african americans reported greater informational social support in both phases of later p 0035 and p 0032 respectively and in the early phase african american caregivers reported more preparedness for the caregiving role our hypotheses that african american caregivers would report more objective burden in both the early and later phases of caregiving were supported in multivariable analyses african american cancer caregivers reported more hours caregiving in the early and in the later phase of caregiving in the later phase of caregiving african americans also reported higher iadl counts and tended to have greater task counts although the latter was not significant our hypotheses that african american caregivers would report fewer personal resources however were not supported african americans appeared better prepared for the caregiving role in the early phase of caregiving african americans tended to have greater informational support and reported greater caregiver preparedness in the later phase of caregiving african americans reported greater instrumental social support discussion to our knowledge this is the first multisite study to explore the caregiving experience in a racially diverse sample of lung and colorectal cancer caregivers in two phases of cancer caregiving our contribution to the literature is significant in the context of african american cancer caregivers engaging in more paid work having less marital support being younger and having less income and more child care african american caregivers perceived greater preparedness for the caregiving role they rose to the challenge of caregiving as reflected in significantly more hours in this role consistent with previous research across a range of health conditions 14 28 29 30 the african american caregivers in our study were younger and less likely to have a spousal relationship with the care recipient the younger age may explain in part the higher proportion of african americans caring for a child and the greater involvement in full time work our study results suggest that caregiver interventions should be tailored to the individuals stage of life and for african american caregivers caring for their loved one with cancer may be in addition to other caregiving and work responsibilities studies have documented cancer caregiving as burdensome for families and impacting quality of life especially if resources are limited 31 32 few cancerrelated studies however have been able to determine whether caregiving burden varies by race in our study african american cancer caregivers reported more hours of caregiving compared to white caregivers african american caregivers in the later phase of caregiving also reported performing more iadls the finding that african americans spent more time in the caregiving role compared to their white caregivers independent of patient stage of disease and comorbidities may reflect a relative lack of other instrumental care resources the greater objective burden african american caregivers carry may be buffered by greater perceived personal resources in the early phase of caregiving african american caregivers reported greater preparedness for the caregiving role these findings may reflect what some researchers have described as a cultural orientation to the caregiving role including a more positive appraisal of their caregiving experience among african americans 33 interestingly the greater preparedness for the caregiving role observed in the early phase of cancer later was not observed in the later phase the reasons underlying this difference are not clear and suggest that factors other than individual level factors may influence how prepared a caregiver feels for the caregiving task african american caregivers in the later phase of caregiving reported greater instrumental support this finding may reflect the fact that caregivers 34 35 feel less prepared for the caregiving role in the later phase and thus relied on greater social support to assist with caregiving future research should explore how this personal resource is integrated into the caregiving experience this study has limitations and strengths the crosssectional design does not allow us to infer causation longitudinal research is needed to test causal pathways in caregiving and to better understand the cumulative impact of caregiving on caregiver and patient outcomes the differential response rates between african american and white caregivers may have also influenced results we do not know if the african american caregivers who responded reflect the african american caregivers in the cancors study finally our paper does not explore burden beyond caregiving duties or tasks for example we do not explore the financial burden of caregiving within this same study sample in a separate paper and analysis we found that the time spent by caregivers in the caregiving role exacted a significant financial burden on caregivers 36 our paper also has several strengths first exploring the experience of caregivers providing support for this group of cancer patients we add to a small but growing literature that examines the caregiving experience in a racially diverse group of cancer caregivers second consistent with the pearlin model of stress we included in our study a number of contextual factors associated with caregiving including caregiver demographics relationship to the patient the caregivers own quality of life assessment and the patients health status as abstracted from medical records before examining the association of race with objective burden indicators and personal resources our finding that racial differences in the caregiving experience persisted even after controlling for this constellation of factors should stimulate future research to better understand the factors that shape the caregiving experience for african americans third using the same study instruments we examined caregiving in two phases allowing for comparisons of the two phases and providing important information on how the caregiving experience may differ at different time points in the cancer trajectory in closing providing quality cancer care should include support of the patient and their caregiver intervention research involving caregivers typically focus on patientrelated outcomes although interventions can improve caregiver outcomes 37 for nurses and other healthcare providers our study has several practical implications first our findings underscore the need for comprehensive and integrated care that includes patients caregivers and providers in a plan that aims to address the needs of the both the patient and the caregiver second providers may affect caregiving experiences and therefore should be careful about making assumptions about availability of and access to resources such as social support and preparedness finally health care providers can support caregivers and patients by understanding that like patients caregiver experiences may change throughout the course of care to better support caregivers oncology nurses should regularly assess the caregiver experience so that interventions reflect the context of caregiving for that caregiver and reflects the changing needs across the cancer care continuum cancer nurs author manuscript available in pmc 2013 july 01

backgroundracial disparities are present in all facets of cancer care however little is known about the types of racial disparities that exist in the informal support provided to patients objectivethis study part of a larger multisite study of care recipients with either lung or colorectal cancer and their caregivers examined the caregiving experiences of african american aa and white caregivers interventionmethodscaregivers were identified by cancer patients in the cancer care outcomes research and surveillance cancors consortium caregivers completed and returned a selfadministered mailed questionnaire that examined their characteristics and experiences analysis of covariance ancova was used to compare racial groups by objective burden and caregiving resources while controlling for key covariates resultsdespite greater preparedness for the caregiving role p0006 aa caregivers reported more weekly hours caregiving than whites 265 ± 31 vs 180 ± 17 p 001 in later phases of caregiving aas reported more social support p 002 more hours caregiving 319 ± 35 vs 169 ± 19 p 001 and performing more instrumental activities of daily living on behalf of their care recipient p 0021 implications for practicenurses play a key role in educating cancer patients and their caregivers on how to effectively cope with and manage cancer because aa caregivers appear to spend more time in the caregiving role and perform more caregiving tasks aa caregivers may benefit from nurse interventions tailored to their specific caregiving experience

introduction foreignborn individuals bear a high proportion of the overall tuberculosis burden in highincome countries 1 in the us immigrants account for 714 of all tb cases and 85 of the multidrugresistant tb cases with mexican nationals comprising nearly 20 in both cases 23 the incidence of tb and mdrtb in the us has declined in the last decade including us states bordering mexico like california and texas despite their reduction in tb incidence between 2009 and 2019 4 5 6 these two states remain among the top four with highest tb incidence 7 furthermore in the texas counties bordering mexico mexican nationals comprise more than 60 of the tb patients 8 the mexican region bordering the us houses a high number of vulnerable populations including drug users illegal immigrants and most recently covid19 patients 9 10 11 12 13 the border has historically attracted immigrants from tb endemic areas like southern mexico and central america 614 in recent years immigrants have progressively accumulated in overcrowded confinements that favor mycobacterium tuberculosis transmission not surprisingly the six mexican border states account for 343 of all tb cases in mexico with tb incidence rates of up to 449100000 in 2016 compared to 138100000 nationally 15 16 17 18 mexico is considered an important migration corridor in the world serving as a country of origin a place of transit and a destination for many immigrants expecting to enter the us 1920 within mexico tamaulipas is a highly dynamic state annually more than 50000 individuals emigrate from tamaulipas to settle in other mexican states eg nuevo león veracruz san luis potosí and coahuila and approximately another 30000 emigrate to the us 2122 nonetheless this population loss is quickly made up by a similar influx of approximately 100000 immigrants coming into tamaulipas each year in search of better job opportunities and improved or safer lifestyles mostly from other mexican states where the economy is depressed such as veracruz san luis potosí and chiapas 21 among the mexicanus border states tamaulipas has the second highest burden of tb and because of its geographical location it serves as a migration waypoint elucidation of the migration patterns of tb patients in tamaulipas would provide a deeper understanding of their contribution to tb incidence in this border state and percolation to the us but such studies are missing the primary objective of this study was to determine the contribution of immigrants to increased tb cases in tamaulipas and identify their place of origin migration destinations sociodemographic characteristics and their likelihood of tb treatment success when compared to local residents material and methods ethics review this study was approved by the institutional review board of the university of texas health science center at houston and the research committee for the secretaría de salud de tamaulipas data source and study population we used data collected for tb surveillance purposes between 2006 and 2013 by the mexican health department for the state of tamaulipas these data included all the new tb cases among patients 18 years and older definitions were based on the official mexican national tb program namely tb diagnosis was based on the detection of acidfast bacilli by smear microscopy or histopathology culture or clinical findings further details on the procedure for selection of 8431 adults 18 years or older with newly diagnosed tb patients were reported elsewhere 23 measures and definitions the primary exposure of interest was immigrant status of the tb patient defined as yes for individuals reporting a place of birth outside of tamaulipas the dataset options included each mexican state or other countries adverse treatment outcomes included failed tb treatment relapse abandon or death treatment was evaluated by merging individual outcomes and categorizing them as successful or not per world health organization definitions 24 drugresistant tb refers to resistance to any firstline antibiotic for tb and mdrtb indicates resistance to both isoniazid and rifampicin patients characteristics previously described in detail 23 included age sex occupation undernutrition diabetes and excess alcohol consumption bcg vaccination based on scarring and hiv serology tamaulipas is divided into different sanitary jurisdictions with those adjacent to the us referred to as border and others as nonborder statistical analysis we used proportions or means to describe the distribution of variables we first evaluated three aspects of migration among tb patients in tamaulipas the proportion of immigrant tb patients their place of origin and their predominant migration routes the chisquare test for trend was used to detect tb incidence rate changes over the eightyear period of study the percent change over time was estimated using both the linear interpolation method and average annual percent change to account for yeartoyear change associations between immigrant status and their sociodemographics comorbidities and tb treatment outcomes were also evaluated univariable logistic regression models were employed to estimate odds ratios and 95 confidence intervals assessing the differences in outcome across levels of covariables all multivariable logistic regression analysis included age and sex and additional analysis was conducted with education status and comorbidities in order to identify the independent contribution of place of birth to tb treatment success adjusted for potential confounders all statistical tests were performed using stata 14 results participants characteristics the characteristics of the study population were described previously 23 essentially the mean age of the 8431 tb patients was 43 years and 655 were males nearly half were unemployed and 58 had at most a primary school education more than 90 had pulmonary tb and 152 had an adverse tb treatment outcome one fourth had diabetes and 53 had hiv we found that the average proportion of patients with tb who were immigrants was 308 over the eight years studied there were minor changes in the proportion of immigrants with tb over time with the lowest in 2006 and 2007 and higher values and high between 2008 and 2013 trend p value 0526 the tb incidence background was maintained similar over the eightyear study period immigration patterns nearly all tb immigrants were born in other mexican states with less than 1 originating from other countries nearly threequarters were residing in border jurisdictions at the time of their tb diagnosis with most in the cities of reynosa nuevo laredo and matamoros most immigrant were born in four mexican states chiapas nuevo leon san luis potosi and veracruz the most frequent destinations for immigrants originating from these four cities were as follows tb patients originating from chiapas were now mostly living in nuevo laredo reynosa and matamoros those from nuevo leon were now mostly in reynosa and nuevo laredo those from san luis potosi had mainly emigrated to matamoros tampico nuevo laredo and reynosa and the tb patients born in veracruz were mainly residing in reynosa tampico matamoros and nuevo laredo characteristics of tb patients associated with immigrant status by place of birth compared to local residents immigrant tb patients born outside of tamaulipas were older decreased odds of bcg vaccination andor decreased odds of having a positive smear for acidfast bacilli at the time of tb diagnosis when evaluating comorbidities immigrants with tb vs those born in tamaulipas had increased odds of diabetes and lower hiv aids when adjusting for sociodemographics a lower odds of a positive afb smear or higher odds of abandoning treatment remained significant analysis was also conducted based on the most frequent states of birth chiapas nuevo leon san luis potosi or veracruz we found that the odds of hivaids was lower in immigrants from chiapas or san luis potosi type 2 diabetes was more prevalent in those born in san luis potosi and veracruz regarding tb clinical characteristics there were no differences between local and immigrant tb patients in the prevalence of the pulmonary location drug resistant tb or smear results except for lower smear positivity for immigrants with tb from veracruz regarding tb treatment outcomes when compared to tb patients born in tamaulipas immigrant born in nuevo leon had a two fold increased odds of tb treatment failure and those born in chiapas had 21fold increased odds of tb relapse when controlling for age sex education level bcg vaccination diabetes and hivaids being an immigrant from nuevo leon remained associated with abandonment of treatment discussion we conducted a study aimed at understanding the epidemiology of tb among immigrants in tamaulipas a mexican state bordering the us we found that immigrants represented onethird of the tb patients with 99 originating from other mexican states among tb patients immigrants were older than localborn residents this was unexpected given that immigrants are usually young and able to travel 1 in our study it is possible that immigrants arrived to tamaulipas when they were younger they may have brought with them a latent tb infection that progressed to reactivation to active tb years laterat the time of this study alternatively they may have had a recent exposure to a tb case with primary progressive tbwe cannot distinguish both possibilities given our crosssectional study design consistent with their older age immigrants with tb had lower levels of education higher prevalence of diabetes and lower bcg vaccination as we have described recently 25 given our recent finding that lack of bcg vaccination at birth is independently associated with higher odds of tb in the elderly it is possible that convergence of these two host factors in immigrants contribute to their development of tb 25 tb immigrants worldwide may be less likely to have treatment success due to various reasons treatment interruption due to their mobile living conditions barriers to access treatment and policy of the host country to provide free tb treatment 2627 in our study abandoning of treatment was not a signature of immigrants as a whole nor among those arriving from san luis potosi or chiapas in particular which are ranked 22nd and 32nd for human development index respectively among the 32 mexican states 2829 in contrast abandonment of treatment was only significant for immigrants born in nuevo leon which has a very high human development index 29 the fact that loss to followup during treatment was not as prevalent in our immigrant population may be supported by the older profile of immigrants who may be already settled in tamaulipas most immigrant tb patients were from out of state and not illegal aliens from another country that could increase their fear of reporting to health authorities fig 1 predominant south to north migration patterns of tb patients from tamaulipas the predominant migration patterns of tb patients diagnosed in tamaulipas is from south and north and to a lesser extent from north to north the south to north routes were from chiapas to nuevo laredo or veracruz to reynosa or san luis potosi to matamoros the north to north pattern was from nuevo leon to reynosa in all cases the final destination cities namely matamoros reynosa and nuevo laredo were in northern tamaulipas and adjacent to the us border the proportion of immigrants from each place of origin towards the indicated destination is shown in the legend for each pathway the names of the other states along the usmexico border as shown as a reference in lighter font when seeking treatment the mexican national tuberculosis program provides free treatment to all tb patients 30 thus our findings are in contrast to the profile of some immigrants who are young refugees asylum seekers or illegal aliens who are under significant stress and develop tb while moving to other countries mexico has a total population of approximately 126 million with close to 50 living in poverty 3132 economic insecurity and drug and human trafficking cartels are main propagators of mexican internal migration movements with about 20 of the population living in states in which they were not born 32 33 34 35 it is locally believed that migration from the poorest regions in mexico may be responsible for a significant proportion of tb cases in the mexican states located across the us border but this has never been systemically evaluated a study conducted 25 years ago among immigrant tb patients identified at local health departments at the four us border states provides some insights 36 of the 164 hispanic immigrant tb patients 154 were born in mexico and ten in central america among the 154 born in mexico 93 had been living in a border mexican town before emigrating to the us and of these 93 51 had first moved to a mexican border town for at least 2 years before emigrating to the us the findings from this study illustrates the influx of immigrants from nonborder mexican regions into the border and then into the usa suggesting the importance of tb control in border and nonborder regions of mexico for control of tb in communities along the texasmexico border 36 our findings provide support for the importance of inquiring on the place of birth as an additional epidemiological risk for tb in these border communities a limitation of our study is that the analysis covered a period dating seven to fourteen years back we do not have data on the proportion of immigrant tb patients in more recent years but we would anticipate an increase this is based on the regional trend for the increase in caravans of immigrants departing from south and central american and caribbean countries where tb is also endemic with hopes of reaching the us but with many remaining stuck in northern mexico 3738 tamaulipas is a remain in mexico state under the immigrant protection protocols implemented in 2019 with top immigrant nationalities from honduras guatemala cuba el salvador haiti and ecuador these policies highlight the epidemiological landscape of the mexican border communities thus we expect that in current times the proportion of immigrants with tb is more than our observed 30 which is already very high we further anticipate there may be a shift in epidemiology from older out of state mexican individuals with diabetes to international and younger immigrants including children living under crowded makeshift conditions at the border and with low bodymass index and stress of migration as risk factors for progression to tb another novel aspect of immigration in contemporary times is the additional challenge to tb control during the coronavirus disease 2019 pandemic in mexican border states poverty overcrowding stress from immigration and lack of access to healthcare have contributed to high covid19 casefatality rates in border mexican states 39 not surprisingly covid19 has had a notable impact on tb services in the usmexico border this together with immigration patterns from south to north is likely to result in higher drug susceptible and drug resistant tb cases in the upcoming years with potential spill over to us border states another study limitation is that we conducted a secondary analysis of data collected for tb surveillance therefore we were not able to calculate the tb incidence among those born in tamaulipas versus immigrants born elsewhere year of immigration was not available either so we could distinguish between migrants who were temporarily located in tamaulipas vs immigrants who had permanently settled in this state furthermore in our analysis we could not adjust for the years of residence prior to tb diagnosis we did not have information on the reasons motivating migration predeparture health status or travel conditions that can increase tb risk 40 we cannot rule out reporting bias due to the stigma associated with migration an association between immigrant status and drugresistant tb was not measured another limitation was lack of access to the identification and treatment of latent tb infection a key action in the pillar 1 of the current who end tb strategy 4142 in summary we find that approximately onethird of the tb patients in tamaulipas are immigrants from within mexico mostly originating from southern states and moving to communities along the us border given the recent increase in migration within mexico due to drugrelated cartels or from latin american countries 43 further studies are necessary to understand in more depth the underlying reasons the detailed migration pathways the prevalence of drugresistance and the tb treatment outcomes in this mobile population understanding these issues will be essential to design strategies for improved tb control in gateway states like tamaulipas such studies will also serve as a model to address the challenge of migration on tb control in other regions of the usmexico border in the adjacent us where immigrants comprise a significant proportion of the tb patients or in other countries worldwide where millions migrate each year from tbendemic regions 44 new contributions to the literature mexico is one of the most important migration corridors worldwide and yet there are few studies addressing the contribution of migrants to tb tamaulipas is a highly dynamic state on the usmexico border here we find that onethird of the tb patients in tamaulipas are migrants with a predominant south to north migration pattern and with endpoint in cities adjacent to the us border there is a need for prospective studies designed to elucidate further details on the motives and timing for migration and the association between migrant status and unfavorable tb outcomes including abandoning treatment as observed in this study data availability the datasets generated during andor analyzed during the current study are available from the corresponding author on reasonable request ethical approval this study was approved by the institutional review board of the university of texas health science center at houston and the research committee for the secretaría de salud de tamaulipas this study was performed in accordance with the ethical standards as laid down in the 1964 declaration of helsinki and its later amendments or comparable ethical standards standards of reporting this study followed the strengthening the reporting of observational studies in epidemiology reporting guidelines publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the mexican state of tamaulipas serves as a migration waypoint into the us here we determined the contribution of immigrants to tb burden in tamaulipas tb surveillance data from tamaulipas 2006tamaulipas 2013 was used to conduct a crosssectional characterization of tb immigrants born outside tamaulipas and identify their association with tb treatment outcomes immigrants comprised 308 of tb patients with 99 originating from internal mexican migration most migration was from south to north with cities adjacent to the us border as destinations immigrants had higher odds of risk factors for tb older age ≥ 65 year old or 24 95 ci 21 28 low education or 13 95 ci 12 14 diabetes or 12 95 ci 11 14 or abandoning treatment adjusted or 12 95 ci 10 15 there is a need to identify strategies to prevent tb more effectively in tamaulipas a mexican migration waypoint

introduction 1 as debates on governance unfold across the social sciences questions of authority and in particular by whom it is held and where it might be found are increasingly bought into view scholars have for example sought to establish whether or not the authority of nationstates is declining in relation to international and local levels of authority and to consider the growing importance of private authority in a variety of fields from urban regeneration to global environmental politics security 1 this article forms part of the work currently being undertaken under the auspices of a philip leverhulme prize and also draws upon research upon funded by the royal geographical society small grants scheme and the transnational climate governance leverhulme trust international network involving a research collaboration between sixteen academics supported by the research assistance of tori milledge at durham university i am grateful to these funding bodies for their support and to colleagues for their contributions to the development of the thinking in this area i would also like to thank ben anderson and matthew hoffman for their thoughtful reflections on the paper as it has been developed and three reviewers for their insightful comments all of which have greatly improved the argument presented the usual disclaimers apply studies to international development however across many of these debates the notion of authority remains curiously unexplored this is a critical omission for this paper argues authority is central to the ways in which governance is accomplished in order to address this issue the paper advances an argument for reconceptualising authority through analysing the modes of authorisation through which it is achieved drawing on theorizations of power which regard it as constitutive of social relations the first half of the paper opens up the potential for authority as a specific form of power characterized by legitimacy or recognition to be undertaken towards at least three purposes instrumental associational and governmental each of which are sustained through particular forms of recognition and compliance and mediated through distinct sociospatial relations in the second half of the paper it considers the case of transnational climate change governance as an arena within which to test this proposition given the sustained debates within this field as to the shifting geographies of authority between publicprivate actors and across different political spaces this provides an important field within which to consider the explanatory value of this approach the analysis suggests that while these modalities of practicing authority are not mutually exclusive they orchestrate the will to govern in significantly different ways with important implications both for how governing is accomplished and for the geographies of global environmental governance in conclusion the paper reflects on the main arguments advanced and considers their limitations as well as their implications for future research between governance and authority broadly speaking governance at whatever level of social organization it may take place refers to conducting the publics business to the constellation of authoritative rules institutions and practices by means of which any collectively manages its affairs central to governing as a specific social relation is authority this stems at least in part from the antecedents of the concept as made explicit by hobbes in leviathan where the term to govern was considered as the capacity to rule with authority that is to rule with some basis in turn this suggests that opening up the process of governance to critical scrutiny involves an engagement with the concept of authority broadly speaking and following weber authority is regarded as the condition in which power is married to legitimacy authority can be considered as a particular form of power distinguished from other currencies of power including coercion selfinterest persuasion and so on by the presence of legitimacy understanding the potential and limits of authority therefore requires further interrogation of the concepts of legitimacy and power through which it is forged authority as legitimate rule authority is commonly understood as the legitimate exercise of power construed as the rightful governance of human action by means other than coercion or persuasion the rightfulness of authority comes from an interpretation of legitimacy as an intersubjective and relational quality whereby actors within a given community come to regard institutions rules and norms as those with which they ought to comply because they are right proper or appropriate essential to the working of authority is therefore its recognition this has important implications for how this particular form of power operates for it suggests that rather than being orchestrated through force the calculation of selfinterest or inducement authorisation is driven by an internal sense of moral obligation control is legitimate to the extent that it is approved or regarded as right further it implies that once accepted as authoritative this recognition means that actors do not seek further justification for compliance with individual decisions but rather accept the judgement of others as one form of power authority therefore stands in contrast to coercion 2 where legitimacy and recognition are absent and power operates through force or other quieter registers of power such as persuasion inducement and seduction where other appeals to reason and selfinterest are made this is not to suggest that relations of authority are freely entered into far from it relations of authority are structured by uneven political economies 2 some theorists suggest that authority and coercion are deeply connected for political authority by definition empowers a ruler to use coercion legitimately others regard coercion and authority as distinct modalities of power separated by the legitimacyrecognition that accompanies authority in this view which this paper adopts while authorisation can be given to governors for the legitimate use of force coercion is a distinct form of unreasoned force what constitutes legitimate force and coercion is of course relational and intersubjective authority in this domain as with others is constantly in the making rather than being an absolute quality and will be regarded differently depending on the relative positions of the actors and entities involved which shape the dynamics of how and with what effect authorisation is given for example in his recent analysis of hegemony in international society clark demonstrates the complex and shifting basis of legitimacy accorded to the us in its various hegemonic guises it is however to suggest that there is a specific quality to authority as a form of power relation and that this matters because coercion and sanction are costly mechanisms of control quite unsuited for regulating activities that require any measure of creativity or enthusiasm it is this distinct quality that leads many to suggest that it authority is central to governing it has been in reconsidering the basis upon which legitimacy and recognition might be established that the notion of authority has most commonly come under critical scrutiny accepting the premise that authority is based on the legitimate or rightful exercise of power the first question that arises is the basis upon which this might be determined frequently authority is interpreted in webers formallegal sense where it is seen to derive from the institutional positions held by actors and specific usually democratic processes however the attribution of legitimacy to different entities has changed historically suggesting that such associations are not absolute furthermore the particular association made between democracy and legitimacy or between certain institutional office and authority is far from exclusive in his foundational work on authority weber identifies tradition religion and charisma as three alternative basses for recognition as agnew argues transparency efficiency expertise accountability and popularity are as much foundations of legitimacy as are rationality and democratic process … thus even ostensibly private entities and supranational governments are often accorded as great or even greater authority than are states acknowledging that legitimacy can take different forms and that public recognition need not mean that a state or public institution must be involved has led scholars to assess the ways in which authority may be accorded to actors beyond the state and to document the rise of socalled private authority this may accrue through recourse to science the market moral authority or to illicit sources in a variation on this theme rosenau describes nongovernmental organisations as deriving authority from several sources morality knowledge reputation issuespecific competence and affiliation in his account of nonstate market driven governance cashore also illustrates how authority is granted to nsmd governance systems by external audiences who are encouraged to accept the nsmd governance system based on economic material benefits moral suasion or because it has become an accepted and understandable practice these insights are useful in displacing the notion of authoritative governance as the sole prerogative of the nationstate and in expanding the basis upon which legitimacy and recognition may be built but do little to challenge a view which regards authority as inhering in the qualities of particular actors and institutions focusing on issues of private authority also brings into focus questions about the entities to which authority pertains given that legitimacy always rests on shared acceptance of rules and rule by affected groups who constitute the community that grants legitimacy and on the justificatory norms they recognize that nature and scope of this affected community is critical to practice of authority the traditional focus of authority as a form of power exercised within the context of the nationstate has meant that affected communities have traditionally been regarded as territorially contiguous and delimited within debates on governance claims are frequently made that such geographies of authority are being rearticulated as authority moves above below and outside the state however as allen suggests for all this talk of a redistribution or shift in capabilities between the different levels of governance the vocabulary of power is still one of capabilities held and the dispersion or distribution of powers between various levels and sites of authority this assumption that authority is a capacity which can be attributed to individuals institutions or particular sets of resources serves to reinforce the sense that if some are gaining authority this must be at the expense of others authority as a modality of power giving sustained theoretical consideration to the ways in which governance is accomplished requires more than an engagement with the basis upon which legitimacy may be established it requires an interrogation of the conception of power upon which notions of authority rest in the main underpinning the conceptualisation of authority there is an ingrained idea of power as an instrument of domination a capacity of some resourceful mix a quantity to be held or divided by actors usually over particular domains while power may operate in different guises of which authority is but one this is often regarded as power that is held by a over b with the result that authority is regarded as the product of an explicit willful agency operating through a bilateral immediate relation there are at least two ways in which such an account of power may be challenged one involves an understanding of power as a general facility for enabling things to happen where power itself is not conceived as a resource but as something generated by the application of resources and skills over tracts of space and time a second approach derives from foucualts conception of power as immanent inseparable from its effects of particular importance to the argument here is one form of power which foucault identifies as government achieved through the conduct of conduct modes of action more or less considered and calculated that were destined to act upon the possibilities of action of other people this involves the gathering of heterogeneous elements … to address an urgent need sometimes termed an assemblage or dispositif and its investment with strategic purpose through this process government operates by educating desires and configuring habits aspirations and beliefs establishing the right disposition of thingsarranging things so that this or that end may be achieved through a certain number of means while facilitative and constitutive perspectives on power differ considerably taken together they offer significant insights into how we might start to conceive of authority differently first rather than being a held and finite capacity both suggest that power is an effect mediated through social relations rather than a zerosum situation in which one actors gain is anothers loss this in turn implies that new spaces of governance may be generative of new forms of power and consequently of authority for hajer the success or otherwise of new forms of network governance depends precisely on their abilities to generate authority second perspectives which regard power as facilitative or immanent allow for the possibility that it can take multiple forms as allen has so eruditely explained power relations are always of a specific kind be that of domination authority coercion seduction inducement and so on so that there is a need to pay close attention to their distinctive characteristics and circumscribed consequences indeed as discussed above authority is often distinguished from other forms of power allens analysis takes this argument further by suggesting that critical to the understanding of power is not only its form but to what purpose it is exercised power may be deployed instrumentally so as to bend will or after arendt through association creating a common will while allen suggests that different forms of power may be deployed to different purposes notably discussing the instrumental and associational qualities of authority as one example this aspect of his analysis remains underdeveloped if both form and purpose are central to modalities of power as they are practiced then further work is required to tease out just what this means in analytical terms furthermore allen stops short of considering other purposes to which power may be effectuated in particular his analysis suggests that where power is regarded as immanent as for example in the work of foucault its differences are subsumed to such a degree that it becomes ubiquitous however central to foucaults work is the recognition that power as sovereignty discipline government operates in different modalities each of which is invested with distinct purpose drawing these insights together suggests that any given form of power as the effect of mediated social relations may be endowed with instrumental associational or governmental purpose authority as one form of power could be enacted instrumentally affected in association or orchestrated through government on this basis the imperative for understanding the ways in which governance is accomplished becomes one not one of establishing the authority of particular actors or governance arrangements of a search for authoritys essence and location but rather one of examining the various practices of authorisation employed in pursuit of the will to govern this in turn means that rather than analyse authority as a singular entity it becomes possible to analyse authorization as a set of different modalities third such perspectives on power open up questions concerning the ways in which authority is manifest and mediated relationally in seeking the basis of its legitimation authority is commonly defined in terms of the consent of the governed and interpreted in terms of some level of obedience to the judgement held over others however where power is conceived differently the ways in which authority may be recognised are open to reconsideration for hajer authority is a relational enactment requiring communications that allow for reasoned elaboration here authority is not about submission not about acquiescence it is achieved through communication it is about the development of a way of seeing things that can be and indeed is taken up by others and which results in the acceptance of a particular line of thinking and acting such a view of the process within which authority gains recognition could accord with an associational notion of power relations whereby recognition is mutually derived or may also be subject to forms of instrumental power where the acceptance of such shared ways of seeing involves concession equally significant here are the ways in which obligations or other forms of enforcement are sustained for if actors evaluate with each decision whether to maintain or withdraw support governance or authority in any meaningful sense of the word is absent where power operates governmentally other forms of recognition and compliance may be at play as murray li suggests when power operates at a distance people are not necessarily aware of how their conduct is being conducted or why so the question of consent does not arise the absence of the explicit recognition associated with either consent or reasoned argument though need not necessarily mean an absence of authorization rather authority may operate by placing action practices symbols and institutions into a meaningful social frame of context by subjecting something or somebody to the operation of a system of meaning significance and power recognition of authority here is implicit and it seems central to the conduct of neoliberal governmentality within which forms of ethical selfgoverning emerge as a means of achieving governmental programmes fourth recognising the generative multiple and relational qualities of power in turn provokes questions of its spatiality where power is viewed as a held set of capacities its geography is usually considered to be a straightforward matter of the spatial extent or scale over which it may be exercised as discussed above new forms of governance are thought to change and challenge these demarcations extending some forms of authority there limiting others here viewing power as constitutive of social relations however challenges such an interpretation rather than having any fixed quality particular spatialities are constituted and produced through the mediated sociotechnical relations within which power is effectuated so that power relationships are not so much positioned in space or extended across it as compose the spaces of which they are a part allen andcochrane suggest that central to the contemporary working of the state are forms of topological power whereby conventional understandings of time and distance are undone by the folding embedding and abstraction of social elements through which state power is reassembled in terms of spatial reach rather than considering reach as a matter of extent here reach is regarded as a matter of pervasiveness as one form of topological politics reach can take different forms such as reaching into political arenas or drawing within close reach key actors allen argues that such a topological perspective is important for it enables us to examine how power is practiced the question becomes then not one of how any one form of power is dispersed across fixed tracts of space and time but rather of how actors and institutions make their leverage and presence felt through certain practices of proximity and reach while the distinction that allen draws between contemporary power dynamics and historical conditions and between the ways in which topological politics and the politics of other spatial orderings are produced can be questioned this analysis is useful in drawing attention to the sociotemporal dynamics of the ways in which power is practiced of how spatiality is constitutive of power relations not only in general but also in the particular ways in which different modes of power take effect rather than seeking to document the relocation of power and authority the analytical task becomes one of considering how different sociospatial relations are constitutive of different modalities of power and how these processes in turn serve to sustain distinct spatial orderings authority is a case in point for allen the quality of authority as a modality of power that depends on recognition means that while it can be geographically farreaching or it can be exercised close at hand the more distant it is the greater the possibility for both the position and the act to pass unrecognized in this original argument allen takes to task assumptions that authority can be readily practiced at a distance his more recent analysis of topological politics however provides one means of thinking about how recognition may be engendered through different practices of reach and connection in analysing how authority is manifest and orchestrated a critical analytical task is to consider how and to what end it is constituted through distinct spatialities and what this might mean for governing those issues which appear not to adhere to particular territorial domains such an analysis provides a different means of considering the fundamental issue of to which entities or communities authority might pertain it suggests that rather than being cast over one or other form of bounded community the practice of authority itself serves to create and sustain the sociospatial nature of the community through which it is realised conventionally authority is viewed as one form of power that takes various guises depending on the source of the legitimacy with which it is conferred the analysis offered here suggests instead that authority can be undertaken in distinct modalities each of which is constituted through the purposes for which power is deployed the nature of recognition and compliance and distinct forms of sociospatial relations on this basis figure 1 distinguishes three ideal type modalities of authority consent consensus and concord given the facilitative and immanent approach to power that underpins this analysis whereby authority is not an achieved condition … but a complex and variable practice these are necessarily abstractions nonetheless they serve to provide a starting point for considering the means through which authority might be pursued regarding authority as an effect means that for each modality it is critical attend to the messy actualities of the purposes to which authority is put and the rationalities and techniques by which it is generated and maintained the ways in which recognition and enforcement are established and the spatial relations through which authorization is constituted in the remainder of the paper these propositions are explored further by putting them to work in a particular case the transnational governance of climate change behavioral rules in the main despite the significant complexity of the term authority itself has received relatively little scrutiny in this context given its importance to ongoing debates in the field this provides a useful arena within which to examine the potential of this approach for understanding the ways in which the practice of authority comes to matter in accomplishing governance the analysis focuses on one distinct subset of this area of research transnational climate governance the term transnational has been used to capture arrangements 3 that work across the boundaries of nationstates and between public and private actors how governing is accomplished within such arrangements is a particular puzzle given the lack of recourse to traditional forms of 3 the term arrangement is used here rather than other terms used in the literature that also have more specific social or spatial meanings that may create analytical confusion in this context authority and the absence of a distinct community through which authority might be manifest deploying the analytic of authority developed above however poses the problem rather differently rather than seeking to locate authority and its extent the task becomes one of understanding how different modes of authorization are socially and spatially constituted and how they come to matter in the governing of climate change transnationally using illustrative examples 4 the three modes of authorization identified above of consent consensus and concord are put to work in an analysis of transnational climate governance the intention is not to regard each of these modes as operating in isolation as it clear from the examples used different transnational governance arrangements may deploy more than one mode of authorization however for the sake of exposition and analytically clarity they are presented in sequence and the connections between them reflected on in the conclusions creating consent at the heart of traditional definitions of authority is the sense that it involves the consent of the governed while consent is usually associated with the formation of democratic states as interest in alternative nonstate forms of governance has grown scholars have demonstrated how such forms of consent can be based on a range of other attributes including expertise moral suasion market potential and so on as consent authority is practiced in a concessionary form where the ability to enlist voluntary agreement or acquiescence in what another proposes or desires is critical in this sense authority as consent has an instrumental quality designed to make others act in ways that they otherwise would not have done the paper draws on these sources in order to illustrate the three ideal types derived above the intention is not to exhaust the possible forms that authority might take nor to examine in detail the multiple forms of authorization adopted in any one network progress of ft500 companies and the cities for climate protection programme which provides municipal governments with tools for assessing their ghg emissions reductions in terms of standard setting the emergence of the voluntary carbon market within which individuals and institutions seek to purchase trade and sell carbon has spawned a wide range of governance arrangements aimed at forms of voluntary regulation although there are thought to be some seventeen standards in operation in 2008 four initiatives had captured 79 of the market the voluntary carbon standard the climate action reserve the american carbon registry and the gold standard although these arrangements differ they characteristically involve constituents who are either voluntarily applying the standards or are certified to be in compliance with the initiative and who concede to be bound by its authority such arrangements have had to engage in a process of generating authority as hajer argues in this sense authority takes effect only where it is enacted and this he suggests means that consent is only forthcoming where authority is worthy of acceptance in this arena attempts to create such forms of worthy acceptance have followed similar lines first they have engaged a heterogeneous array of actors in efforts to claim both legitimacy and independence for example although established by different actor groups as the cdp gold standard and voluntary carbon standard have developed they have sought to engage partners from across the public private and civil society spectrum with the specific intention of enhancing their legitimacy second in most cases such networks have served to meet demand amongst the constituents who are bound by their rules in the case of the voluntary offset market the emergence of standards has been critical in lending legitimacy to the process of trading emissions in terms of both its environmental effectiveness and additional benefits for the cdp the intention has been to develop standard forms of reporting on the climaterelated business activities of major firms with a view to providing the investment community with knowledge of the business risks and opportunities that climate change may present here authority is not pregiven but rather generated in the relation between standard settingmonitoring networks and the constituents who require accept and embody the new rules of the game third and critical to this process has been the process of setting monitoring and verifying standards in such networks authorization stems from the types of standards or forms of disclosure adopted for example a focus on high quality additional sustainable development benefits for the gold standard the presence of independent verification and their general applicability any offset project or firm could be subject to assessment through the same means in this manner such networks fulfil the criteria which hajer suggests is critical for the enactment of authoritythey contain the potential for reasoned elaboration providing a set of rationalities and practices through which their rightfulness can be accepted not only on face value but continually demonstrated and achieved it is through these techniques that recognition in which constituents concede to standards and standard making bodies takes place alongside this concessional form of recognition obligations to comply are sustained through various process of exclusion where for example those voluntary offset projects which do not meet the grade are barred or companies who refuse to report their climate related activities are named and shamed this is not to suggest that such practices are always universal or complete in their study of the reporting of ft500 companies under the cdp kolk et al found that reporting that is actually engendered by the cdp process is far from a comprehensive and comparable assessment of climaterelated activities meaning that it is very difficult to get insight into reported emissions let alone firms actual achievements while firms may have conceded authority to the cdp on the one hand their compliance with the reporting requirements suggest that this process is met with considerable contestation these relations between concession and compliance are mediated as arrangements seek to both explicitly distance themselves from constituents in order to retain the sense of impartiality and draw them within reach through the use of all manner of protocols reporting devices toolkits and standardised measures as allen and cochrane suggest such arrangements reach into and form part of the activities of constituents at the same time through the use of case studies visual imagery personal endorsement and so on constituents are also drawn within close reach of the arrangement itself this is a form of sociospatial relation that is mediated through connection where ties may be stretched or compressed as some form of distanciation between the certifying body and its constituents is maintained in order to defend its raison detre while simultaneously constituent elements are bought close to hand and deployed in order to give vitality to the arrangements claims and intentions by focusing on the substance of the connections not the fact of them or their extension it becomes possible to think about networked relationships as mutable and shifting as the practice of authority unfolds while enabling arrangements to pull constituents within reach the connections through which such forms of authority unfold also allows actors to withdraw their active participation while ostensibly remaining part of the arrangement serving to undo the concessionary recognition upon which authority as consent depends constructing consensus in turning to consider the associative way in which power may be deployed a second mode through which authority may be practiced within transnational climate governance arrangements consensus can be derived unlike consent based on an instrumental sense of bending the will of others an associational view of power following arendt is about the power to connect to bring together but not to suppress the interests and differences that commonly divide the basis of authority in consensus is of course familiar in science where scientific truths are those that enjoy a consensus within a scientific community authoritative knowledge claims are those that enjoy scientific consensus it is also regarded as central in the operation of transverse relationships of power that is those which cut across conventional lines and practices including human rights and environmental campaigns given the concern of climate governance arrangements with issues of science and with green politics it is hardly surprising to find that consensus is a mode of authority which they employ described as a classic instance of trying to reinforce the good one example of an arrangement where authority as consensus is practiced is the climate group established in 2004 in order to provide a means of exchanging best practice on climate change action amongst businesses and subnational governments in the us and uk from this position the climate group has grown to involve some seventyfive members including large businesses regionalstate and city governments central to this initiative has been the language of opportunity epitomised in such phrases as profits up carbon down a slogan used to brand a series of casestudy reports as to the achievements of businesses with regard to emissions reductions as one of the banner headlines of the website used to opine the climate group believes reducing emissions is good for business 5 the climate group actively seeks to practice authority by forging consensus amongst different sectors around the notion that addressing climate change could provide opportunities a second example of transnational climate governance where authority as consensus is practiced is the c40 cities climate leadership group established by then mayor of london ken livingston and his deputy nicky gavron together with the climate group the original c20 was formed by 18 cities in 2005 as a parallel initiative to the group of eight gleneagles summit on climate change in 2007 this network entered into a partnership with the clinton climate initiative and expanded its membership to include 40 of the largest cities in the world together with 18 affiliate cities for c40 consensus has been built around the notion that the battle to prevent catastrophic climate change will be won or lost in our cities and that global cities can and should respond to this challenge and should be recognised for this effort the practice of authorisation as consensus takes place through a variety of techniques by which arrangements seek to secure constiuents around common positions and translate their efforts into standardised measures of benefit one core technique deployed is the development and take up of best practice regarded as a means not only through which learning can occur but by which common baselines for what might be expected can be established indeed so central is best practice to the climate group that its mission is sometimes described as putting the world on track for a low carbon economy by rapidly expanding the uptake of best practice on reducing greenhouse gas emissions 6 through the dissemination and exchange of best practice the development of policy tools including for example the greenhouse indicator which provides realtime emissions data for australian states the use of standards including the climate principles for financial investors as well as the deployment of particular projects and programmes the climate group has sought to gather maintain and reproduce a consensus as to what constitutes good climate governance likewise c40 also engages in the active production of casestudies of best practice and exemplar projects as a means through which to develop an understanding of what constitutes climate governance in seeking to bring a diverse range of cities and urban conditions into one governable community like the climate group they also employ a diverse set of techniques for example a biannual summit brings the political leaders of c40 cities together in order to make public their declarations of commitment and to share learning also significant are efforts which seek to smooth out the differences between cities including specific programmes for retrofitting office buildings developing new urban planning as well as reporting efforts that gather together the diverse climaterelated activities being undertaken into one whole so that c40 becomes seen as for example 40 cities 297 million residents 4734 climate actions arup 2011 1 where authority is practiced through consensus recognition is mutually constituted that is it is experienced and performed between constituents with regard to one another and held in common between them members gain legitimacy for the positions adopted on climate change because of their membership with other key actors important to this form of associational authority is the way in which the heterogeneity of interests is turned to common will such arrangements frequently define themselves in terms of their leadership in creating a coalition of the willing this is not to suggest the process of creating consensus is without struggle dissent and contestation the very process of creating consensus about the climate governance problem necessarily involves the exclusion and negation of other accounts of what climate governance might entail however resulting conflicts and contradictions are managed less by technique than by compromise in its dual sense parties to the assemblage make compromises and in so doing they become implicated their positions compromised and their critiques contained where authority as consensus is practiced compliance is not subject to sanction but instead constantly mediated and renegotiated through compromise in this dual sense goals are not reached but principles hold constituents may not deliver on specific outcomes but continually justify their intentions to do so in order to remain party to the consensus at hand as consensus authority is constituted through seeking to establish proximity between the constituent members positions resources artefacts and so on that make up a particular transnational climate governance arrangement as mutuality and compromise are forged individual examples of best practice are bought into contact through new lines of reasoning and argument summits and committees draw individual members together in real timespace virtual webinars are used to develop common standards and forms of knowledge in such a manner constituent members become adjacent so that for example officials at melbourne can argue that they hold more in common with london or new york than with other australian cities these are then not space spanning networks but arrangements within which authority is generated through the mediation of social relations which make proximate the seemingly politically and geographically distant and within which the experience of one may serve to approximate for another configuring concord as modes of authorization consent and consensus are more or less conscious processes in which power is deployed instrumentally to seek concession or through means of association to generate a commonality of will for governing climate change as discussed above a third register of power where its operation is regarded as immanent to social relations and it is achieved through the conduct of conduct gains its purchase through disposing of things in such a manner that particular ends may be accomplished in this mode rather than involving a process of explicit recognition or consent authority emerges through doing those things that are naturalised discursively and normally in this manner a further mode of authorization can be identified one which operates through a process of concord the bringing into agreement of heterogeneous elements social and material in such a manner that they are taken for granted as authoritative in the shaping of conduct as rose and miller put it gaining routine authorization is a question of the complex assemblage of diverse forces such that aspects of the decisions of individuals groups organisations and populations come to be understood and regulated in relation to authoritative criteria as with the working of power in its instrumental and associational registers power in its governmental guise is seen here as working through the generation of sociospatial relations in an analysis of the disputes over chesapeake bay lipshutz draws our attention to one such example here the authority of first nation and environmental groups to determine the environmental management of the area was not determined by their capacities or by forms of public recognition and neither did either party poses authority in isolation the moral power associated with protests against logging is not possessed or owned on the basis of righteous analysis that authority has to be created in action authorization as concord emerges as the result of both the strategic normalisation of particular discourses concerning in this case the climate problem the mundane practices through which networks operate and the artefacts which they put in place to hold networks together several examples of the practice of concord were cited during research interviews with the climate group and the reeep in both cases the work of aligning previously unconnected elements in order to normalise climate change was regarded as central to their day to day operation and raison dêtre californias 80 emissions reductions target … they wouldnt have done that without us not because they were not able to design the target … but they were very naturally worried about the reaction they would get from businesses so the same day that they announced it we organised a business leaders forum on the same day and in the same place so business leaders got to be on the telly talking about how progressive and successful they were we produced a brochure on success in california and arnie was pleased because he got to make his statement surrounded by business leaders looking like they supported him we … havent provided them with the specific tools but weve made weve helped make things happen and thats what well continue to try and do the practice of concord involves not only the bringing into agreement of diverse social actors and discourses but also the mobilization of particular artifacts and materials such as press releases targets carbon accounting tools or renewable energy technologies through which this is achieved discussion with the reeep as to the roles of the projects funded by the uk foreign and commonwealth office shows the importance the resulting material changes in the energy landscape were seen to have for the network as a whole those projects are supposed to be about lesson learning spreading best practice and about influencing policy … a bunch of relatively small projects on their own which doesnt influence wider policy is a bit of a waste of time so there is no logic in the fco putting the in both a strategic and a mundane sense authority practiced as concord gains recognition through becoming taken for granted as part of the landscape through which governing climate change has to be achieved in this sense authority depends on its habitual recognition and the shaping the disposition of constituents through governmental rationalities and technique rather than being achieved externally compliance works through creating what constitutes normal expectations actions and so on and seeking to govern the conduct of others through the creation of selfgoverning subjects critical to achieving such forms of authority are the practices through which such arrangements are able to make their presence felt even where they may appear to govern at a distance being present appears to be a critical means through which authority as concord is spatially mediated for example by being explicitly on hand operating as a backdrop for the activities of others or by normalizing particular ways of saying and doing climate governance by way of illustration both reeep and the climate group have established regional centers within their networks through which to engage with different actors and policy arenas to this end in each case particular moments are also used as a means of establishing their presence and they seek as the examples above suggest to broker relations between their constituents in such a manner as to become taken for granted as part of the way in which governing climate change is accomplished in this sense it is the mediation of sociospatial relations within transnational climate governance arrangements through practices of making present that serves to constitute concord as a particular mode of authority and the ways in which it takes effect conclusions conventionally authority is regarded as a capacity derived from the marriage of power with legitimacy while retaining the essence of this relation this paper has argued for a more critical and sustained engagement with the concept of authority that attends in particular to the notion of power drawing on the work of john allen it argues that authority can be regarded as one modality of power constitutive of and constituted through distinct sociospatial relations however rather than retaining a singular analytic of authority as allens work does this paper suggests that by considering the purposes for which power is exercised the ways in which recognition and compliance may be achieved and the sociospatial relations through which authority is practiced three distinct modalities of authorization as consent as consensus and as concord can be discerned in the case of transnational climate governance authority as consent can be found in those arrangements who adopt monitoring and standard setting procedures recognition here rests on the concession or submission of constituents to the rules of the game established through the practice of standardisation and various forms of exclusion are practiced where constituents fail to abide by these obligations authority as consent is in these cases mediated by sociospatial practices of connection which work to hold constituents at arms length to enter into their routines and to draw them into the making of particular standards and arrangements in a second mode authority operates in an associational register through consensus and rests on the ability of networks to generate narratives and techniques through which to establish mutual recognition and continually undertake the compromises through which obligation is maintained the dynamics of consensus and compromise shift across different arrangements but those studied here are dominated by consensual positions on the good news story of climate change reducing the scope for more radical critique and action in forging authority as consensus practices of proximity are critical and serve to draw constituents adjacent in the rationalities and techniques through which transnational climate governance arrangements are composed and maintained as concord authority is practiced through the bringing into agreement of heterogeneous elements in order to shape the conduct of network constituents in place of the acquiescence of consent or the conscious mutuality of consensus concord works through its taken for granted and habitual nature where compliance is policed by processes of normalization and the government of the self examples suggest that the creation of concord is both a strategic endeavor and also a routine matter for transnational climate governance arrangements such relations are mediated through practices of making present which for example serve to create windows of opportunity political momentum and common knowledge as well as to cement day to day routines in each case rather than regarding authority as an attribute ascribed to a particular entity by a predetermined and geographically delimited or contiguous community this approach suggests that authority and the sociospatial order to which it pertains are coproduced while for the sake of exposition each of these modes of authorization is presented in isolation the examples included suggest that this is rarely the reality transnational governance networks appear to deploy multiple modes of authorization simultaneously utilising the different ways in which power is practiced in each mode and investing each with different strategic purpose an intriguing but empirical question concerns their relation and succession for example whether some modes are required before others or some necessarily pursued in tandem a task for future work is to explore and explain in more detail how why and with what effect modes of authorization are deployed within particular forms of governance arrangement a further concern is with the contestation and limits of authority for swyngedouw such new forms of governance are expressive of the postpolitical configuration in which radical dissent critique and fundamental conflict are evacuated rather than being free from such forms of contestation it is possible to regard consent consensus and concord as the means through which such forms of conflict emerge and are held at bay as hinted at above authorisation comes undone whether this be in relation to the degree of concession granted the unravelling of compromise or of mundane forms of disruption and resistance regarding governing as a project rather than a secure accomplishment means insisting on its limits the implications of the argument offered here are that where these limits are encountered authority comes to its end and the different modalities that power can assume persuasion coercion inducement and so on may come into play where authority is undone governing may be replaced by alternative forms of social relation most often in this case of that form of persuasion often termed advocacy understanding this dynamic and the ways in which transnational climate governance arrangements may move through different modalities of power also warrants further sustained attention nonetheless by thinking of the nature of power and legitimation differently this paper offers some novel ways of examining how governing is accomplished this is significant for it implies that the absence of the power over others in governing arrangements established between and beyond traditional political arenas of the state does not negate their authority it also raises questions about the basis upon which issues concerning the legitimacy and accountability of such arrangements should be assessed rather than seeking to look for statelike forms of authority beyond the nationstate we need to consider the multiple and often mundane ways in which authorization is achieved and to consider how practices of accountability and transparency might be woven into this fabric in a different way summerville j adkins b and kendall g the climate group carbon down profits up third edition the climate group london available online

within debates about the emergence and nature of governance it has become commonplace to debate the whereabouts and possibilities of authority traditionally authority is conceived as a property of some actor or institution and regarded as divisible over time and space drawing on theories of power which regarded it as constitutive of social relations this paper proposes an alternative account of authority in which it is seen as one form of power that can be enacted towards three distinct purposes instrumental as consent associational as consensus and governmental as concord involving particular forms of recognition and compliance and mediated through distinct sociospatial relations the paper examines the potential of such an approach through exploring the workings of authority in transnational climate change governance given the sustained debates within this field as to the shifting geographies of authority between publicprivate actors and across different political spaces this provides an important test of the explanatory value of this approach the analysis suggests that while these modes are not mutually exclusive they orchestrate the will to govern murray li 2007a in significantly different ways with important implications both for how governing is accomplished and for the geographies of global environmental governance

introduction on july 24 2021 the general office of the cpc central committee and the state council of china promulgated the opinions on further reducing the burden of homework and afterschool training for students 1 the publication of opinions aimed to relieve students academic pressure freeing more time to enrich extracurricular life however in todays educational environment the problem of how to allocate leisure time does not seem to have been fully resolved as the double reduction policy has not been able to fully alleviate the academic pressure 2 in chinas examoriented education system there is a great contradiction between the examination system academic pressure and physical and mental health and how to balance the relationship between them under the premise of relieving student pressure has become a major task for education departments schools and parents 3 if adolescents face more burden and stress in the long term it will lead to numerous problems such as learning burnout 4 learning burnout has been shown to be a risk factor for depression school dropout and selfharm 5 another important problem resulting from the double reduction policy was that under the condition of relatively reduced learning time some students were addicted to watching short videos playing games chatting and other recreational activities on smart phones which occupy most of their leisure time 6 after the promulgation of the double reduction policy according to the 50th china statistical report on internet development by june 2022 chinas internet users reached 1047 billion an increase of 1785 million compared with december 2021 and the proportion of internet users using mobile phones was 996 adolescents accounted for 135 of the total 7 because adolescents are not mature physically and mentally and their selfcontrol ability is weak although smartphones are convenient for them to communicate learn and enjoy themselves better excessive use of smart phones brings many adverse effects such as mobile phone dependence 8 in previous studies the most studied individual factors were depression anxiety sleep quality academic performance and academic stress 9 10 11 12 family factors have been reported in many studies 1314 social factors included social networking online shopping social support and current status of mpd within covid19 15 16 17 18 but within social policy there is a lack of studies such as in the educational context furthermore to our knowledge the role of the adolescent social support to mediate the relationship between the learning burnout and mpd has not been clarified mpd during adolescents mpd is defined as excessive and uncontrolled use of a mobile phone the urgent need to use a mobile phone after a period of time and changes in mood when use is blocked or difficult with consequences that can affect realworld relationships academic performance physical and mental health 19 mpd is a considerable concern especially among adolescents haug et al 20 compared mpd detection rates in different age groups among 1519 students in switzerland those aged 1516 was the highest one followed by 136 among those aged 1718 both of which were higher than those aged 19 and older compared with young adults mpd was more common among younger adolescents the problem of mpd in adolescents is widespread across the globe it has been reported that 624 of high school students in philippines 21 703 of high school students in brazil 22 266 of middle school students in korea 23 and 254 of middle school students in china 24 these surveys showed that significant variations between regions and countries about the prevalence of mpd with its vast land area and large population chinas 30 provinces are very different in terms of economy society ideology and geography in terms of economic development china consists of three regions the highly developed east the moderately developed middle and the least developed west 25 research has suggested that the occurrence of mpd may also be influenced by economic development levels with low economic levels positively predicting mpd in adolescents 1526 therefore whether the mpd detection rate is higher in western china needs further investigation the relationship mpd and learning burnout learning burnout is a negative mental state of student learning that has been defined as emotional exhaustion depersonalization and reduced personal achievement caused by course pressure course load or other psychological factors in the educational process 27 the emergence of burnout is accompanied by a gradual depletion of the selfregulation resource which leads to the failure of the selfregulation mechanism when suffering from depression and anxiety 28 according to compensatory network use theory mobile phones and the internet can be used as a way of compensating for negative emotions in adolescents but the failure of selfcontrol in the use of mobile phones was positively correlated with mpd 29 in addition direct and indirect evidence for learning burnout and mpd in adolescents has been provided by previous studies direct evidence comes from zhang et al 30 study of 1475 adolescents in china which showed that mpd was a direct predictor of learning burnout results from a separate study of 675 adolescents showed that mpd in adolescents had a significant positive effect on learning burnout 31 indicative evidence from two longitudinal waves of data from 1702 early and 1636 late finnish adolescents revealed a crosslagged path between excessive internet use and learning burnout among both groups of adolescents with learning burnout being predicted by later excessive internet use and excessive internet use being predicted by later learning burnout 32 both theoretical underpinnings and previous studies have demonstrated the relationship between mpd and adolescent learning burnout however previous empirical studies have focused more on the impact of mpd on learning burnout with little empirical evidence to suggest that learning burnout may also be an influencing factor of mpd based on the above theoretical analysis hypothesis 1 is proposed in this study h1 leaning burnout has a significant positive effect on mpd the mediation role of social support in the linking mpd and learning burnout society is a macro educational environment and rich social resources need to be fully utilized to provide an important platform for students to broaden their horizons and develop in an allround way under the double reduction policy chinas measures to reduce students learning burnout and mobile phone use mainly focus on two aspects homeschool linkage and government supervision however problems such as underdevelopment and underutilization of social support resources remain due to the lack of empirical research to guide these measures 2 as a multidimensional system social support system plays an important role in maintaining it is often used as a positive resource which can alleviate individual burnout to a certain extent and thus reduce the occurrence of bad behaviour 33 hobfoll 34 proposed resource conservation theory to explain burnout processes such as stress and exhaustion in terms of resource loss and gain he argues that the depletion of resources that individuals strive to obtain and maintain is due to the loss of resources or the imbalance of resource utilization due to increased work and that these include material and construction resources social support resources and energy resources 35 prevailing research have suggested that social support is one of the most important resources in combating learning burnout and has been the most extensively studied resource in buffering against burnout 3336 in a study of 378 adolescents from turkey social support was found to be negatively associated with learning burnout 37 the relationship between mpd and social support is supported by evidence circumstantial evidence suggests that social resources are a quality and quantity buffer against the development of internet addiction in a study of 567 adolescents those with larger social networks and higher scores on social support reported the least likelihood of becoming addicted to using the internet 38 therefore as a crucial buffer resource social support can not only alleviate the burnout caused by the imbalance of individual resource allocation but also help individual avoid problematic internet behaviors 39 a metaanalysis also provided direct evidence of the negative association between social support and mpd 40 an empirical survey of adolescents in poland has also shown that social support is an important resource for avoiding mpd 41 additionally cohen and willss 42 social support buffer theory suggests that that social support maintains and promotes physical and mental health by regulating the adverse effects of individual stress and burnout on psychological behavior a range of buffering effects of social support for mental health and problem behavioral outcomes have been demonstrated 4344 mpd as a result of learning burnout previous studies have shown that learning burnout and mpd can damage the sense of social support specifically leading to a reduction in school participation and family closeness 45 therefore if adolescents are not provided with adequate social support their learning burnout will not be alleviated which indirectly leads to mpd although both the theoretical underpinnings and the empirical research supported a pinpoint correlation between mpd learning burnout and social support there is a lack of known about the mediating role of adolescents social support in the relationship between learning burnout and mpd accordingly we propose research hypothesis 2 and hypothesis 3 h2 social support has a significant negative effect on mpd h3 social support mediates between mpd and learning burnout therefore a crosssectional study was conducted to investigate mpd status in guizhou province in western china and to explore the impact of learning burnout on mpd among adolescents under the double reduction moreover we further examined the mediating effect of social support on the relationship between learning burnout and mpd the hypothesized mediation model was drawn in this study as shown in figure 1 methods participants and procedure a multistage stratified cluster random sampling method was used to obtain participants for a descriptive crosssectional design study the stratification was based on the 2020 gdp level of guizhou province in western china 46 type of school and grade three regions were selected then four junior middle schools four senior middle schools and two vocational middle schools were randomly selected in each region every school surveyed has fully implemented the double reduction policy in each selected target school a total of 4 classes in each grade were randomly selected we first contacted education authorities school leaders and relevant classroom teachers and with the help of relevant subject teachers trained investigators completed field questionnaires of students in relevant classes it took about 2025 minutes for the students to complete the questionnaire before the survey was conducted all participants were informed about the survey and their consent was obtained consent was also obtained from the parents or legal guardians of the participants the survey started in december 2021 and all questionnaires were collected by january 2022 exclusion criteria were students who did not attend school for various reasons during the survey period refused to be surveyed and had other mental disorders a total of 18838 questionnaires were distributed during the survey period 1233 students submitted incomplete questionnaires with a response rate of 9345 in the first two times of data analysis questionnaires of 16216 students were finally included for analysis with an effective rate of 9211 there were 7921 boys 8695 girls 7868 middle school students 5901 high school students and 2447 vocational middle school students the age was 11 22 years old our study was approved by the human experiment ethics committee of guizhou medical university measures the selfrating questionnaire for adolescent problematic mobile phone use is a standardized questionnaire designed to effectively evaluate the mpd status of adolescents 47 the questionnaire includes 13 items to assess mpd covering three dimensions of withdrawal symptoms cravings and physical and mental health statusthe likert 5 scale was used with total scores ranging from 13 to 65 with the 75th percentile as the cutoffthe effectiveness and reliability of sqapmpu have been tested by previous studies 48 cronbachs α 0921 of the scale in this study the adolescent student burnout scale which has been used to measure adolescent learning burnout problems was originally designed by wu et al 49 based on the maslach burnout inventorystudent survey 50 the inventory consists of 16 items measuring 3 factors of student burnout exhaustion cynicism toward the meaning of study and sense of inadequacy at studying each item was scored on a 5point likert scale 3174 ranging from 1 to 5 the validity and reliability of asbi have been previously examined 51 this study adopted cronbachs α 0831 for the scale social support was assessed by the social support scale 52 17 items and 3 measurable dimensions of subjective support supportive utilization and objective support were included in the questionnaire likert fivepoint scoring method was used to evaluate each item that is the range was from 1 to 5 points for inconsistent to consistent the sum of the scores of all 17 items is the total score of the scale which reflects the overall status of social support of the subjects the validity and reliability of social support scale has been previously examined 53 cronbachs α 0952 was adopted in the scale of this study data analysis ibm spss240 for windows statistical software was used for descriptive analysis to describe the detection rate of adolescent mpd chisquare test was used to analyze the detection rate of mpd among adolescents with different gender school type ethnicity and other demographic characteristics the relationship between learning burnout social support and mpd was evaluated using the analysis of the hierarchical linear regression model the multiple linear regression model was corrected for demographic variables that potentially distorted the data structural equation modeling was used in amos to fit variable relationships and validate models maximum likelihood method was used to estimate the parameters aic bic gfi cfi tli χ 2 df and rmsea were used to determine the degree of fit of the model 5455 in the mediating effect model mpd score was used as the dependent variable learning burnout score as the independent variable and social support score as the mediating variable the statistical significance level was set at 005 thus all the p values below 005 were interpreted as significant results characteristics of the participants as shown in table 1 a total of 16216 adolescents were included in this study for these 264 were classified as mpd there were significant differences in rate of mpd between the learning stage the rates of mpd were higher in senior middle school and secondary vocational school there were nationbased differences in rate of mpd and mpd was more frequent in minorities the rate of mpd among adolescents from rural was higher than that in urban the rate of mpd was higher among adolescents from families with lower economic status adolescents who reported lower parents educational level showed a higher proportion of mpd the rates of mpd were highest in adolescents with poor perceived academic record or higher perceived academic pressure association of learning burnout and social support with mpd in adolescents multiple linear regression was used to examine the relationship between learning burnout social support and mpd school grade ethnic group economic status of living family fathers education level mothers education level perceived academic record and perceived academic pressure were taken into the model as control variables the results showed that learning burnout positively predicted mpd social support negatively predicted mpd detailed results are shown in figure 2 mediating effect analysis table 2 presented the results of the mediating effect model analysis the direct effect value of learning burnout on mpd was 0392 the mediating effect value of social support was 0048 and the total effect value was 0440 the direct effect accounted for 891 of the total effect and the mediating effect accounted for 109 of the total effect figure 3 showed 3176 the mediating effect path of social support in the association between learning burnout and mpd among adolescents all path coefficients were statistically significant the results showed that aic 35352000 bic 35390469 gnfi0999 cfi 0999 tli 0998 χ 2 df 7625 rmsea 002 the model fit index showed that the mediating effect model was acceptable discussion the prevalence in western china this study reveals that the positive rate of mpd in guizhou province in western china was 264 the positive rate of mpd was higher than that of shandong college students in east china 56 and that of hunan college students in central china 57 and anhui junior high school students 58 it was lower than that of asian university students 59 and higher than that of global metaanalyses results 60 although mpd prevalence appear to vary due to differences in mpd definition sample size assessment tools economic level survey duration and social and cultural background even when these differences are taken into account our results still indicate that mpd was serious in adolescents and it seems to be improved compared with previous surveys in other parts of china the positive mpd rate in western guizhou is higher than that in eastern and central regions possibly because guizhou is an economically backward western province its per capita gdp ranks 29th out of 31 provinces according to the data one reason it has become a major labor exporter in china 61 more parents are choosing to work in the more economically developed eastern and central regions according to statistics guizhou had 475000 leftbehind minors by the end of 2020 ranking 6th in china 62 as teenagers are often separated from their parents their mobile phone use cannot be supervised and problems with their mobile phone use cannot be detected in a timely manner 63 the effect of learning burnout on mpd the hypothesis 1 was supported in this study as learning burnout positively affected mpd policies do not work to reduce and adolescents learning pressure or learning burnout south korea is a very striking example in south korea 3177 shadow education has failed because it has led to severe educational inequality government policies have eased some of the pressure on students but intensive reading and private tutoring in south korea have not been changed by the policies 64 this problem may also exist in japan japans loose education has led to a decline in the academic ability of japanese students in basic education and the direction of deloose 65 both japan and south korea have promulgated or implemented educational decisions of reducing the burden but their feasibility and longterm effect often become mere formality because they cannot meet the needs and wishes of the country and society for the development of education as american scholar g allison said in the process of realizing the policy goal the function determined by the plan only accounts for 10 while the rest 90 depends on the effective implementation in the case of chinas double reduction policy it has achieved temporary results in shortening students homework time and cancelling offcampus training but under the guidance of only score and only academic qualification the problem of academic burden and learning burnout has not been fundamentally solved 66 whats more since chinas school admission system parental expectations and students sense of achievement are also important sources of learning burnout among adolescents helping them reduce it is still a long way off 6768 a comparative study of china and germany the data showed that chinese adolescents had higher average burnout scores and the positive correlation between high level of learning burnout and high level of internet addiction or mpd 69 after the double reduction policy the time allocated to study is reduced and the entertainment time such as playing mobile phone is increased 2 teenagers with high levels of learning burnout low academic performance and other negative feelings need a medium or a way to release them and after the rapid development of modern electronics mobile phones are the most effective tools to quickly release negative feelings 1270 over time uncontrolled excessive use of mobile phones leads to mpd this result can be reasonably explained by the theory of compensatory network usage which implies that mpd can be a coping strategy for learning burnout due to escape incentives 2871 when individuals lack the resources to combat learning burnout networked devices such as mobile phones are the best substitutetherefore mpd should be avoided by controlling learning burnout the effect of social support on mpd our results also suggested that social support positively influences mpd which consistent with hypothesis 2 social support from parents and teachers as well as friends and classmates is strongly associated with mpd among adolescents and young adults the relationship between mpd and social support has also been confirmed by other studies with similar findings to ours the study of 567 polish students showed that students in the mpd category had lower social support levels compared to nonmpd students and that low social support levels were also positively associated with isolation and social fear among students which led to more frequent use of mobile phones 41 a study of 1149 turkey college students found that those who used their phones problematic had fewer support resources from family teachers and friends than those who used their phones normally 72 furthermore a metaanalysis in china found that the negative correlation between mpd and social support in the eastern region with the best economic development level is lower than that in the central region but because of the lack of studies on the relationship between mpd and social support in the western region with the lowest level of economic development few studies were included in the metaanalysis so the relationship between the two is not significant 63 our results of this study also showed that social support negatively predicts mpd among adolescents in western china which makes up for the shortcomings of previous studies this research results showed that the correlation coefficient between mpd and social support in the western china is 0099 which is lower than the correlation coefficient in central china and eastern china of the above metaanalysis the reason for this phenomenon may be that most of the previous studies selected college students as research subjects 63 while the subject of our study is middle school students middle school students have simpler social networks so it is easier for them to receive social support which mainly comes from parents teachers and classmates who are more closely connected 73 in addition middle school students mobile phone ownership rate is lower than that of college students 74 so they are less likely to become addicted to mobile phones even if they lack social support in addition the scales for social support and mpd are different which also affects the result the mediation of social support results of this study indicated that social support had a mediating effect between learning burnout and mpd which was consistent with hypothesis 3 specifically learning burnout negatively impact social support and social support negatively 3178 impact mpd among adolescents the theory conservation of resources and social support buffer theory have been verified by this result for the mediating role of social support the likely reason is that support from family teachers and friends is used as a resource to perform selfcontrol and which is prior studies that indicated a positive relationship between a low level of selfcontrol and mpd 75 learning burnout is considered to be a negative emotion that depletes adolescents limited resources and gradually negatively affects selfcontrol 76 many offcampus education institutions have disappeared or are on the verge of closure as the double reduction policy has been effectively implemented for more than a year 77 a survey of 400 students in fuzhou china found that 565 of students now spend less than 90 minutes on written homework an effective reduction in homework load from 48 before policy implementation 78 however previous studies have mainly focused on the direct effects of the double reduction policy learning burnout is a subjective perception of students and cannot be measured by offcampus education and homework volume under the condition that the examinationoriented education and examination system in china remains unchanged the indirect impact of the double reduction policy is the mpd problem of students students learning burnout may not be effectively alleviated and the increase of students leisure time are the two causes of mpd an effective way to alleviate learning burnout and thus alleviate the mpd problem of students is to provide social support for students under the double reduction policy therefore it is necessary to keep a close eye on mpd in adolescents with learning burnout symptoms and it is important to provide them with adequate social support resources and encourage students to return to real life from virtual networks policies are regarded as a social determinant in the development of societies that can influence health and wellbeing by shaping the socioeconomic and healthaccess environment 79 specifically the makers of the double reduction policy educators and the public can contribute to reduce learning burnout and avoid the occurrence of mpd of adolescent by supporting measures into standard educational practice 8081 compensating for psychological loss through mobile networks is not entirely negative for individual learning burnout normal use of mobile phone is considered as constructive compensation which will return to normal development after the completion of compensation while excessive use of mobile phone will form pathological compensation 82 there is a need to build social support buffers through individuals families and policymakers forming a systematic compensation comprehensive psychotherapy approach to avoid the pathological compensation consequences of excessive mobile phone use among adolescents first of all the government should fully develop community resources to meet the needs of adolescents to relax after learning burnout 2 secondly in addition to banning students from using mobile phones the cultivation of students physical quality and sports quality should be taken as the key content and schools should expand physical education programs and cultivate students sports hobbies 83 thirdly parents should guide teenagers to make the most of their time at home and strengthen the supervision on childrens mobile phone use and timely detect stop and correct adolescents mpd 84 additionally previous studies have found that the cause of mpd in individuals is not entirely due to the lack of realistic social support resources but also may be due to the failure to make good use of existing social support 41 therefore in addition to providing adequate social support to adolescents we should also pay attention to their emotional social support and support utilization limitations the results of this study are innovative but there are constraints to consider first our crosssectional study cannot determine cause and effect future cohort studies are needed to identify causal trends between learning burnout and mpd and to better understand the specific effects on the relationship second selfreported variables can lead to information bias objective measures for mpd should be used in the future studies conclusion we found that the positive rate of mpd in guizhou province in western china is at a high level which requires control in addition mpd was also significantly positively predicted by learning burnout and social support level played a mediating role in the relationship between learning burnout and mpd in adolescents this study emphasizes that a high level of social support may contribute to the reduction of mpd risk in learning burnout students under the double reduction policy we suggest that social support intensification is probably an effective and viable strategy for mpd reduction in learning burnout students ethics statement our study complies with the declaration of helsinki our study was approved by the human experiment ethics committee of guizhou medical university all respondents read the consent form and completed the survey voluntarily informed consent was obtained from the participants and their parents disclosure the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper

this paper investigated the prevalence of mobile phone dependence mpd and its associated with learning burnout under the double reduction policy among adolescents in guizhou province in western china in addition the influence of the mediating mechanism of social support on this relationship was investigated methods the sample was collected from 16216 adolescents in west chinas guizhou province from december 2021 to january 2022 via multistage stratified random sampling the selfrating questionnaire for adolescent problematic mobile phone use sqapmpu was used to assess the mpd the adolescent student burnout scale asbi was used to assess the learning burnout and the social support scale sss was used to assess the social support a hierarchical linear regression model was used to analyze the relationship between mpd learning burnout and social support the mediating effect of social support between mpd and learning burnout was analyzed by structural equation model results prevalence of mpd was 264 among adolescents in guizhou province in western china after adjusting for confounding variables like demographics multiple linear regression model has revealed that learning burnout positively predicted mpd and social support negatively predicted mpd the structural equation model showed that 109 of the effect was explained by the mediating effect of social support conclusion these findings could inform service delivery and policy formulation to reduce learning and avoid mpd in adolescents

background almost 50 years ago pierce 33 sought to unpack the mechanism of subtle and stunning daily racial offenses known as microaggressions pierces seminal description of the construct of microaggressions laid the groundwork for a reframing by sue et al 41 who defined racial microaggressions as subtle daily and unintentional racial slights committed against people of color because they are members of a racialized group sue et al 41 proposed nine categories of racial microaggressions described as assumptions that a person of color is not a true american assumptions of lesser intelligence statements that convey colorblindness or denial of the importance of race assumptions of criminality or dangerousness denials of individual racism promotion of the myth of meritocracy assumptions that ones cultural background and communication styles are pathological being treated as a secondclass citizen and having to endure environmental messages of being unwelcome or devalued since sue and colleagues taxonomy was proposed numerous researchers have examined these categorizations finding generally similar but not identical groupings based on qualitative and factor analytic studies there has been a surge of qualitative quantitative and theoretical work expanding our understanding of the nature experience and consequences of microaggressions since sue and colleagues proposed their taxonomy of microaggressions in 2007 41 microaggressions towards targeted racial or ethnic groups are persistent and occur frequently in academic settings 40 they are increasingly recognized to compound with the intersections of gender sexual orientation and other stigmatized identities and these additional identities have been incorporated into sue et als original taxonomy 42 as of this writing multiple overlapping yet distinct taxonomies have been proposed including several with empirical support in this paper we examine the experience of racial microaggressions among african american college students and provide a qualitative description of the resulting taxonomy using focus group data comparing our findings to sue and colleagues 41 original work and the expanded set of themes in sue and spanierman 42 nature and maintenance of microaggressions although there has been some debate about the nature of microaggressions and how they should be defined we contend that microaggressions are actual things that can be identified and measured and not simply the subjective experience of the target although this not universally agreed upon by scholars due to the subtle nature of microaggressions they are sometimes minimized as simple cultural missteps or racial faux pas 47 microaggressions are not however innocuous gaffes but are a form of oppression that reinforces existing power differentials between groups whether or not this was the conscious intention of the offender 3547 this reinforcement of a power differential contributes to the maintenance of microaggressions because it favors the ingroup and in an effort to retain the extant power structure outgroup members are punished socially when they challenge microaggressions essed 11 has written extensively about everyday racism as a tripartite framework whereby racist practices involve the marginalization of those identified as racially or ethnically different the problematization of those cultures and identities and repression of resistance against racism through humiliation or aggression simply put racial microaggressions are a subtle and common form of racism that maintains white supremacy harms of microaggressions the cumulative daytoday stress caused by microaggressions 33 has been reliably associated with negative physical and emotional health outcomes for decades multiple studies indicate significant associations between experiencing microaggressions and higher levels of depression 1830 anxiety 51 posttraumatic stress disorder symptoms 52 impaired psychological wellbeing 116 and decreased selfesteem 931 studies also have demonstrated a relationship between discriminatory stress and physical ailments including hypertension 8 hypothalamicpituitaryadrenal axis dysfunction 19 higher body mass index 21 and coronary heart disease 36 microaggressions are damaging to young people and adults alike and the context of students of color in academic settings is particularly salient school campuses in the united states have long been recognized as sites that magnify racial tensions present in the broader society 17 and young people may be exposed to raciallyfocused situations and conversations more frequently at school than at home 43 studies of college students have demonstrated a significant relationship between racial discrimination and increased substance use 434 delinquency 6 decreased academic outcomes 20 and selfesteem 54 depression symptoms have been found to mediate a relationship between racial microaggressions and suicidality in students 32 raising grave concerns about the consequences of daily microaggressionrelated stress on young people focus of this study given the many harm of microaggressions 48 it is critical that we understand the experience of the targets of microaggressive actions as the field moves towards the development of effective tools for the reduction of racial microaggressions our taxonomies must be based increasingly on empirical findings for greatest utility in identifying both their occurrence and the harms that occur as a result this paper seeks to elucidate the experience of racial microaggressions experienced by black students at predominately white institutions of higher learning with a focus group design utilizing qualitative data and compare findings to sue and colleagues taxonomies of racial microaggressions the question being explored was how current black college students experiences might correspond to or differ from these original and revised types method recruitment study participants were recruited from one private and two public pwis located in the southernmidwestern and pacific northwest united states participants were recruited using a combination of posted fliers the undergraduate psychology recruiting pool and word of mouth interested parties were directed toward an online screening tool which included a demographic questionnaire the lead research assistant contacted eligible participants to schedule a time for focus group participation study eligibility criteria were selfidentification as black african american biracial or continental african the institutional review boards social and behavioral sciences committees for the various institutions approved the research and all respondents were consented according to the rules and regulations of their respective irbs the informed consent procedure included a preamble consent provided online for the initial collection of demographic and selfreport data and a written form that was reviewed with researchers and signed right before the focus groups commenced analytical approach the research team selected an interpretative phenomenological analysis approach to codify the data 10 this method of analysis is well suited to small homogeneous samples and the use of a semistructured interview format ipa utilizes prompts and funneling to identify and connect themes among individual perspectives on how study participants make sense of their social and personal worlds 37 data from each of the focus groups were audio recorded and transcribed verbatim by the research team after the initial transcription each transcription was checked by a second trained research assistant focus groups the research team consisted of a diverse group of clinical psychologists graduate assistants and research assistants each of the focus groups was conducted by either one of the principal investigators or an advanced level graduate or research assistant in every case at least one of the facilitators was an african american faculty member background information about the definition and types of microaggressions were provided during each focus group with some examples from sue et als 41 paper focus group questions centered on the participants experience with racial microaggressions with six initial prompts and a variety of suggested subprompts that might be used to clarify discussion following each prompt though facilitators were encouraged to also explore topics that organically arose in the room data analysis initial coding was completed exclusively by two pairs of graduate and undergraduate students at the institutions where the focus groups occurred the initial coding results were reviewed and discussed by the coders as well as the faculty research team which included an expert on racial microaggressions as well as one with ipa experience who had trained the team during these discussions themes would be explored for convergence and sent back to the coders to determine if consensus might be reached that the codes appeared to capture the meaning that each team intended finally the identified themes were compared to the theoretical groupings of microaggressions from sue et als 41 taxonomy and reviewed a final time by the authors to further verify agreement across the study team on the categorization of the data this allowed for the consideration of whether terms that already existed in the literature might serve as better labels that would bridge these results to existing literature as well as to avoid unclearly renaming a welldescribed phenomenon results the following section details the 15 resultant categories from our ipa analysis which are also summarized in table 1 not a true citizen this type of microaggression first described by sue et al 41 as alien in own land is based on assumptions that the target is not a true american reinforcing notions that nonwhites are probably immigrants communicating exclusion illegitimacy and lack of belonging that can make people of color feel like outsiders this type of microaggression has often been described in relation to the experiences of asian and latinoa americans but african american focus group participants reported experiencing it as well some exemplars of this theme are as follows my head is shaved actually i hear a lot of things its really annoying about… a lot of people especially from my friends they think that i shaved my head for like oh do shave your head for a religious thing or like an african ritual or something because they see like you know like the pictures and stuff in the media and they automatically assume that like and i hear it a lot too… oh where are you from are you from like africa female respondent just a few months ago someone who works in the office of admissions was with students from tanzania and she asked me where i was from i said cadence kentucky and she said no before that where are you from and i said kentucky i was born here and she said no seriously your name is redacted so you have to be from outside of america but we were in the presence of tanzanian students who table 1 categories of microaggressions category name description 1 not a true citizen when a question statement or behavior indicates that a person of color is not a real citizen or a meaningful part of our society because they are not white racial categorization sameness when a person is compelled to disclose their racial group to enable others to attach pathological racial stereotypes to the person includes the assumption that all people from a particular group are alike assumptions about intelligence competence or status when behavior or statements are based on assumptions about a persons intelligence competence education income social status derived from racial stereotypes false colorblindness invalidating racial or ethnic identity expressing that individuals racial or ethnic identity should not be acknowledged which can be invalidating for people who are proud of their identity or who have suffered because of it 5 criminality or dangerousness demonstrating belief in stereotypes that people of color are dangerous untrustworthy likely to commit crimes or cause bodily harm 6 denial of individual racism when a person tries to make a case that they are not biased often by talking about antiracist things they have done to deflect perceived scrutiny of their own behaviors myth of meritocracy race is irrelevant for success when someone makes statements about success being rooted in personal efforts and denial of existence of racism or white privilege 8 reverse racism hostility expressions of jealousy or hostility surrounding the notion that people of color get unfair advantages and benefits due to their race pathologizing minority culture or appearance when people criticize others based on perceived or real cultural differences in appearance traditions behaviors or preferences 10 second class citizen ignored invisible when people of color are treated with less respect consideration or care than is normally expected or customary this may include being ignored or being unseeninvisible 11 connecting via stereotypes when a person tries to communicate or connect with a person through use of stereotyped speech or behavior to be accepted or understood can include racist jokes and epitaphs as terms of endearment 12 exoticization and eroticization when a person of color is treated according to sexualized stereotypes or attention to differences that are characterized as exotic in some way 13 avoidance and distancing when people of color are avoided or measures are taken to prevent physical contact or close proximity 14 environmental exclusion when someones racial identity is minimized or made insignificant through the exclusion of decorations literature or depictions of people that represent their racial group 15 environmental attacks when decorations pose a known affront or insult to a persons cultural group history or heritage obviously didnt want to be asked where they were from female respondent racial categorization sameness this category is intended to describe the microaggressions that occur when a person of color is compelled to disclose their racial identity to others often leading to the expression of pathological stereotypes based on that identity it also applies when people make comments or assumptions that people of a given race are all alike this results in the harmful ascription of stereotypes that may serve to disconnect an individual from their actual heritage or lived experience to incorrectly ascribe attributes to ones heritage or experience or to force unwanted attributes or group responsibility to an individual 41 not all forms of colorblindness were considered negative by focus group participants who often welcomed the idea that they could be treated equally by others rather than being racialized however they did not typically believe that their race was unseen or unnoticed by those professing colorblindness thus the category is renamed here as false colorblindness to account for the various examples in the data where colorblindness functionally prevents honest discussions about important racial issues i i think just from professors as well as from students that are like oh i dont see color or ignoring the fact that they might have said something that was bigoted or racist and not acknowledging that they have an issue or being able to address people as people and also acknowledging that they have different ethnicities and different ethnic backgrounds another instances when i see microaggressions play out is in the differences in the way that you dress i can dress in you know a pair of timbs or a pair of boots and just a baggy sweatshirt you go out because im feeling a little lazy that day and have everybody walk to the other side of the street but the second i put on a button down and a little bit tighter pants and some dress shoes or you know something along the lines of that then everybody feels a little bit more comfortable you know and its like why is it that all of a sudden my perception is changing just because of the attire that i have on female respondent denial of individual racism in contrast to false colorblindness this type of microaggression occurs when a person tries to make a case that they do not have any racial biases which may be triggered by perceived scrutiny of the offenders behavior this may take the form of talking about antiracist things the person has done or connections the person has with other people of color this category was supported by our data however and when employed as a response to criticism it can be invalidating to people of color who are trying to draw attention to a problematic behavior this microaggression occurs when people deny the ongoing existence of systemic racism or harmful discriminatory behavior specifically in regard to personal achievement or barriers to achievement they embrace the myth of meritocracy and the notion that the determinants of success are unequivocally rooted in personal efforts refuting that white privilege is an unearned benefit resulting in tangible differences in outcomes at a personal or societal level i ive had a mixed girlfriend of mine sit there and say … black people are just blaming the system and they just need to take advantage of you know the opportunities they have and its like well really whathow many opportunities do we have can you sit up here and put on a list of how many opportunities we as african americans have compared to all the opportunities that whites have or you know asian americans or mexican americans because if you sat up there and compared the list our list is going to be pretty short you know can you explain to me why it is that we have so many african american men in prisons a lot of african american women in prisons who still havent gone through trial and its two years later that theyve been sitting in jail i know friends who have seen their friends sitting in jail awaiting trial for two years female respondent reverse racism hostility this microaggression includes expressions of jealousy or hostility surrounding the notion that people of color get unfair advantages and benefits due to their race often coupled with the assertion that white people are being treated unjustly and are suffering as a result the idea that people of color are undeserving of success is often embedded in this sentiment then he said that black on white crime is also very prevalent and that we should stop killing them because of their race and that i have black privilege the manager brought in this black guy to interview he was clean cut he had dreads but they were nice and stuff like no big deal he has dreads and i know our doctor was like is she going to hire him i was listening and i was like is this a racial thing cause he looked perfectly fine cleancut nice suit super nice guy female respondent also embedded in this sentiment is the idea that whiteness is preferred and consequently there is something negative or shameful about a nonwhite identity hence microaggressions may include statements that advance pronouncements of apparent whiteness as complimentary our focus group participants overwhelmingly reported statements such as these to be upsetting and insulting i was studying with this kid in my sociology class and we had been studying for a while throughout the quarter and pretty much this time we were studying and he was like you know c youre not that black youre pretty white male respondent second class citizen ignored invisible this microaggression captures situations in which people of color are treated with less respect consideration or care than is normally expected or customary this category is meant to include both the experience of being treated as a second class citizen and the experience of being ignored unseen or invisible my name is redacted and people think its difficult for people to say and some people assume that its ghetto even though it is a last name whenever she her former manager would see me or ask me to do something she would be like oh i cant think of your name it was going on for weeks to the point that it was getting ridiculous i think that she felt like that because my name was harder or different that she didnt need to try and learn it she didnt have enough respect for me to learn my name and treat me like everybody else female respondent with all the shootings that have been happening in the black community i kind of felt a certain way when i didnt hear anything from my school that there was some kind of support for us to just acknowledge that there are people that are here that can be affected but with the orlando shootings there was a different response there were emails there were ceremonies and i was just like i thought they werent allowed to interfere…the first thing i said to myself was like theyre not allowed to probably bring it politics and other things into schools thats why they didnt send an email but then there was such an overwhelmingly overwhelming response to the orlando shootings i was like thats not the case female respondent connecting via stereotypes many focus group participants described awkward situations in which white students attempted to communicate or connect through use of stereotyped speech or behavior believing that will help them be accepted or understood he just came up to me and he was like so wassup and hes like talking with his hands and doing all these gestures just like wassup like trying to talk to me but using like things that he thinks like i guess to connect with melike cause were… i dont know what it was but it was just weird and made me feel uncomfortable um so i just asked him i was like what like what are you trying to say what are you doing and basically i just had to end the conversation … why try to use like this hip cool language to try to connect when we could have had like a conversation just as well female respondent this category can include using racial jokes or even racist epitaphs to try to fit in or as terms of endearment shes caucasian and like we hang around a lot of black people so she just generally has a pretty black group of friends you know and shes always dated african american people and so she feels like its ok for her to freely use the nword female respondent exoticization and eroticization this occurs when a person of color is treated according to sexualized stereotypes or perceived differences are characterized as exotic in some way some examples shared by our participants included the following i dated quite a few white women and i agree that they fetishize us they dont really look at me as like a man its ah oh a black man or a stereotypical big dude kind of thing male respondent ive actually been to a few frat parties and i stopped going because every time i go theyll be like hey the black girls here theyll be like hey can you twerk on me or something and i always get that and im just like ugh and its really sad because like white women will come up to me and ask can you teach me how to twerk female respondent many participants also shared microaggressions they had experienced surrounding their hair and the frustration they felt over people asking pointed questions or attempting to touch it when i dont wear my headscarf i have really curly thick hair so its like ohhh can i touch it no you cant touch my hair or yeah how do you get your hair like that im like its water just water or is that a wig no its not a wig its my hair and then it has taken me awhile to like accept my hair and how you know curly it is and its high maintenance and to accept my curl pattern and then to have people tell me oh maybe you should wear your hair straight its like… its like a slap in the face female respondent these types of microaggressions were not described in sue et als 41 original taxonomy but are similarly represented in a category called sexual objectification in sue and spanierman 42 avoidance and distancing this occurs when people of color are avoided or measures are taken to prevent physical contact or close proximity this includes the exclusion of members of targeted groups through physical distancing it can also include avoiding close relationships and difficult discussions about race we were alternating group leaders to lead discussions about a paper we read for the week and it was kind of like this random thing so i was excited when it was my turn to be the group leader because i was interested in the subject i had spent hours thinking of you know thoughtful questions to talk about and then nobody showed up to my group… there was like five different group leaders and so everyone kind of dispersed to the other four groups and no one showed up to my group and i was just in tears because this has happened my whole life like no one has ever wanted to hear what i had to say female respondent i ride the bus every day and so often like ill have like two open seats next to me and like so much of a person avoids and theyll go choose to sit next to someone really close than have like have open space next to them that happens to me a lot male respondent environmental exclusion certain microaggressions that are more apparent on systemic and environmental levels have been defined previously as environmental microaggressions 41 environmental exclusion is a microaggression that occurs when someones racial identity is minimized or made insignificant through the exclusion of decorations depictions or literature that represents their racial group it can also be used to describe situations where representations of people of color are not present in the classroom or workplace 25 i feel like there isnt enough representation of prominent black people anywhere or people of color or see it at all the news or on the internet i mean you can search for it but its not going to be like anywhere you can find male respondent were learning about what happens to white people when they get sick for instance so a white person is pale when they get anemia well how do you tell if a black person is anemic i mean there is a way to tell but they dont ever talk about that so i think that it is mostly geared towards white people treating white people and not people of color female respondent diversity in leadership can be incredibly valuable to students interest and engagement one noted i finally have like a black female professor that like i didnt even realize it until i had her this semester that i couldnt really relate and get interested in the topics that im studying im interested in them obviously but like i couldnt get interested in them like i am now because she… i relate to her more and so like when i first walked into my classroom at the beginning of the semester and saw a black woman like intakes full excited breath i was like overwhelmed i was excited female respondent environmental attacks the category of environmental attacks is intended to describe situations in which decorations or depictions pose a known affront or insult to a persons cultural group history or heritage for example on the topic of confederate flags participants reported feeling afraid and uncomfortable like oh my gosh thats so uncomfortable im like uh oh … its like im unwanted in that area youre just like oh my gosh what if they do something to me they must hate me they dont want me to be here like maybe i should leave female respondent if you were to see a swastika or any other symbol of somebody who went through a similar situation they would immediately take it down but anything that has to do with pertaining to the black struggle what we went through they dont really seem to acknowledge it just like they arrested that lady i think it was in south carolina when she went up and took that flag down and she got arrested for it that really makes me mad female respondent at one point members of the executive office at one of the universities had dressed up in stereotypical mexican garb for a halloween party students expressed feelings of hurt about the event especially because the university president had participated 50 personally i felt that although im not hispanic when he wore the sombrero and threw the party i felt it affected me to because if you can disrespect those students at this university then you are disrespecting me as well female respondent discussion overall the students in this study reported a variety of microaggressive experiences on campus and these caused distress confusion and led them to question their perceptions of events students were not quick to ascribe racist intentions to perpetrators but often did so after careful evaluation of the situation and many times opted to ascribe no motivations to offenders at all this is consistent with essed 11 who explains that accounts reflect interpretations of realitybased inferences from the targets general knowledge and rational comparisons between racist and nonracist situations the pain frustration and helplessness which racism often causes are strong incentives to carefully examine an event before judging it discriminatory and lends further support to the need for as comprehensive a taxonomy as possible the accounts shared by our participants are not unlike accounts from other black university students in one sample of black students attending a pwi midwestern campus students described their uncertainty and withdrawal from the heavy pressure to speak for a homogenous black experience in light of both faculty and classmate pressure to do so 45 in qualitative studies across the united states including ivy league universities black students report a variety of experiences that saturate both campus and social environments adjacent to schools that emphasize a lack of belonging and black men describe specific black misandry that served as a constant sources of environmental stress 3839 young black womens experiences emphasize the challenging narrow range of expectations and stereotypes ranging from exotic sexualization to an expectation of strength or irrational anger 24 these findings highlight the taxing necessity for black college students to carefully monitor their environments for signs of threat while simultaneously restricting and monitoring their own behavior to avoid the pitfalls of fulfilling a stereotype that leads to further racist mistreatment subtle forms of racism such as microaggressions can be difficult to identify quantify and rectify because of their nebulous and unnamed nature although racial maltreatment exists on a continuum of discriminatory action ranging from gross and intentional to tiny unconscious slights 12 there is a need for a unified language in the study of the experience of this form of covert racism the burgeoning research on the topic of microaggressions while important in identifying the vast scope and depth of the problem has made it increasingly difficult to identify such a common language that integrates multiple perspectives and provides an opportunity to adequately capture emerging categories our study identified 15 common categories of microaggressions as experienced by people of color including the 9 originally described by sue et al 41 in comparing our findings to sue and colleagues 9 categories which are also a part of the sue and spanierman 42 taxonomy we find many similarities and some notable differences as well class citizen but we added invisibility to the name to underscore that being unseen is also prevalent among people of color especially black women other new categories were connecting via stereotypes which has been noted in the literature in various contexts and exoticization and eroticization which has come up repeatedly in both the quantitative and qualitative literature as noted previously sue and spanierman 42 added a category called sexual objectification but this only refers to women whereas men of color are often sexually objectified as well we also added avoidance and distancing which is captured only a little by sue et als criminalityassumption of criminal status but this category seemed inadequate because there were many reasons apart from danger that people of color may be avoided 14 we split sue et als environmental microaggressions into two categories the first focusing on macrolevel exclusion and the second called environmental attacks we split this from the larger category of environmental microaggressions to capture these particularly hurtful and often frightening depictions 727 which have been an ongoing source of consternation public attention and institutional resistance 550 finally although we found evidence for a tokenism category we did not have enough responses to formalize this tokenism is often described as the inclusion of individuals only because of their race for the illusion of inclusivity 25 while this theme has been documented in the literature surrounding racial aggression it was not specifically addressed by the moderators during the focus groups thus the data did not yield exemplary material that would fall into this category it is also not discussed by sue et al 41 or sue and spanierman 42 the ipa approach utilized in this study may differ from expectations of those familiar with ipa research particularly the final number of themes is greater than the general approach to the identification of metathemes most common in qualitative work this is an artifact of the researchers goals and philosophy in approaching the topic that is this is not only an elaboration of themes revealed in the discussions of the focus groups it is also an attempt to consider themes at a common level of analysis with existing microaggressions literature this is reflected in the greater frequency of specific microaggression types in empirical research compared to the less frequent utilization of proposed metacategories of microaggressions limitations and future directions this study is not without limitations the sample included selfidentified predominately black students from three institutions in only two geographical regions some types of microaggressions are more common for black people than people in other ethnoracial groups 42 future work on this topic may result in an updated taxonomy that accounts for the increasing intersectionality of marginalized identities such as gender sexual orientation or religion for example donovan et al 9 assessed the intersectionality of race and gender among female graduate and postgraduate students and weber et al 46 interviewed graduate students that identified as sexual minorities these studies explicated unique categories not represented here but relevant for those specific groups this paper has focused on a classification system based the actions of perpetrators but there may be better and more equitable ways to classify these behaviors for example in some situations it may be better to classify microaggressions based on the intention of the perpetrator or the impact on the victim likewise future research should examine the differential harms to victims resulting from the different types of microaggressions described herein conclusions without an adequate understanding of the illusive dynamics of subtle racism microaggressions will remain invisible and harmful to the wellbeing selfesteem and standard of living of people of color while previous literature has either embraced the taxonomy developed by sue et al 41 or proposed a novel taxonomy unique to specific data this study utilizes the sue et al 41 and sue and spaniermans 42 framework as a starting point toward understanding our own focus group findings we also move that work forward by splitting the original alien in ones own land and environmental microaggressions into two categories and drawing attention to the need to further examine microaggressions that typify connecting though stereotypes and tokenism although this paper is not the last word on how to best categorize microaggressions we hope this serves as a step in the right direction and call for more work in this area based on a systematic review of research of studies to date ultimately a unified language of microaggressions may better allow for improved measurement of this construct in both qualitative and quantitative studies it may also facilitate selfreport of microaggressions by aggressors to better enable them to honestly and earnestly explore personal biases and minimize the associated negative social outcomes it may further relieve the onus of those who are the recipients of repeated microaggressions to prove the validity of their perceptions and experiences 1 it is our hope that this work will contribute to moving the field toward a shared language of microaggressions and thus a consensus will emerge across multiple fields of interest surrounding the study of prejudice and racism abbreviations gpa grade point average hpa hypothalamicpituitaryadrenal ipa interpretative phenomenological analysis irb institutional review board pwi predominately white institutions authors contributions mtw jwk and dcr conceptualized and designed the study and collected the data jmc and md assisted with recruitment and data collection mds and jmc assisted with methodology and initial data analyses mtw mds and rmw drafted the manuscript all authors approved the final manuscript competing interests the authors declare that they have no competing interests

background pierces the black seventies an extending horizon book 1970 conception of subtle and stunning daily racial offenses or microaggressions remains salient even 50 years after it was introduced microaggressions were defined further by sue and colleagues am psychol 62271 2007 and this construct has found growing utility as the deleterious effects of microaggressions on the health of people of color continues to mount microaggressions are common on campuses and contribute to negative social academic and mental health outcomes method this paper explores how black college students experiences correspond to or differ from the microaggression types originally proposed by sue et al am psychol 62271 2007 themes were identified from focus group data of students of color n 36 from predominately white institutions pwis of higher learning n 3 using interpretative phenomenological analysis results we identified 15 categories of racial microaggressions largely consistent with the original taxonomy of sue et al but expanded in several notable ways new categories in our data and observed by other researchers included categories termed connecting via stereotypes exoticization and eroticization and avoidance and distancing lesser studied categories identified included sue et als denial of individual racism and new categories termed reverse racism hostility connecting via stereotypes and environmental attacks discussion while previous literature has either embraced the taxonomy developed by sue and colleagues or proposed a novel taxonomy this study synthesized the sue framework in concert with our own focus group findings and the contributions of other researchers improving our understanding of microaggressions as they impact people of color may better allow for improved understanding and measurement of this important construct

introduction gender differences in social status have existed for a long time in primitive society due to the difference in body shape and strength between men and women men were better able to undertake the powertype labor the distribution of housework between the husband and wife was uneven and the status of women became increasingly lower over time class status refers to the different social class levels which are represented by a series of social status indicators such as the educational level and income of the subject in china since the 1990s people have been arguing endlessly on the issues of having a good marriage is more important than having a good job the ultimate significance of women is to find a good spouse to get married and nourish children and having a good marriage and you can reduce 20 years of struggling besides under the concept of gender inequality womens rights and interests are difficult to be protected which affects womens values and class identity influenced by the development of market economy background at that time some women think that they can change their destiny by choosing to marry successfully instead of individual efforts and attach their values to their spouses rather than themselves in the past few decades the proportion of women in the political institutions of almost every country in the world has increased significantly and the trend of womens labor force participation has also gradually increased the social status of women has been greatly improved compared with that in the past under the background of economic transformation in china womens social class is gradually stable in the constant changes recently the education level of chinese women has been increasing according to the data of china womens development program in 2019 released by china statistics bureau the number of female postgraduate students in china reaches 1448 million accounting for 506 of all postgraduate students this data confirms the progress of women in receiving equal education and the importance of womens voice in scientific research however has womens identification with their own class changed regarding the meaning of the phrase class identification through literature review we can find that scholars agree with the views of mr and mrs jackman class identification is the individuals perception of their own social class structure therefore the existing research mainly defines class identification as comprising the following actions each social member will measure or judge his social status according to his or her own conditions and will belong to a certain level of society the objective social status will affect the subjective class identity however the improvement of the objective social status does not always involve the improvement of selfidentity in the subjective sense as there are still significant differences between them gender inequality between men and women comprises not only the actual inequality but also the psychological inequality in todays advocacy of gender equality we should not only pay attention to womens social status but also to the appeal of womens psychological identification with class equality which is more conducive to social stability health and sustainable development the research on class identification has been relatively extensive and has involved psychology sociology economics gender research and other research fields moreover experts and scholars have different research perspectives on class identification and the measurement standards have not been completely consistent these scholars have mainly studied the influence of the social environment and personal characteristics on class identification however the class identification of female groups has gradually attracted attention female class identification not only emphasizes womens recognition of themselves but also reflects whether women attach importance to gender equality some scholars pay attention to the relationship between socioeconomic status and female class identification and believe that the higher the social status of women is the higher their class identification is there are also studies that focus on married women as the main object of study in order to analyze whether their class identification mainly comes from themselves or their spouses in addition additional studies have focused on the differences between the class identification of urban and rural women it has been found that compared with that of urban women the sense of class identification of rural women is generally lower and that rural women are more dependent on their spouses regardless of whether the study focuses on the determination of whether married womens class identification comes from themselves or their spouses or focuses on the differences in class identification between urban and rural women all of these studies provide important insights for further research on the index factors influencing female class identification however these studies mainly focus on one aspect of the influencing factors of female class identification and there are few comprehensive female class identification studies that examine the topic from the perspective of the young to middleaged personal growth experience in particular there are few studies on the impact of mothers on the class identification of the next generation of females and on the impact of lifestyle on female class identification this paper creatively puts forward the female class identification framework which mainly includes the mothers intergenerational influence female personal characteristics lifestyle gender consciousness and spouse status this paper summarizes some experiences that may have an important impact on womens own class identification in the process of womens growth and analyzes whether these factors truly affect female class identification and the degree of influence therefore to provide a theoretical and practical reference for further promoting gender equality and female class identification this study constructs an econometric ordered logit model and uses the data of the china general social survey obtained in 2015 in order to study the influencing factors of womens class identification literature review class identification is an important research field of social development stratification many scholars have focused on the status of the objective social class in the past now scholars have begun to pay attention to the differences in subjective class identification in the past the subjects of the study have mainly been urban residents and migrant workers and these studies have mainly explored the impact of a series of factors such as life experience administrative level the fathers professional reputation and housing consumption on class identification regarding the focus of the research which is advocacy related to pursuing equality between men and women the current research object is mainly female groups the analysis of which may improve to a certain degree of research significance the understanding of the class identity of female groups womens class identification is a kind of perception or feeling of their own position in the social class structure baxter points out that the womens class perception is influenced by the states gender openness and gender equality this phenomenon is reflected in a series of female groups comprising rural women the investigation and research reveals that rural womens class identification comes more from their own working conditions the education level of their mothers and themselves and the participation of the community as well as the interpersonal communication with the people inside and outside the village therefore we can define the following as factors that affect womens class identification gender consciousness intergenerational influence of mothers lifestyle and spouse status in the family the core unit of society there is strict gender division in the division of labor generally in terms of the family division of labor women are mainly responsible for housework while men are mainly responsible for going out to work in addition most men still hope that women can play the traditional role of a good wife and good mother and this expectation has an important impact on womens gender consciousness which will also affect womens own class identification some studies have found that womens self class identification is greatly affected by family because women usually associate their selfworth with their husbands in particular after distinguishing between urban and rural areas age and education level it is found that the traditional cognition of married women on their own class status will not change significantly because they live in the city are young and have higher education even when their income and education level are higher than that of their husbands their psychological attachment to their husbands will not be fundamentally changed in addition womens subordination psychology may lead them to think that their spouses class is more important than their own in addition because of the failure of these women to form their own independent class identification these women think that their spouses class determines to a great extent their own class identification class identification is also based on the concept of mobility and network the class identity of contemporary people will be affected by the previous generation when the upper generations class identification is low then the contemporary generations class identification will also be low in the process of womens growth their mothers play an irreplaceable role in establishing the womens image and promoting class identification some studies have shown that the mothers education experience family economic level and objective class level have a significant impact on the womens perception of class mobility with all kinds of information pouring in individuals are no longer limited to uninteresting work and pay more attention to forms of entertainment the members of each class show their relationship with and distance from other classes through the choice of interest taking as an example the investigation and research on the sports consumption psychology of different social classes of people the results show that with the improvement of the social strata the sports consumption attitude tends to be stronger when scholars take the middle class as the research object they find that the unique taste shown in leisure tourism consumption has become the label with which individuals identify themselves and the expression of this taste is a way for them to distinguish themselves from other people the literature review reveals that the existing literature on class identification especially female class identification mainly focuses on one aspect of the influencing factors there is no comprehensive study that focuses on the four factors namely gender consciousness the intergenerational influence of mothers lifestyle and spouse status in order to conduct a longterm study of womens class identification this type of comprehensive study is the innovation of this paper class identification is not just affected by one aspect but is constantly changing due to different experiences it is necessary to comprehensively consider and analyze the real influencing factors of female class identification therefore to provide a certain reference for future research on female identification this paper will use the cgss data obtained in 2015 to study the influence of gender consciousness mothers intergenerational influence lifestyle and spouse status on female class identification real gender equality not only exists because women can enjoy privileges but also because they can define their own class selfidentification such recognition is not defined by anyone else or any external factors this study is of great significance to the rise in womens status in all walks of life and more importantly to the pursuit of a more equal and harmonious social environment proposed research hypothesis the hypothesis between gender consciousness and female class identification gender consciousness is an important aspect of the research on gender relations and mainly includes a series of indicators such as the gender division of labor the difference in ability between men and women marriage consciousness and gender discrimination in employment the statistics on these indicators are included in the cgss data obtained in 2015 these views in the research on gender consciousness show that women agree with the low status of women in the relationship between men and women therefore we propose hypothesis h1 the more women accept the view that womens status is low the lower their sense of class identification is the hypothesis between mothers intergenerational influence and female class identification in the research on family relationships studies have found that the mother has an important influence on the daughters family outlook and values in daily life if the family relationship is longterm unequal ie if the father is stronger and the mother is always the weaker side this situation is likely to lead to the formation of a childs view of discrimination against women in rural areas for example girls may be easily overlooked and thus have less access to education as time goes on women who have no opportunity to receive education may still neglect their daughters education in the next generation which leads to the lower class identification of women in the next generation therefore we propose hypothesis h2 the higher the social status of the mothers is the stronger the social identification of women the hypothesis between lifestyle and female class identification maslows theory from the lower level to higher levels divides needs into five categories physiological needs security needs social needs respect needs and selfrealization needs when individuals can basically meet their own survival needs they will pursue higherlevel needs the higher the level of the residents need is the more likely it is that the residents life is not limited to work and the more they enjoy life in contrast after satisfying our basic postnatal tastes individuals will have a better sense of happiness as the residents satisfy their needs at one level does the residents class identification also improve at the same time therefore we propose hypothesis h3 among women the higher their taste of life is the higher their class identification is the hypothesis between spouse status and female class identification in the division of the class identification in the husband and wife relationship one kind of relationship is a dependent type that is one in which the female completely relies on the spouse to determine her own class it is undeniable that whether a woman is married or not has a great influence on her life state after marriage women are more likely to devote their energy to their families and the quality of the spouses class will also affect womens class identification more importantly in reality the way in which the work unit of a females spouse is viewed may determine the spouses degree of recognition in the society thus affecting womens social identification therefore we propose hypothesis h4 among married women the better the spouses work unit is the higher the females class identification is data source and variable setting data the data used in this study were obtained from the chinese general social survey carried out in 2015 and sponsored by the china social science foundation the data were originally collected by renmin university of china and academic institutions in china by screening the control variables and eliminating the invalid questionnaires 4702 valid female samples were obtained variable setting in this study all variables are divided into explained variables explanatory variables and control variables to facilitate reading and checking the code of each variable is consistent with that in the cgss2015 questionnaire through sorting the basic information of each variable is shown in table 1 explained variables the explained variables mainly reflect the females class identification that is the response to the following question in the cgss2015 questionnaire what level do you think you are currently at to respond to this question in the questionnaire the respondents are presented a total of 10 options a response with a value of 1 indicates the bottom level and a value of 10 indicates the top level the numbers in the middle increase as the level increases the higher the number for the response is the higher the class the women think they belong to is and a higher number also indicates that they attach more importance to and recognize their social status to refine and stratify the explained variables the responses in which participants selected options 13 are grouped into the lower class and are assigned a value of 1 responses of 47 are grouped into the middle class and assigned a value of 2 responses of 810 are grouped into the upper class and assigned a value of 3 through statistical analysis the average value of female class identification is found to be 1749 and the standard deviation is 0485 which indicates that most womens class identification is lower than the middle class explanatory variables the explanatory variables are divided into four aspects gender consciousness the mothers intergenerational influence lifestyle and spouse status influence gender consciousness in the cgss2015 questionnaire there are five items about gender consciousness the conceptual focus of each of the five items and the corresponding item text are as follows gender division of labor consciousness represented by the statement do you agree that men focus on career women focus on family gender ability consciousness represented by the statement do you agree that male ability is naturally stronger than female ability marriage consciousness represented by the statement do you agree that having a good marriage is more important than having a good job gender discrimination in employment represented by the statement do you agree that female employees should be fired first in an economic downturn and housework distribution consciousness represented by the statement do you agree that husband and wife should share the housework equally all these items reflect womens views on gender equality for example if women agree with the idea that mens natural abilities are stronger than women they may feel inferior and dare not fight for their due rights and even be less able to correctly recognize their social class the participants are asked to respond to the above questionnaire items by answering as follows if the respondents totally disagree relatively disagree are indifferent to agreeing relatively agree or fully agree with the item statement they respond by assigning a value of 1 2 3 4 or 5 respectively the average values for the gender division of labor consciousness marriage consciousness and housework distribution consciousness were between 3 and 4 indicating that these three concepts were relatively neutral among female investigators however the average value of gender ability consciousness was 2934 and the average value of gender discrimination in employment was 1818 which indicates that most women do not agree with the view that men are born with strong ability and women are discriminated against in employment mothers intergenerational influence if the mother has always been in a low position in the family or the mothers selfexperience has intentionally or unintentionally set up a low female image for the children it will affect the class identification of the next generation class identification is closely related to education political status and work unit therefore in the cgss2015 questionnaire three items focusing on the mothers intergenerational influence are included namely what is the highest education level of the mother what is the political status of the mother and what is the employment status of the mother at the age of 14 these three items represent the main background of the previous mothers generation significantly the mothers employment status may affect the familys income and even the status in childrens hearts and indirectly affect the shaping of childrens female class identity values for the mothers highest education level the response values are assigned as follows no education is assigned a value of 0 private school and primary school education are assigned a value of 1 junior high school education is assigned a value of 2 vocational high school senior high school secondary school and technical school education are assigned a value of 3 undergraduate and specialty college education are assigned a value of 4 and postgraduate education and above are assigned a value of 5 according to the data statistics the average of the highest education level of the mothers is 0595 which indicates that the mothers education level is mainly primary school or no education according to the calculation of the time the period in which the mothers received education was mainly from 1950 to 1980 which was a period in which education was not popularized the survey results confirm this fact regarding the unpopularity of education during that period as being basically true for the political in total disagree 1 fully agree 5 3294 1484 gender ability consciousness in total disagree 1 fully agree 5 2934 1521 marriage consciousness in total disagree 1 fully agree 5 3070 1641 gender discrimination in employment in total disagree 1 fully agree 5 1818 2147 housework distribution consciousness in total disagree 1 fully agree 5 3787 1388 mothers intergenerational influence in this table the code in brackets below each index represents its corresponding question number in cgss2015 status of mothers the party member response is set to 1 and the others are set to 0 the average response value is 0017 indicating that the majority of mothers are not party members through statistical data it is found that the number of female respondents whose mothers are not party members is 4096 the employment status of mothers at the age of 14 will also affect the employment identification of the next generation the value of no job is assigned as 0 that of agricultural work is assigned as 1 and that of nonagricultural work is assigned as 2 the average value of this index is 0886 which indicates that most of the mothers of the women surveyed are engaged in agricultural work lifestyle in the questionnaire of cgss2015 four items are selected to represent the four aspects of lifestyle the frequency of leisure reading social intercourse cultural activities and fitness exercises because now people pay more attention to the quality of life than before if they carry out fitness exercises social intercourse and other activities it also proves that their quality of life has increased and the objective social class has improved the subjective social class identity will be affected by the objective social class so the lifestyle affects the objective social class affecting the subjective social class identity the answers to the questions for these items are as follows every day several times a week several times a month several times a year or less and never which are assigned a value of 1 2 3 4 and 5 respectively for the convenience of statistics since never and several times a year or less mean that they have little impact on life these responses are assigned a value of 0 several times a month is assigned a value of 1 and several times a week is assigned a value of 2 the leisure reading factor was represented by participating in cultural activities such as listening to concerts watching performances and exhibitions the respondents answers had an average value of 0141 indicating that most women hardly have time to engage in leisure reading the social factor was represented by meeting with friends which had an average response value of 0488 the factor of cultural activities was represented by surfing the internet and the average response value was 0677 the factor of fitness exercise was represented by taking part in physical exercise and the average response value was 0602 the average value of the latter three factors fluctuated up and down 05 indicating that the frequency of the latter three factors was less than several times a month but a response indicating that the respondent had never participated in these activities was never given spouse status for most chinese women marriage has a great impact on their outlook on life and values to study how much influence a spouse has on female class identification it is necessary to screen the womens marital status one of the questions about marital status in the cgss2015 questionnaire is what is your current marital status women who choose unmarried are asked questions related to their parents and the sample data of women with spouses are automatically screened out through stata150 software the literature review reveals that the main factors related to female class identification are the spouses education level political status and work unit type similar to the research on the mothers intergenerational influence these three factors play an essential role in the social status of female spouses in the traditional chinese concept the social status of female spouses will also affect womens judgment on their social class the evaluation of females spouse education level is the same as that of mothers intergenerational influence research with an average of 1966 indicating that most womens spouses have basically a primary or junior high school education the political status of the females spouses is the same as before with an average value of 0126 indicating that most spouses are not party members in the questionnaire for responses to questions regarding the work unit type of the females spouses the responses indicating the spouse worked in the party and government enterprises institutions and the army were assigned a value of 2 responses indicating social organizations and no work were assigned a value of 1 the average response value was 1593 indicating that the working units of female spouses were mainly concentrated in the party and government enterprises institutions and the army control variables the control variables are mainly the individual factors influencing female class identification the females age political status marital status education level work status the household registration type social equity housing property rights family economic class and family class at 14 years old among them age is a continuous variable taking the survey year 2015 as the time point the age of the respondents in 2015 was calculated after a series of variables such as political status and marital status are selected the values are assigned according to table 1 in particular this paper selects the property rights index of the house as the control variable because the chinese people think whether the house property certificate contains the owners name is an important feature of family status the age of 14 is an important period of human brain development as the familys class at the womens age of 14 will deeply affect the surveyed womens view of hierarchy through the data statistics we found that the average age of the investigated women was 50018 and the standard deviation reached 16702 indicating that the age difference of the investigated women was very large the average value of the womens political status was 0045 indicating that women who were not party members accounted for a large proportion of the respondents the average marital status of women was 0928 indicating that unmarried women occupied a small proportion of the respondents the average education level of women was 1792 which indicates that most of the women surveyed had a primary or secondary school education the average value of womens work status was 0806 which indicates that most womens jobs are nonagricultural a finding that is more in line with the current main working conditions the majority of the workers are employed in nonagricultural industry as the employment in the agricultural industry is gradually decreasing the average value of the female household registration type was 1312 which indicates that female respondents have a disposition to agricultural household registration the average value of the womens sense of social justice was 3194 which is relatively balanced the average value of the womens housing property rights was 0358 indicating that most of the surveyed women did not own their own housing property rights the average value of the females family economic status was 2662 ie close to 3 which indicates that most women think their family economic status belongs to the middle or lower class the average family class of women at the age of 14 was 1381 indicating that most of the surveyed women considered their family class to be middle or lower class at the age of 14 model construction and result analysis model construction since quantifying the female stratum requires an ordered variable we chose the ordered logit model for the analysis after the data were processed the multicollinearity test of the data was first carried out according to the variance inflating factor the larger the value is the more serious the multicollinearity between explanatory variables is generally when the value of vif≥10 it means that there is serious multicollinearity between explanatory variables and other explanatory variables when the value of vif is closer to 1 it means that the multicollinearity is weaker in this paper the mean value of multicollinearity is 139 and the multicollinearity among the variables is 3 thus there is no multicollinearity in each index therefore we can analyze the influence of each index variable on female class identity the formula is as follows y i βx i ε i among the variables y i is the potential female class identity x i denotes the variables affecting the female class identity β is the parameter to be estimated and ε i is the random disturbance term the corresponding relationship between the unobservable potential variable y i and the observable variable y is as follows y 1 2 3 y i ≤ µ 1 µ 1 y i ≤ µ 2 y i µ 3 among them the actual observed female class identity is y with values of 1 2 and 3 indicating the lower middle and upper levels respectively µ 1 and µ 2 are the cutting points both of which are parameters to be estimated and µ 1 µ 2 explanatory variables and female class identification to study the influencing factors of female class identification from different perspectives this paper establishes five different models model 1 is only the control variable model 2 adds the gender consciousness factor to model 1 model 3 adds the mothers intergenerational influence factor to model 2 model 4 adds the lifestyle factor to model 3 and model 5 adds the spouse status factor to model 4 through the results of each model we can see the significant characteristics of each index variable results analysis through the use of different research angles to study the influencing factors of female class identification the results in table 2 are obtained therefore the results of each model can be analyzed separately gender consciousness and female class identification model 2 is based on the control variables of model 1 to which various factors of gender consciousness are added in order to carry out the research the gender division of labor consciousness is found to have a significant positive effect at the level of 1 which indicates that the more women agree with the view that men focus on career women focus on family the higher the womens class consciousness the main reason for this is that most chinese women are more traditional when their husbands are successful in their careers women are willing to be their supporters the more successful their husbands are the greater they feel that their own class will be promoted at the level of 1 marriage consciousness has a significant negative impact on class consciousness which indicates that the more women accept the view that having a good marriage is more important than having a good job the lower their own class consciousness especially in the marriage market many women hope to change their own class through marriage and such women generally have low selfrecognition gender discrimination in employment is significant at the level of 5 that is the more women agree that female employees should be fired first when the economy is depressed the higher the womens class consciousness which is inconsistent with the original hypothesis in conclusion hypothesis h1 of gender consciousness has been partially verified mothers intergenerational influence and female class identification model 3 is based on the addition to model 2 of various factors of the mothers intergenerational influence based on a literature review and the psychological definition of a family relationship the main factors selected in this paper are as follows the mothers highest education level political status and work status however these three indicators are not significant therefore in this study we refuse to assume h2 and find that mothers have no influence on the class identification of the next generations of women in the family the reason may be that with the gradual popularization of modern social views and the increasing number of female workers the acceptance of the former view that men are in charge of the outside world and women are in charge of the interior or housewives has now been reduced therefore the working status of mothers has little impact on the female class identification of the next generation lifestyle and female class identification model 4 is based on the addition of various factors of lifestyle to model 3 in model 4 the factors of lifestyle are not significant which shows that the improvement of lifestyle has no influence on female class identification however note that in model 5 after considering the influence of the females spouse the social activities show a significant negative influence at the 10 level while fitness exercise shows a significant positive effect at the 10 level this may be because women will put more energy toward family after marriage if womens social activities are too frequent it is not conducive to family harmony and can thus affect womens class identification the positive effect of fitness exercise may be because the couples fitness exercise can promote the relationship between husband and wife but can also increase the happiness and sense of gain in womens daily life such that it can enhance womens class identification therefore hypothesis h3 is partially proved indicating that lifestyle has some influence on female class identification spouse status and female class identification model 5 establishes a model of a married females class identification from the model it can be found that the education level of a spouse has a significant effect on female class identity at the level of 10 in reality when women are looking for marriage partners the partners education level is a very important choice factor this view can be proved by the finding that the spouses education level has an important impact on the married womens class identification however there was no significant effect of the spouses work unit type and political status on the womens class identification therefore hypothesis h4 has been partially proved female personal characteristics and female class identification in model 5 we can clearly find the significance of each control variable index the working status of women is positively significant at the level of 10 which indicates that the social stratum identity of women in nonagricultural work is higher than that of women in agricultural work or unemployment the womens sense of social justice is significant at the level of 1 which indicates that the womens feeling regarding the fairness of social justice is very important for female class identification the economic status of the womens family is positively significant at the level of 1 which proves the importance of family economic status to women the better the family economic status is the higher the class identification of women the family class of women at the age of 14 is significant at the level of 1 as the age of 14 is a critical period for the formation of ones values therefore the family class at the age of 14 will affect the womens future class identification which is a finding consistent with the statistical results conclusion and discussion conclusion with the continuous progress of social civilization gender equality has always been the goal advocated and pursued by modern society the countries in the world have made great progress in improving laws and regulations and protecting the womens status however have the womens own values truly progressed with the development of society can a woman recognize herself based on the feelings from the bottom of her heart not from the external evaluation or her husband when the female individual subjective social class identity is higher it shows that they are confident about their situation considering a higher social class and a higher degree of identity and dependence on society the more critical practical significance is that the level of womens social subjective cognition is directly related to the effective solution of many social problems the likelihood of influence on the relationship with other social members and the resolution of social contradictions based on the cgss2015 data in this paper a female class identity framework is constructed and the ordered logit model is used to analyze the influence of gender consciousness mother intergenerational influence lifestyle and spouse status on the womens class identification the conclusion is as follows the factors of gender consciousness have a significant impact on female class identification the factors of the mothers generation have no influence on female class identification on the premise that women have spouses the factors of lifestyle have some significant effects on female class identification the status of the spouse especially the education level of the spouse has a significant positive impact on female class identification discussion the main contribution of the study is that compared with previous studies this paper does not only consider the influence of a single factor but also comprehensively considers several essential factors that may affect the formation of class concept in womens personal growth experience to restore the process of the construction of womens class concept the results of the model further not only prove that gender consciousness and spouse status have the significant effects on womens class identity but also indicate that mother intergenerational influence has little impact on womens class identity this is also a vital breakthrough compared with previous studies the influence of mother on daughter may not be as significant as people think the shaping of postnatal concept is more important highlighting the importance of social guidance and the formation of ethos however there are some limitations in this study this paper only considers the whole class concept of women there are significant differences in the growth environment and education situation between urban and rural women in china which is also the direction of our future research besides there are still insufficient indicators in this paper for example there are only three indicators related to the mothers intergenerational influence and spouse status which may not fully explain and our research takes womens marriage as the end of the research period but women may also experience some changes in their middle and old age if we can consider a more extended period that is to study all the influencing factors of womens whole life class identity the interpretation of womens class research will be more accurate the last limitation is that we only used cgss data and the regional differences factors are not taken into account in the future we can use the relevant international public data to conduct more comprehensive research especially compare the differences in factors influencing female class identification between different countries and regions from the conclusion of this study there are many factors that affect the womens class identification therefore it is necessary to improve the womens ability and strengthen the womens consciousness of power it is suggested that womens class identification should be promoted from the following aspects protecting womens basic rights and interests much discrimination toward women still exists in society one obvious example is the gender discrimination in the process of job hunting some companies do not recruit female job seekers even though there are no explicit regulations for recruitment for women who have given birth or are about to give birth the company will give the opportunities that originally belonged to them to male employees or new employees which not only increases the reproductive pressure of women but also increases the work pressure of women therefore women should be given tolerance and equal treatment in vulnerable periods such as illness childbirth or family changes therefore we should also improve the relevant laws and policies to protect the rights and interests of women in employment and entrepreneurship from the perspective of the overall interests of the society if as mothers women have independent work they can not only gradually get rid of their dependence on their spouses but also strengthen their own class identification especially for the next generation confirming the socalled adage teaching by example is better than words the example these mothers will create better in 2020 chinas newly revised civil code has strengthened the superior protection of womens rights and interests provided more trustworthy and reliable legal protection for women and rectified all kinds of adverse social phenomena affecting women in particular the law includes such contents as rural womens right to land opposition to sexual harassment and privacy protection and recognition of womens family contribution these newly drafted legal provisions have built a solid legal barrier for promoting gender equality and womens allaround development while emphasizing the equal civil legal status of men and women the superior protection of womens rights and interests has been strengthened for the protection of womens class the law has made some progress but it still needs womens awareness and fight for their rights and interests promoting womens independent education real equality is the equality recognized by ones own heart some women firmly believe in gender inequality and therefore enjoy the goods or the treatment that they receive from their weak position as women however in fact real equality comes from womens deep recognition of themselves when they have the confidence they can fight for the rights they deserve and will not let others take advantage of womens status therefore in the new era we should implement the concept of womens selfreliance and women should pursue a completely independent life in view of this the state can also carry out various training lectures in order to strengthen womens skills and can conduct public welfare activities in order to improve womens cultural literacy so that women can have a greater sense of participation and happiness in society 3 enrich national entertainment activities the grassroots government can better promote the participation of all people in entertainment especially the collective entertainment activities involving the family as a unit these activities play a very important role in promoting family harmony and womens class identification in addition these types of activities also effectively enable women to avoid the role of only being a housewife and increase their sense of social participation the lack of which can lead to their disconnection from society and then the reduction of their social identity improving womens education with social progress the level of development of rural areas will gradually catch up with that of the cities however in some surveys we can still find the differences in womens status between urban and rural areas at present there are still many girls who do not have the opportunity to study therefore in the process of promoting womens status rural areas are still the most important and the most difficult bottleneck to break through in rural areas we should not only strengthen the legal protection of women and change rural womens views on gender equality but also protect the right of rural girls to receive education and promote rural womens employment opportunities gender equality is advocated by many countries in the world however little attention has been paid to womens own class identification especially the influence of womens personal growth experience on their own class identification moreover the degree of this influence has not been fully studied based on womens personal growth experience from youth to middle age to study the factors that dominate female class identification this paper creatively constructs a female class identification framework from five aspects the mothers intergenerational influence female personal characteristics lifestyle gender consciousness and spouse status this study can provide a theoretical and practical reference for further promoting gender equality womens own class identification and womens psychological health collected by renmin university of china and academic institutions in china we appreciate the assistance of the institutes in providing the data the research findings are the product of the researcher neither the original collectors of the data nor the archives bear any responsibility for the analyses or interpretations presented here data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation 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

in advocating gender equality today we should not only pay attention to womens social status but also call for the womens psychological identification of class equality what dominates female class identification to answer this question based on the data of the chinese general social survey cgss in 2015 this study constructs a female class identity framework from five aspects the mothers intergenerational influence female personal characteristics lifestyle gender consciousness and spouse status in this study the ordered logit model is used to empirically analyze the impact of various factors on female class identification and the results show the following 1 gender consciousness has a significant impact on female class identification 2 lifestyle has a significant impact on the situation of having a spouse 3 spouse status has a significant positive effect on female class identification but 4 the mothers intergenerational influence has no effect on female class identification therefore this paper suggests that we should improve laws and regulations to protect womens normal rights encourage women to establish an independent and selfimprovement character and enhance the class consciousness of women especially rural women in order to achieve the overall improvement of female class and psychological identification

apprehending various physical systems under the framework of networks has been in practice since a couple of decades 12 recent years have realized the need of this framework in understanding a myriad of social phenomena in various disciplines ranging from psychology to economics 3 for instance in understanding spread of behaviour across a population 4 assessing organizational performance 5 outbreak detection of disease propagation 6 in this letter we delve in to the intricacies of society using bollywood the largest film industry of the world 7 as a model being a mixture of art business and entertainment bollywood with 100 years of cinematic heritage has emerged as a key artifact providing a host of insights into shifting ideals fantasies lifestyles opinions and views of the everevolving indian society 8 making nearly one thousand feature films and fifteen hundred short films per year the indian film industry is the largest in the world cinemas in the uk have been screening bollywood movies since the late 1960s and the spread of indian population overseas renders bollywood stars to gain popularity both home and abroad 9 bollywood provides a legitimate ground to capture the dynamically evolving nature of the diasporic society where definitions of lead actors and their credentials of success was captured in terms of the payoff and overlap of the actors and the prevailing gender disparity in the society was emphasized upon 10 although hollywood a much smaller counterpart has been investigated using various statistical techniques 11 analysis over an evolving time scale was not emphasized upon and impact of interaction strengths on social behaviour has also been largely ignored despite the realization of importance of weights in understanding system dynamics 12 for example importance of weak ties has been emphasized in maintaining integrity of social systems 13 further the strength of interactions have been found to play a pivotal role in analysis of many other systems such as foodweb structure metabolic networks scientific collaboration ties air transportation networks internet traffic 14 suggesting that weights in interactions should be incorporated in order to have a more comprehensive picture of the structural organization of a system hence forming a fair ground for us to investigate the weighted bollywood networks this letter using random matrix theory an involved mathematical tool which has demonstrated its success in unveiling crucial properties of various complex systems ranging from many body quantum systems 15 to biological ones 16 analyses the weighted social networks and reveals that weights play a decisive role in extracting crucial aspects of human behaviour furthermore we demonstrate that structural analysis of weighted networks unfolds individual credentials to impact success much more than the influence of the fraternity they work in interesting revelations as well as differences from the unweighted networks appear from the spectral analyses of the weighted bollywood networks using rmt which provide an insight in to the preferences of the society based on randomness methods construction of weighted bollywood coactor networks we divide the massive bollywood data collected for a span of 60 years from the movie repository websites 17 into fiveyear window periods time intervals on one hand should be large enough to capture specific properties of the society as well as to yield statistically significant results and on other hand should be reasonably small to capture the changes since the model system is based on rapidly changing society 8 we find intervals of five years to be an apt time frame the networks for each of the datasets are constructed where actors are the nodes and connections with their coactors are the links 10 an additional attribute considered here being weights by weight we refer to the number of movies an actor has coacted with another actor in a particular fiveyear time span the adjacency matrix a of the networks thus generated are given as a ij w ij if i ∼ j 0 otherwise where w ij is the number of times actors i and j act together in a particular span properties of networks constructed with different datasets are provided in table 1 structural parameters clustering coefficient of a node is defined as the ratio of the number of links between the neighbours of the node to the possible number of links that could exist between the neighbours 18 betweenness centrality for a node i is defined as 18 β c st n i st g st where n i st is the number of shortest paths from s to t that passes through i and g st is the total number of shortest paths from s to t spectral properties the spectra of the corresponding adjacency matrix is denoted by λ i 1 n and λ 1 λ 2 λ 3 λ n in rmt it is customary to unfold the data by a transformation λi n where n is average integrated eigenvalue density 19 in absence of any analytical form for n we perform unfolding by numerical polynomial fitting using the smooth part of the spectra obtained by discarding eigenvalues towards both the ends as well as degenerate eigenvalues rendering the dimension of the unfolded spectra n ef f using the unfolded spectra we calculate spacings s λi1 λi distribution ρ and fit it by the brody distribution characterized by the parameter β 19 as follows p β as β exp αs β1 where a and α are determined by the parameter β as a α α γ β2 β1 β1 we analyze the long range correlations in eigenvalues using ∆ 3 statistics which measures the leastsquare deviation of the spectral staircase function representing average integrated eigenvalue density n from the best fitted straight line for a finite interval of length l of the spectrum 19 and is given by ∆ 3 1 l min ab xl x n aλ b 2 dλ where a and b are regression coefficients obtained after least square fit average over several choices of x gives the spectral rigidity the ∆ 3 in case of goe statistics ∆ 3 statistics depends logarithmically on l given as ∆ 3 ∼ 1 π 2 ln l as the value of l increases the number of data points for the same size of the network becomes less and we choose the value l around 14 of the unfolded spectra in order to perform statistical calculations weights and success correlation we pick the top ten actors from the list of filmfare award nominees 9 for each span and compare their positions in degree order in unweighted networks to those of weighted networks further we calculate the ratio of their award nominations across consecutive spans occurrence of both these ratios greater than one simultaneously for consecutive spans for any actor indicates that working more frequently with a confined set of actors as compared to the previous span is implicative in his success the value of the first ratio above one and that of the second ratio less than one implies that working with the same set of actors more often as compared to the preceding span does not assure success of an actor results and discussions hierarchical nature of weighted bollywood networks the size of the networks increase with time indicating the growing success of the bollywood the drastic change in the size during 199802 span combined with the industry status conferred to the bollywood 20 indicates that financial security has an upper edge over artistic excellence almost constant value of k across 60 years indicates the characteristic nature of the model system in turn reflecting the overall connectivity of actors themselves further we find that the degree distribution exhibit power law for the weighted bollywood networks as also observed for the unweighted networks 10 suggesting that overall contribution of weights does not bring about any significant change in the distribution of number of coactors in the networks next we find negative correlation between degreecc for all the datasets as also observed for other social networks 22 what follows from the method of network construction is that the new comers in the industry who have acted in just one movie in a particular span will have their cc 1 at the time of their entry into the network further though there are various algorithms 21 known to yield networks with the power law degree distribution the preferential attachment here seems to be most logical one 10 leading low degree nodes to get associated with high degree nodes a low degree node even when it forms a subset of the large number of coactors of a high degree node it is connected with while entering into the system cannot link with all the coactors of the high degree node hence leading table 1 properties of weighted bollywood networks of each 5 years block datasets n ef f is the effective dimension of the network the l 0 and l 0 represent the extent of l 0 up to which spectra follow goe statistics expressed in percentage terms for unweighted 10 and weighted bollywood networks respectively denotes that the ∆ 3 statistics does not follow goe statistics to lowering the cc of the high degree node and it can be comprehended that more the number of associated low degree nodes more will be the lowering in the cc of the high degree node this depicts that in a society being associated with a large number of people and more number of less associated people might lead to poor clustering of oneself note that the power law degreecc correlation might be arising due to the hierarchical nature 2 of the bollywood owing to several reasons such as the actors grouping together for low budget movies directors preferences 8 etc the small value of γ indicates less prominent hierarchical structure moreover similar nature of degreecc correlation across the datasets reflects the stationary nature of the bollywood networks strengths of bollywood ties affect randomness the model considered here being based on a rapidly changing society 8 provides an apt platform to understand the impact of this change on human behaviour across time the structural analyses while demonstrating important universal properties fail to discern time varying transitions leading us to go beyond structural analyses and we turn up with spectral analysis under rmt framework the nearest neighbour spacing distribution is one of the most popular technique in rmt which provides the information about short range correlations in eigenvalues and form a basis to understand universality in the corresponding spectra we find that the nnsd of the weighted bollywood networks when fitted with eq 3 yields value of β close to one indicating that the spectra follow the universal goe statistics of rmt this is not very surprising as nnsd for the unweighted bollywood networks have also been observed to follow goe statistics 10 this universal goe behaviour suggests that there exists some minimal amount of randomness in the weighted bollywood networks sufficient enough to introduce short range correlations in the eigenvalues though it does not quantify the amount of randomness existing importance of randomness in the establishment and the conservation of complexity in social structures has been investigated deploying interaction dynamics of a population of wild house mice 24 both unweighted and weighted bollywood net works following this universal behaviour is indicative of the notion that irrespective of the strengths in bollywood ties their underlying networks possess some randomness which might be instrumental in conferring robustness 10 to the system the nnsd only captures short range correlations in the eigenvalues in order to gain a deeper insight to the impact of weights in randomness we analyze long range correlations in the eigenvalues using the ∆ 3 statistics we find that the weighted bollywood networks for different spans follow random matrix prediction of goe statistics up to a certain value l 0 and deviates afterwards the value of l 0 for which the statistics follows universality has been used as measure of randomness in networks 25 further aiding us to deduce properties of the model when weights are considered in defining the network what follows that the datasets 197377 and 198387 failed to follow random matrix predictions while 199802 dataset possessed the maximum amount of randomness among all other datasets in weighted bollywood networks 0 3 6 2 1 0 ln cc 0 3 6 2 1 0 0 3 6 2 1 0 0 3 6 2 1 0 0 3 6 2 1 0 ln cc 0 3 6 2 1 0 0 3 6 2 1 0 0 3 6 2 1 0 0 3 6 ln k 2 1 0 ln cc 0 3 6 ln k 2 1 0 0 3 6 ln k 2 1 0 0 3 6 ln k 20 in the following we demonstrate how inclusion of weights in the networks not only changes the statistical properties yielded through long range correlations but also provides an insight in to the hidden patterns in the underlying system table 1 shows that the length l 0 for which individual sets follow rmt is remarkably different for the weighted and unweighted bollywood networks except for 196367 and the spans from 19731992 all other datasets witness increase in randomness of bollywood networks on considering weights randomness in unweighted networks solely relied on the distribution of the zero and one elements and the statistics they yield leaving the zero elements in the matrices unaltered the one elements are replaced with their corresponding weights in case of weighted networks thus introducing an extra dimension to calculation of spectral properties of the networks and could be one of the reasons which contribute to increase in randomness the five datasets defying this argument depict a completely different picture indicating that working in closed circles might have rendered the underlying networks to adopt some structure we predict that some kind of defined priorities might have existed in those time frames in bollywood we found that in 197377 span we witness director hrishikesh mukherjee to have preferred the popular duo amitabh bachchan and jaya bhaduri in three out of six movies that he had directed in that span similarly director yash chopra chose the duo amitabh bachchan and neetu singh twice out of the four movies that he had directed in that span 9 in the spans where decrease in randomness was witnessed wars communal riots and resulting conflict of bollywood stars with state government 9 were observed which led to financial crisis 26 leading the top directors of those spans to give preference to certain sets of actors over others note that while networks with different size might have same amount of randomness 27 varying amounts of randomness might be observed in networks of same size and average degree 25 hence the variations in the ∆ 3 statistic for different datasets are not due to the variations in size and they capture changes in interaction patterns due to the inclusion of weights in the underlying networks how centrality affects proximity of coactors through above analysis we observe that spectra has proved its credibility in discerning universal social behaviour and capturing crucial properties of human behaviour like selective preference to known candidates under crisis we probe further to investigate the impact of the changing society on human behaviour relating the spectra with the timebound events happening in our model system using betweenness centrality as a tool in our analysis of weighted bollywood networks β c presents a negative correlation with cc although few nodes appear having reasonably high β c yet high cc these nodes apart from connecting different bollywood circles might be instrumental in connecting their coactors within their domain among them few of the actors like kamal haasan padmini manorama uday kumar jairaj are established actors of other regional film industries owing to their successful realm in their respective regional film industries they might be playing a central role in connecting their bollywood coactors combining with the functional importance of these nodes and their long span in the industry 9 our analysis suggests that they are not arising due to random fluctuations corresponding configuration model exhibiting a smooth β c cc anticorrelation with no scattered data points strengthens our argument no such nodes have appeared we plot the values of l of ∆ 3 statistic for the data together with that of the goe the extent up to which our data points are concurrent with the goe fit provides the value of l 0 in the datasets 199802 onwards indicating that the corresponding networks do not possess central nodes which are clustered incidentally 199802 dataset has been revealed in ∆ 3 statistics analyses of weighted bollywood networks to be the most random based on the value of l 0 these observations direct us to suggest that the bollywood actors on account of experiencing more financial security owing to endowment of industry status to bollywood in 1998 20 tend to enjoy the freedom of working randomly with the coactors of their choice devoid of any kind of bias emphasizing that financial security is a key feature driving different strata of society 8 impact of weights on success of bollywood superstars apart from holding a rich database which has proved its efficiency in understanding the social behaviour of the time varying society our model also provides an additional measure which facilitates the assessment of success using award nominations for which we create a database of filmfare nominees for 60 years segregated in to fiveyear time spans 9 a popular notion evident in organizations demonstrates that group facilitation encourages coordination and leads to successful ventures 28 bollywood acting as a mirror of the diasporic society 8 provides us an opportunity to investigate whether working in closed circles is implicative in success of individual actors or is it driven only by calibre and brilliance of actors this is expected to draw a finer picture of the dynamically evolving society we conduct a thorough analysis of the change in positions in degree sequence of the bollywood stars for the weighted networks as compared to the unweighted ones we find that in none of the datasets either of these trends was consistently portrayed by majority of the leading successful actors of the respective era this observation is quite counterintuitive to the aforementioned popular notion this inconsistency might be due to the fact that an actors success does not solely depend on the credentials of his coactors but on his own artistic excellence for instance the movie mangal pandey the rising was declared a below average movie by the box office india but its lead actor aamir khan gained critical acclaim leading him to win the filmfare award for best actor in 2006 9 a very common example of group activity ie cooperative learning methods where every member of the group is assigned a subtask stands successful only if group rewards are provided 29 since in bollywood there is no division of task and every actor has the whole sole responsibility of making the movie hit group accomplishment does not stand valid keeping in view the amount of popularity bollywood celebrities have gained over the years both home and abroad and the sustenance of bollywood in adverse situations one can safely assume that bollywood acts as a representative unit of the society this leads us to propose that in a social system unless subtasks are assigned and group recognition is bestowed upon individual accountability remains as the key to success conclusion to summarize the universality in structural properties such as degree distribution and degreecc correlations indicate time independent or stationary nature of the bollywood further degree distribution following power law has been known to be important for robustness of underlying system 2 which in present context reflects the sustenance of our model system across time in situations of dire socioeconomic crisis 30 changes in the society 1998 onwards as reflected in β c cc correlation plots are related with the endowment of industry status to bollywood whereas changes in the society during 196367 and 197392 as reflected in ∆ 3 statistic relates consecutive wars communal riots and conflict of bollywood actors with the state government using rmt we demonstrate that weights in interactions have a profound impact on the social structure although weights emerge naturally in real world systems they have less often been investigated in real datasets despite significant advancements in network theory in the past two decades in our analysis randomness in the weighted social network in certain time spans which witnessed social and financial chaos sheds light on how the society is structured relating it with evidences where certain actor pairs were supported over others by the leading directors of the respective era although this conveys that the weighted model networks under consideration depict some social here x refers to the ratio of the degree order in unweighted and weighted bollywood networks across consecutive time spans a refers to the ratio of the award nominations across consecutive spans order universality in nnsd is indicative of the minimal amount of randomness implicated to be important in conferring robustness inconsistency in the statistics of success of individual node of the network correlated with their performance in defined circles based on weighted interactions has led us to suppose that self excellence appears more dominant than group coherence further spectral and structural analysis based on proximity and centrality reveals importance of financial security driving the society although the model considered here is known to predominantly capture the behavioural aspects of the social framework of a part of the global population 31 the view that despite inherent population heterogeneity human mobility portrays a deeprooted regularity 32 leads us to believe that the social behaviour revealed through our analysis would stand universally predictive furthermore importance of weights in prediction of social patterns being revealed in the light of rmt adds one more milestone to the success list of rmt supplementary material bollywood bollywood is the largest film industry in the world which accounts for around 40 of the total revenues of the indian film industry according to the ciikpmg report of 2005 1 a total of 8931 movies have been documented so far in bollywood from 1913 to 2012 bollywood is not only confined to the asian subcontinent but has global outreach ref 8 of manuscript the large fraction of indian emigrants 2 invites the screening of bollywood movies across the globe in various countries for example in countries like uk morocco and many more the bollywood actors see huge enthusiasm from the people over there 34 method for construction of networks from the bollywood data collected for a period of 60 years spanning from 1953 to 2012 from the movie repository website names of all the movies and their corresponding information are extracted using python code initially we document names of all the films as per their chronological sequence from the websites by incorporating the desired url 5 in the code along with a builtin string function which takes the page numbers as input each film of every page bears a unique cast id in the website navigating to which via movie info provides us with complete information about the film in the python code we store the unique cast ids of films in a temporary variable and retrieve relevant information using appropriate keywords from respective html pages we also manually browse through the websites and in order to collect any yearwise missing data if any henceforth we merge the data from all the websites and omit repetitions harvesting the complete data includes manual verification formatting removal of typos and compilation of data considering the rapidly changing nature of the bollywood network we segregate the curated massive bollywood data in to datasets each containing movie data for fiveyear window periods we create the database of all actors and assign a unique id number to each actor in every span which we preserve throughout our analysis we get rid of ambiguities in spellings of names of actors presented in different websites by extensive thorough manual search and crosschecking to avoid overlapping of information and duplication of node identities while constructing networks seeing a 9 growth from 2009 to 2010 according to the fccikpmg report of 2011 6 and a further 115 growth in 2011 in comparison to 2010 according to the 2012 report 6 it is a sphere which sees blazingly fast growth leading us to expect drastic changes in small time frames tracking by their unique id numbers we create a coactor database for each span where every pair of actors who had coacted in a movie within those five years are enlisted degree distribution of weighted bollywood networks the degree distribution of the weighted bollywood networks are observed to follow power law for some of the datasets power law exponent comes out to be less than two which might be due to the finite size effect method of unfolding unfolding is usually done by a transformation λi n where n statistical significance of the plots the statistical significance of the plots are presented in the form of χ 2 which measures the extent of deviation of the observed data from the hypothesized model 7 configuration model we construct a configuration model 8 with the same degree sequence as of a real dataset and plot the β c cc correlation for ten different random realizations representing fluctuations construction of filmfare awards database filmfare awards were first introduced by the times group 9 after the central board of film certification was founded by indian central government in 1952 to secure the identity of indian culture the reason we chose filmfare awards amongst all other awards is that it is voted both by the public and a committee of experts thus gaining more acceptance over the years instead of the awards bagged we take into account the award nominations in order to avoid the interplay of some kind of bias affecting the decision of the cbfc committee in selecting the winner by manual navigation through every year of filmfare awards available on the web we create database of all categories of filmfare awards and extract their respective nominees chronologically from the html pages using python codes henceforth we use c codes to count number of times every actor is data pertaining to directors and actors of movies table s1 accounts for the directors who were seen to prefer a set of actors over the rest in particular time spans the corresponding movies and their actors have also been enlisted si data pertaining to events in the society the events in the society which have been related with decrease in randomness of the five datasets are enlisted in table s2 final figures of overseas collection of hindi films from various countries as well as the collection of hollywood films in india the movie mangal pandey the rising was declared below average at box office owing to its gross turnover of 5501 million which is much less than the double of the movie budget of 380 million 12 data pertaining to relation between change in degree order and success for bollywood stars we first sort all the actors in descending order of their weighted degrees in all datasets then we pick top ten actors from each span who have the highest number of filmfare award nominations to their credit we find the ratio of their positions in degree order in unweighted networks to those of weighted networks for these 10 actors from each dataset denoted by x the value of this ratio above 1 means that the actor has coacted with hisher coactors relatively more frequently than the rest of the actors of that span this ratio x is calculated for each actor in the dataset under consideration the previous span and the succeeding span in order to assess the impact of coactors having acted more frequently on the success of the actors we calculate the ratio of x for each actor in consecutive time spans and also the ratio of their award nomanations in respective spans occurrence of ratio of x and ratio of a in respective consecutive spans for any actor greater than 1 simultaneously indicates that working in closed circles are implicative in success in bollywood si table 4 list of lead actors in 0307 dataset rising up in degree order as we proceed from unweighted bollywood network analysis to weighted analysis indicates that the actor has not been nominated even once in that span x refers to the ratio of the position of each actor in degree order in unweighted network to that in weighted network a refers to the number of times an actor is nominated in a particular span new comers and their coactors table s13 enlists the high degree coactors of the new comers of a particular span si table 5 list of lead actors in 9802 dataset rising up in degree order as we proceed from unweighted bollywood network analysis to weighted analysis indicates that the actor has not been nominated even once in that span x refers to the ratio of the position of each actor in degree order in unweighted network to that in weighted network a refers to the number of times an actor is nominated in a particular span new comers are the actors who have acted in just one movie in a particular span the second column consists of the names of the high degree coactors these new comers have coacted with the third column consists of the positions of the high degree coactors in degree sequence established actors of regional film industries

despite the tremendous advancements in the field of network theory very few studies have taken weights in the interactions into consideration that emerge naturally in all real world systems using random matrix analysis of a weighted social network we demonstrate the profound impact of weights in interactions on emerging structural properties the analysis reveals that randomness existing in particular time frame affects the decisions of individuals rendering them more freedom of choice in situations of financial security while the structural organization of networks remain same throughout all datasets random matrix theory provides insight into interaction pattern of individual of the society in situations of crisis it has also been contemplated that individual accountability in terms of weighted interactions remains as a key to success unless segregation of tasks comes into play

globally depression affects approximately 5 of individuals each year and is a leading cause of morbidity and burden of disease in many countries in addition to its direct toll on quality of life and longevity depression also has indirect effects on longterm health via the elevated risk of several somatic disorders depression generally has its onset in young adulthood and is associated with female sex lack of a romantic partner and low socioeconomic position however risk factors of adult depression can be present earlier in life in particular childhood adverse experiences such as violence neglect or maltreatment but also less severe and more frequent events such as parental separation predict the occurrence of depression later in life childhood adverse experiences are especially frequent among children growing up in families with low socioeconomic position leading to the question of the role of socioeconomic circumstances early on in life with regard to adult depression risk moreover childhood adversity predicts academic achievement and educational attainment which in turn are associated with adult labor force integration and income research suggests that family socioeconomic circumstances primarily predict adult depression via multiple risk factors as well as adult socioeconomic attainment this points to the possibility that the risk of adult depression is shaped by an individuals socioeconomic trajectory from childhood onward yet to date research on this topic has been limited as specified by the lifecourse theory an individuals lifelong socioeconomic position could influence health via exposure to negative circumstances in periods that are critical in terms of health or social development as well as through the accumulation of disadvantage additionally socioeconomic attainment can be influenced by mental health difficulties via a phenomenon of health selection although this has been observed primarily among persons who have severe mental illness finally upward mobility could protect individuals from later mental health problems by helping them acquire material and psychological resources that favor wellbeing with regard to longterm depression risk exposure to disadvantage in critical periods of development and lifelong accumulation of disadvantage as well as upward mobility could be especially relevant in the present study we examined associations between individuals intergenerational socioeconomic mobility and adult depression using data from the french consultants des centres dexamens de santé study a large communitybased survey of people residing in france we hypothesized that compared with individuals with persistently high socioeconomic position those who experience persistently low socioeconomic position or downward mobility have higher levels of depression while upward mobility is associated with a more favorable pattern of mental health our study is to our knowledge novel in that we ascertained depression using not only participants selfreported symptoms but also registerbased antidepressant use which is indicative of symptoms that are severe enough to be picked up by health professionals and require treatment additionally with the notable exception of studies that combined measures of maternal and paternal occupational grade most investigations have considered paternal occupation parental educational attainment or perceived financial situation as measures of childhood socioeconomic position in the present study we specifically took into account the role of maternal and paternal occupational grade including identifying participants with parents who were out of the labor force methods study population constances is a large prospective communitybased cohort study designed to be nationally representative of the population of france aged 1864 years and affiliated with the national health insurance scheme which covers 85 of the population the study aims to recruit 200000 participants over a period of 6 years it was launched in 2012 and recruitment is ongoing participants are randomly selected and invited to undergo a health examination at one of the 22 health screening centers run by the national health insurance system throughout the country during this daylong baseline visit rich medical data are collected respondents are also asked to complete questionnaires regarding their health health behaviors socioeconomic characteristics and occupational trajectory in addition data on participants healthcare use are obtained directly from the national health insurance system by september 2016 approximately 112000 persons had already been enrolled in the constances study and data had been compiled and cleaned for 67057 participants who agreed to take part in constances in 2012 2013 and 2014 overall the geographical distribution of constances study participants matches the national distribution of health screening centers where they are recruited compared with nonparticipants participants were more likely to be male to be older than 40 years of age to have high occupational grade to be out of the labor force to earn more than average income to have regular medical followup and to have no chronic health problems the constances study was approved by bodies regulating ethical data collection in france commission nationale informatique et liberté and all participants signed an informed consent measures intergenerational socioeconomic mobility participants socioeconomic mobility was ascertained based on 1 childhood socioeconomic position and 2 adult socioeconomic position participants who reported that their fathers or mothers did not work or that they did not know their parents had levels of depression comparable to those whose parents had low socioeconomic position they were included in the group with low childhood socioeconomic position combining both childhood and adult socioeconomic position we obtained 5 intergenerational mobility groups 1 persistent high socioeconomic position 2 upward mobility 3 persistent intermediate socioeconomic position 4 downward mobility and 5 persistent low socioeconomic position adult depression was ascertained with the center for epidemiological studiesdepression scale questionnaire a 20item questionnaire that identifies the presence of common symptoms of depressive symptoms such as sad mood loss of pleasure and interest and difficulties with sleep or appetite in the present study to identify participants who had elevated levels of depressive symptoms we used the score cutoffs of 16 for men and 20 for women which were previously validated in france additionally information on the use of antidepressant medication was ascertained directly from the french national health insurance databases for the period of 20102013 among participants who purchased antidepressants at least once 535 bought treatment for at least 6 months elevated symptoms of depression were associated with antidepressant use covariates to study the relationship between participants intergenerational socioeconomic mobility and depression we controlled for several covariates potentially associated with the study outcome sociodemographic characteristics age living with a partner number of children country of birth fathers country of birth mothers country of birth parental history of psychiatric disorders and suicide health behaviors alcohol abuse assessed using the alcohol use disorders identification test and chronic health problems cancer functional limitations statistical analyses to test associations between participants intergenerational socioeconomic mobility and adult depression we used the following approach for each outcome first we tested bivariate relations second using persistently high socioeconomic position as the reference group we used logistic regression analyses that were successively adjusted for participants 1 sociodemographic characteristics 2 history of parental psychiatric disorder or suicide 3 health behaviors and 4 chronic health problems in additional analyses because of secular differences in socioeconomic mobility according to generation and sex we tested for interactions between participants intergenerational mobility and their sex and age all analyses were conducted using the sas version 9 results table 2 shows characteristics of our study population in relation to adult depression overall 173 of men and 190 of women had high levels of depressive symptoms factors associated with depression included female sex young age not living with a partner absence of children own and parental birth in a country other than france parental history of psychiatric disorder tobacco smoking alcohol abuse cooccurring diabetes cancer or functional limitations and intergenerational socioeconomic mobility during the course of the study period 117 of men and 202 of women used antidepressant medications associated factors included age over 45 years not living with a partner presence of children parental birth in france parental and own history of psychiatric disorder tobacco smoking alcohol abuse cooccurring health conditions and intergenerational mobility as shown in table 3 participants intergenerational mobility was associated with elevated depressive symptoms and antidepressant use specifically compared with individuals with persistently high socioeconomic position we observed higher levels of depressive symptoms in all other groups with odds ratios ranging from 119 among participants who experienced upward mobility to 223 among those who experienced persistently low socioeconomic position this association decreased after controlling for covariates but in the fulladjustment model participants with a socioeconomic trajectory other than persistently high socioeconomic level had higher odds of depression with regard to antidepressant use we also observed a graded association with intergenerational mobility compared with participants with persistently high socioeconomic position odds ratios for antidepressant use ranged from 115 among participants who experienced upward mobility to 184 among those with persistently low socioeconomic position in a fulladjustment regression model only associations of downward mobility 124 and persistently low socioeconomic position with antidepressant use remained elevated and statistically significant in additional analyses we found statistically significant interactions between participants intergenerational socioeconomic mobility and sex and age with regard to depression but not antidepressant use therefore our stratified analyses were limited to elevated depressive symptoms overall the association between intergenerational socioeconomic mobility and elevated symptoms of depression appeared stronger in women than in men and among younger participants than among those who were aged 30 years or older our study conducted in a large communitybased sample in france showed that intergenerational socioeconomic mobility was associated with adult depression associations with both elevated symptoms of depression and antidepressant use followed a gradient of odds gradually increasing along the spectrum of socioeconomic trajectory among participants with persistently low socioeconomic position the likelihood of being depressed in adulthood taking into account all relevant covariates was 182 times higher than among participants with persistently high socioeconomic position these results suggest that adult depression reflects longterm processes that are shaped by lifelong socioeconomic factors and are consistent both with the hypothesis of critical periods of development and detrimental consequences of an accumulation of disadvantage importantly the elevated likelihood of depression is not confined to individuals who belong to the most disadvantaged socioeconomic groups limitations and strengths our study has several limitations which need to be acknowledged first constances is a longitudinal cohort study based on voluntary participation and as in other cohort studies participants tend to be healthier and have higher socioeconomic position than nonparticipants this implies that associations between socioeconomic position and mobility in the general population may actually be stronger than we report second participants childhood socioeconomic positions were obtained retrospectively which may result in information bias however there is no reason to believe that participants systematically underor overreported their parents occupational grades and the degree of error in this measure should be limited third data on depressive symptoms were selfreported which may have led to an overestimation of the number of cases compared with a clinical diagnosis however the strength of the association with intergenerational socioeconomic mobility that we report is consistent with studies that have examined social inequalities with regard to depression using clinical measures moreover the results we obtained studying antidepressant use are comparable indicating that among most individuals reporting high levels of depressive symptoms a health professional also identified psychological difficulties and prescribed treatment fourth for administrative reasons data on antidepressant use were available only for a subsample of participants and did not cover the exact same period as data on selfreported depressive symptoms nevertheless it is unlikely that the disparity in timing between the two measures of depression in our study induced systematic bias fifth some participants may have purchased antidepressants and not taken them while others may have used treatment that they purchased in the past or that was purchased by another member of their household such errors may induce classification bias of unknown direction most likely introducing some noise within our analyses our study also has strengths that deserve to be highlighted first we used data collected in a large communitybased sample of people living throughout france which makes our results broadly generalizable to the population second we had access to different measures of depression known to be complementary including externally validated antidepressant use third we had data on participants adult socioeconomic position as well as both their parents occupational characteristics and country of origin which allowed us to investigate intergenerational socioeconomic mobility in a thorough way intergenerational socioeconomic mobility and adult depression our study is in line with other research showing that socioeconomic circumstances across the life course predict depression risk 38 unsurprisingly we found an especially high likelihood of depression among individuals belonging to the most unfavorable socioeconomic group in adulthood that is those who experienced persistent low socioeconomic position and downward mobility the association between adult socioeconomic circumstances and depression may reflect the direct consequences of unfavorable living conditions on individuals mental health but it may also reflect the social drift that can accompany mental health difficulties in other words different mechanisms may be at work and future investigations based on a longer followup period should examine concurrent changes in socioeconomic position and depressive symptomatology over time interestingly we also found that compared with persons in the most favorable socioeconomic circumstances those who had an intermediate socioeconomic position were more likely to have high levels of depressive symptoms hence as in other investigations conducted in our group and by other researchers we observed a social gradient in depression which may result from higher levels of stressful experiences and lower levels of material wellbeing than among persons in the most favorable socioeconomic circumstances importantly this suggests that the population global burden of depression primarily lies among individuals who are in intermediate positions rather than most disadvantaged situations finally participants who experienced upward mobility also had elevated levels of depressive symptoms this indicates that childhood socioeconomic circumstances continue to influence mental health above and beyond the role of adult achievement importantly in our study participants socioeconomic position was ascertained via occupational grade and our data are consistent with secular changes in labor market characteristics we did have a lack of information regarding parental occupation among a minority of participants who reported not knowing their mothers or fathers nevertheless our composite measure of childhood socioeconomic position is a reflection of the family background that study participants experienced before age 15 years childhood is a period when individuals lasting personality and style of interpersonal relations are defined the experiences of maltreatment negative life events and poor parenting disproportionately frequent among families with low socioeconomic position during this sensitive developmental period can have lasting effects on emotional development into adulthood moreover it may also be that upward mobility which implies a change in social environment is a source of stress and can result in social isolation both of which contribute to the risk of psychological difficulties clearly depression is a multifactorial disorder and the mechanisms through which intergenerational mobility influences lifelong risk require further study particularly in settings where changes in socioeconomic position depend on external rather than individual circumstances age and sex specificities in our study the association between intergenerational socioeconomic mobility and adult depression followed a similar pattern in both sexes however in women the association between downward mobility and persistently low socioeconomic position and depressive symptoms was stronger than it was in men there is evidence showing that women experience longer and more severe episodes of depression than men additionally women are less likely to have stable employment and when they are employed they earn lower incomes than men which has been shown to contribute to lasting depression finally women are also largely responsible for caring for young children and elderly parents and this family burden could also contribute to depression risk overall women probably experience higher levels of socioeconomic disadvantage which translates to multiple stressors and have more severe and chronic depressionaltogether these phenomena could contribute to wider socioeconomic inequalities in depression than in men we also found that the relationship between intergenerational socioeconomic mobility and depression was stronger among participants aged 1829 years than in older age groups this age group includes young people transitioning to the labor market who are most likely to experience unemployment and job instability which may influence their mental health furthermore individuals who experience psychological difficulties may be less likely to obtain employment that matches their qualifications thereby leading to a social drift importantly we did not specifically examine the impact of unemployment on depression but future research should address this issue studying sex and age specificities in detail because the peak age for depression incidence is between 20 and 30 years of age particular attention should be paid to young peoples socioeconomic circumstances and employment opportunities in order to favor longterm mental health conclusion adult depression reflects individuals intergenerational socioeconomic mobility with both childhood and adulthood circumstances playing a role upward mobility and intermediate socioeconomic position do not protect individuals from depressive symptoms to the same extent as persistently favorable socioeconomic circumstances the relationship between socioeconomic mobility and adult depression appears stronger in women and young people which suggests that specific efforts to promote favorable laborforce integration in these groups would yield mental health benefits overall these findings suggest that factors contributing to depression risk and socioeconomic inequalities in this area are at play during the entire life course policies aiming to reduce poverty and promote educational attainment and employment opportunities across the population could help reduce levels of depression later in life by ascertaining their patients past and present socioeconomic circumstances clinicians may gain precision in identifying persons at high risk of depression that is likely to be severe and lasting conflict of interest none declared

using data from the nationally representative consultants des centres dexamens de santé constances study in france 2012france 2014 n 67057 we assessed the relationship between intergenerational socioeconomic mobility and adult depression center for epidemiological studiesdepression scale scores of ≥16 in men or ≥20 in women and antidepressant use socioeconomic position was ascertained by occupational grade childhood maternal and paternal measures prior to age 15 years combined adulthood participants own we used logistic regression models adjusted for sociodemographic characteristics parental history of psychiatric disorders and suicide health behaviors and chronic health problems compared with the reference group persistently high socioeconomic circumstances participants in other groups had elevated levels of depression for upward mobility multivariate odds ratios or 121 intermediate socioeconomic position 128 downward mobility 166 persistently low socioeconomic position 182 downward mobility and persistently low socioeconomic position were also associated with elevated odds of antidepressant use for downward mobility multivariate or 124 for persistently low socioeconomic position 136 in supplementary analyses the association of socioeconomic mobility with depression was stronger in women than in men and among younger participants aged 1829 years than among older participants factors that contribute to depression risk and socioeconomic inequalities in this area appeared to be at play already in childhood this should be acknowledged by clinicians and policymakers childhood depression lifecourse epidemiology socioeconomic inequality socioeconomic mobility abbreviations constances consultants des centres dexamens de santé or odds ratio

introduction korea is one of the most developed countries in the world with a rapidly aging population the percentage of older adults in south korea is currently 9 and is projected to reach 38 by 2050 ranking it as one of the countries with the highest percentage of elderly population 1 falls are a major cause of disability healthcare utilization and mortality in older populations 2 fallrelated deaths in older persons have been on the rise in the past 15 years and the incidence of injuries due to falls among older adults aged 65 years or older is estimated to be 87 risk factors for falls include balance deficits living arrangements history of previous falls difficulties with ambulation visual impairments age gender multiple risk factors and certain chronic diseases 3 falls can be caused by interactions between multiple risk factors 4 given the negative effects of falls on the physical and mental health of older adults it is imperative for healthcare practitioners to identify factors leading to falls and develop ways to prevent communitydwelling older adults from falling 4 of 11 more than half of older adults experience falls at home where they tend to spend the majority of their time at 5 the aging population living at home with physically disabling conditions is found to be more likely at a high risk for both falls and hip fractures which is one of the most devastating and expensive problems faced by older adults it commonly results in a permanent disability nursing home placement or death 67 a previous study reported that falls occurred while engaging in activities such as slipping walking transferring and going up or down the stairs 8 and during activities such as eating cooking and resting alone 9 however it is difficult for older persons with disabilities to perform these activities alone and they need assistance from family members therefore focusing on characteristics related to their living arrangements such as the number or composition of household is important to understand and plan for the proper care of these individuals 10 we hypothesize that the number of household members residing with older adults might be associated with the incidence of falls a larger number of family members living with older adults with functional disabilities is found to be associated with better instrumental and social support 11 in addition the amount of care both formal and informal received from cohabitating household members is minimal or unavailable to older adults living alone 1213 in addition the number of household members is known to reduce the survival and functional decline of older populations 10 therefore the association between the number of household members and falls among older adults with disabilities living at home should be investigated several studies have examined the association between the number of household members and falls among older people a previous study conducted in australia showed an increased risk of fall among those living alone compared to those living with someone although this was not discussed 14 older adults living alone were found to have more falls than those living alone in china 15 another study found that people living alone were more likely to be associated with falls than those living with their family members or with people outside their family in communitydwellings middleaged and older adults in rural areas of the united states 16 however previous studies focused mostly on the status of cohabitation studies on the association between the incidence of falls and the number of cohabitating family members have not been reported in addition the presence of a household member can be important for older persons with a disability to reduce falls and injuries caused due to falls studies examining the association between number of household members and falls and injuries caused due to falls are insufficient especially those on the disabled older population finally despite the relevance of this issue studies on this topic have not been conducted in korea which is a developed country with a rapidly aging population it is necessary to study the relationship between the number of household members and the incidence of falls among senior citizens with disabilities this will enable identification of risk factors for fall management of elderly adults with disabilities who have difficulties in performing daily life activities however no such study has been reported in literature yet therefore the identification and removal of risk factors associated with falls are of high clinical priority thus the first aim of this study was to investigate the effects of the number of cohabitating household members on overall falls and injuries related to falls including hip fractures and others needing medical treatment in the disabled aging korean population based on a previous study the present study hypothesized that a smaller number of family members who cohabitate in a household with disabled older persons is associated with higher odds of the older person experiencing overall falls falls needing medical treatment and hip fractures caused by falls in addition the incidence of falls is high among elderly people with physical and psychological disabilities according to a literature review the inability to perform basic and instrumental activities of daily living is associated with a faster rate of decline in the cognitive functioning of older adults 17 which in turn was identified as a risk factor for falls among older adults 18 considering that the presence of cognitive dysfunction would affect fall risk research on the association between the number of household members and falls according to cognitive status needs to be discussed therefore we additionally investigated the effects of the number of household members on the incidence of overall falls falls needing medical treatment and hip fractures caused by falls according to the cognitive status of the elderly participants methods data data were obtained from the 2008 2010 and 2012 waves of the korea longitudinal study of aging which is a nationally representative study of noninstitutionalized south korean adults across 15 large administrative areas all data are available via a national public database 19 assuming a target sample size of 10000 persons and an average household size of 167 members aged ≥45 years a total of 1000 enumeration districts were selected and stratified by area and housing the first wave of the survey conducted between july and december 2006 involved 10254 older adults in 6171 households all participants were interviewed facetoface using a computerassisted personal interviewing method in the second wave of the survey conducted between july and november 2008 reinterviews were conducted with 8688 respondents from the first wave the third wave of the survey conducted in 2010 included 7920 respondents from the first wave finally 7486 respondents from the original panel were interviewed in the fourth wave of the survey study population this study targeted individuals who needed assistance for performance of activities of daily living or instrumental activities of daily living therefore 1516 of the 10254 participants included in the 2006 survey and those who did not need any help for either adl or iadl were excluded from the study population in addition we only included participants who had all the information required for this study therefore we excluded participants with missing body mass index and care hours thus the final sample for 2006 comprised 1414 observations the number of observations in the followup years was as follows 1063 in the 2008 survey 995 in the 2010 survey and 845 in the 2012 survey identified as a risk factor for falls among older adults 18 considering that the presence of cognitive dysfunction would affect fall risk research on the association between the number of household members and falls according to cognitive status needs to be discussed therefore we additionally investigated the effects of the number of household members on the incidence of overall falls falls needing medical treatment and hip fractures caused by falls according to the cognitive status of the elderly participants methods data data were obtained from the 2008 2010 and 2012 waves of the korea longitudinal study of aging which is a nationally representative study of noninstitutionalized south korean adults across 15 large administrative areas all data are available via a national public database 19 assuming a target sample size of 10000 persons and an average household size of 167 members aged ≥45 years a total of 1000 enumeration districts were selected and stratified by area and housing the first wave of the survey conducted between july and december 2006 involved 10254 older adults in 6171 households all participants were interviewed facetoface using a computerassisted personal interviewing method in the second wave of the survey conducted between july and november 2008 reinterviews were conducted with 8688 respondents from the first wave the third wave of the survey conducted in 2010 included 7920 respondents from the first wave finally 7486 respondents from the original panel were interviewed in the fourth wave of the survey study population this study targeted individuals who needed assistance for performance of activities of daily living or instrumental activities of daily living therefore 1516 of the 10254 participants included in the 2006 survey and those who did not need any help for either adl or iadl were excluded from the study population in addition we only included participants who had all the information required for this study therefore we excluded participants with missing body mass index and care hours thus the final sample for 2006 comprised 1414 observations the number of observations in the followup years was as follows 1063 in the 2008 survey 995 in the 2010 survey and 845 in the 2012 survey study variables overall falls falls needing medical treatment and hip fractures caused by falls for outcome variables overall falls falls needing medical treatment and hip fractures caused by falls were used each outcome was assessed using selfreported binary questionnaires with yes or no responses the incidence of falls was assessed via a question that asked whether the participants had experienced falling in the past two years or not falls requiring treatment were assessed via a question that asked whether the participants had recently experienced severe falls requiring medical treatment hip fracture caused by falls was assessed via a question that asked whether the participants had a hip fracture due to falling number of household members the number of cohabitating family members in the household was assessed using selfreported questionnaires it was classified as none one two or more control variables to assess the independent influence of the dependent variables we considered possible covariates among the various sociodemographic and healthrelated variables sociodemographic variables included age sex educational level and equivalent household income age was divided into four categories 4564 years 6575 years 7685 years and 85 years the patients were divided according to sex educational level was divided into four categories lower than elementary school middle school high school and college graduate or higher equivalent household income was calculated as the total household income divided by the square root of the number of household members these scores were then divided into quartiles ≤25th percentile 25th50th percentile 50th75th percentile and 75th100th percentile care hours was defined as the number of hours during which care was provided to the participants by their primary caregiver and was used as a continuous variable healthrelated variables included iadl bmi minimental state examination scores number of chronic diseases and regular exercise functional status was measured using the 10item korean instrumental activities of daily living scale which includes items on personal grooming excursions for short distances transportation use making and receiving phone calls managing money performing household chores preparing meals shopping taking medications and doing laundry during the health examination survey height and weight were directly measured when the participants wore light clothing and no shoes height was measured to an accuracy of 1 cm and weight to 01 kg for each participant bmi was calculated as the weight in kilograms divided by the square of the height in meters the mmse was used to measure cognitive function using the korean mmse with a total score ranging from 0 to 30 the validity of the test was confirmed in a previous study 20 statistical analysis we used the chisquare test for binary variables and the wilcoxon mannwhitney u test for ordinal variables to calculate the frequency and proportion of each variable we ran a generalized estimating equation owing to its flexible approach for analyzing correlated data from the same individuals over time 21 the outcomes in our study were falls falls needing medical treatment and hip fractures caused by falls all of which were binary therefore three gees with a logit link were conducted separately to test the association between the number of cohabitating family members in the household and each outcome to determine whether the probability of these three outcomes changed over time we included time as a categorical covariate in the model covariates of interest from all participants were added to the model to determine their effects on the probability of reporting any changes in the incidence of falls falls needing medical treatment and falls with hip fracture and to determine the probability of changes in the dependent and independent variables annually for all analyses a p value of 005 or lower was considered statistically significant all analyses were conducted using the statistical analysis software sas version 94 and independent variables annually for all analyses a p value of 005 or lower was considered statistically significant all analyses were conducted using the statistical analysis software sas version 94 results table 1 presents the general characteristics of the covariates included in this study at baseline data from 1414 respondents were included in the baseline year 2006 when broken down according to the number of family members in the household 127 participants lived alone 540 cohabitated with one member and 747 cohabitated with two or more members table 2 shows the adjusted effect of the number of members in the household on overall falls falls needing medical treatment and hip fractures caused by falls older adults living alone and those living with one person had higher odds of experiencing overall falls 213 95 confidence interval ci 136334 or 154 95 ci 108219 respectively than those living with two or more family members in addition those living alone had higher odds of experiencing both falls needing medical treatment and hip fractures caused by falls than those living with two or more family members table 3 outlines the adjusted stratified analysis of the association between the number of cohabitating family members in the household and overall falls falls needing treatment and hip fracture caused by falls according to the cognitive function of the participants compared to participants with normal cognitive function those with cognitive decline exhibited higher odds of experiencing overall falls falls needing medical treatment and hip fracture caused by falls when living alone results table 1 presents the general characteristics of the covariates included in this study at baseline data from 1414 respondents were included in the baseline year 2006 when broken down according to the number of family members in the household 127 participants lived alone 540 cohabitated with one member and 747 cohabitated with two or more members table 2 shows the adjusted effect of the number of members in the household on overall falls falls needing medical treatment and hip fractures caused by falls older adults living alone and those living with one person had higher odds of experiencing overall falls 213 95 confidence interval ci 136334 or 154 95 ci 108219 respectively than those living with two or more family members in addition those living alone had higher odds of experiencing both falls needing medical treatment and hip fractures caused by falls than those living with two or more family members table 3 outlines the adjusted stratified analysis of the association between the number of cohabitating family members in the household and overall falls falls needing treatment and hip fracture caused by falls according to the cognitive function of the participants compared to participants with normal cognitive function those with cognitive decline exhibited higher odds of experiencing overall falls falls needing medical treatment and hip fracture caused by falls when living alone discussion this study aimed to identify the association between the number of cohabitating family members in a household and the incidence of overall falls falls needing medical treatment and hip fractures caused by falls among the disabled elderly korean population our results indicate that living alone is associated with higher odds of falls falls needing medical treatment and hip fractures caused by falls particularly for participants with cognitive decline these findings are consistent with those of a us study based on a communitydwelling population of middleaged and older adults in a rural area 16 and with studies conducted in the uk 13 and australia 14 these studies reported that older persons living alone exhibited an increased risk of falls than those living with people on the other hand a study based on chinese communitydwelling older adults in hong kong suggested that living with others may not be as safe as we assume 22 the present study targeted people with disabilities as they are more vulnerable to falls and injuries 18 furthermore the present study examined the incidence of overall falls injuries caused by falls including falls needing medical treatment and hip fractures caused by falls the association between the number of household members and overall falls falls requiring medical treatment and hip fractures occurring due to falls can be explained by several possible mechanisms our study revealed that compared to living with two or more family members living alone was associated with higher odds of overall falls falls needing medical treatment and hip fractures caused by falls participants living alone lacked social support in terms of informal care and living arrangements which have been reported to be associated with falls 23 studies have also reported that elderly people living alone were more likely to live with lower social support and higher use of community health services 2425 considering that disabled elderly people need more social support even for basic activities of daily life those living alone would be exposed to falls and injuries due to falls more often than those living with two or more household members additionally a relatively high poverty rate while living alone could affect access to safe equipment to prevent falls older adults who live alone are more likely to live in poverty later in life than those living with family members 24 furthermore home modifications can reduce the incidence of injuries caused by falls even at low cost 26 however for those who are poor and live alone access to safety equipment for making home modifications and safer outdoor activities may be low due to the relatively low affordability of such equipment 27 in addition the effect of living alone on the experience of overall falls falls needing medical treatment and hip fractures caused by falls was only significant and slightly larger among those with cognitive decline according to a previous study a decline in cognitive function increases the risk of falls 28 it has been reported that older people with cognitive impairment have slower walking speed poorer obstacle clearance impaired coordination and balance reduced balance control when performing a secondary task and a greater likelihood of developing mobility problems 29 30 31 the neurodegenerative process associated with dementia may also increase the risk of falls by increasing the likelihood of autonomic dysfunction including symptomatic orthostatic hypotension 32 finally fall risk may be increased by the use of psychotropic medications particularly sedative hypnotics antipsychotics and antidepressants 33 which are more commonly prescribed to people with cognitive disorders considering that disabled elderly people are already vulnerable to falls the subgroup of participants with cognitive decline who live alone have higher odds of experiencing overall falls falls needing medical treatment and hip fracture caused by falls a major strength of our study is its novel approach for investigating the impact of different numbers of household members on falls and injuries caused by falls in the disabled elderly korean population our findings emphasize the need to focus on providing support for the prevention and treatment of falls among disabled elderly people living alone especially for those with cognitive decline additionally this study was performed based on a nationally representative aging korean population however this study has some limitations first the longitudinal design used in this study diminishes our ability to determine the causal relationship between the number of household members and falls and injuries caused by falls in other words our results could reflect a causal relationship contrary to that ascribed to the relationship between the number of household members and falls and injuries caused by falls future studies should investigate the effect of changes in the number of household members on health outcomes or the effect of the same on later health outcomes second the respondents reports were subjective and imperfect measures potentially affected by perception bias and adaptation of resources in addition the association between the number of household members and falls can differ according to older adults residential places such as homes and institutions however this study only focused on those people living at home because the klosa survey targeted only those individuals living at home further studies on this topic must compare these findings to the responses of participants living in an institution finally due to the observational nature of this study it cannot completely eliminate the possibility of residual confounding such as receiving geriatric care and other potential sources of bias our findings have several implications for policy considering that participants living alone were identified as a vulnerable group for falls more effective and attentive fall prevention interventions should be designed and implemented to lessen the economic and human burden especially for the disabled elderly population elderly people living alone should be given more attention as they are a population in need of care often those living alone receive less supportive care and are more likely to use one or more community health services 25 therefore health care services should be adjusted to provide a form of home visiting health care services for the disabled elderly living alone to lessen their risk of falls that may occur while travelling from their home to the clinic and daily living at the same time it will also be necessary to encourage those living alone who do not use the available services to use care additionally educational programs are needed for disabled adults to teach them how to maintain balance or fulfill tasks through balance training instruction on safety and adaptive equipment compensatory techniques to help improve safety and reduce the risk of falls schemes to provide financial support to acquire safety equipment may also be considered 34 conclusions our results indicate that living alone is associated with higher odds of overall falls falls needing medical treatment and hip fractures caused by falls particularly in participants with cognitive decline considering that participants living alone were identified as a vulnerable group for falls a more effective fall prevention intervention should be designed in particular government support for prevention and management of falls in disabled older adults living alone in the form of home visiting care services and promotion of use of safety equipment is required author contributions conceptualization jk data curation jk and ysl formal analysis jk writing jk and ysl supervision thk all authors have read and agreed to the published version of the manuscript

objectives to investigate the effect of the number of cohabitating household members on falls among an disabled aging korean population methods we used data from the first to the fourth waves of the korea longitudinal study of aging using the first wave at baseline data included 1414 individuals aged 45 years and older who needed assistance for performance of activities of daily living adl or instrumental activities of daily living iadl we classified falls as overall falls falls requiring medical treatment and hip fractures caused by falls the number of cohabitating family members was classified as none living alone one two or more a generalized estimating equation with logit link was used to examine the association between the number of cohabitating household members with overall falls and injuries caused by falls results compared to living with two or more household members living alone was associated with higher odds of overall falls falls needing medical treatment and hip fractures caused by falls odds ratio or 213 95 confidence interval ci 136334 or 213 95 ci 128353 or 193 95 ci 101369 respectively these associations were particularly strong in individuals with cognitive decline conclusions living alone is associated with higher odds of overall falls falls needing medical treatment and hip fractures caused by falls particularly for those with cognitive decline conclusions intervention programs to prevent falls in disabled aging adults especially those living alone and those with declined cognitive function need to provide home care services and promote the use of safety equipment

introduction the emergence of the novel coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 and first reported in december 2019 in the city of wuhan of hubei province in china has been a major point of global concern the world health organization declared the covid19 outbreak a public health emergency of international concern on january 30 2020 and a global pandemic on march 11 2020 12 as of the time of writing this article more than 49 million cases of covid19 have been confirmed in over 200 countries with the number of confirmed deaths approaching 15 million 3 the ongoing covid19 pandemic and its associated consequences can trigger feelings of fear concern and anxiety among the population a study including 1304 participants from 75 cities in turkey found a strong positive association between the pandemic and fear among the population leading to unfavorable consequences such as depression anxiety psychological distress and poor mental health 1 a new term coronaphobia is being used to delineate fear of covid19 7 a systematic review of 19 studies from eight countries described the high rates of anxiety depression posttraumatic stress disorder psychological distress and stress among people during the covid19 pandemic 8 repercussions of extreme fear can include issues such as social withdrawal stigmatization and social discrimination and can also end with suicide as with cases reported in india and bangladesh 17 9 10 11 another study found a positive impact of wearing face masks on the physical and mental health of the population in comparison with a community that discouraged face masks 12 populations vulnerable to increased levels of fear include the elderly pregnant women and patients with preexisting psychiatric illnesses 13 in these extraordinary circumstances resulting in unusual challenges for everyone people must adopt coping strategies against fear and stress in an attempt to maintain physical and mental stability and wellness higher stress levels can lead to anxiety and disturbed sleeping and eating patterns and subsequently worsening physical and mental health conditions 14 although coping strategies can vary from person to person recommendations from the saudi center for disease prevention and control include decreasing time spent watching or reading the news selfeducating using reliable resources participating in selfrelaxation practicing hobbies communicating with others exercising and practicing healthy eating 15 while a multitude of ongoing studies concerning the physical manifestation treatment and vaccination of covid19 are emerging there are relatively few studies investigating the effects of the pandemic and related situations on the mental health of the population this study aimed to assess fear of covid19 and stressrelieving practices among social media users in the western region of saudi arabia materials and methods study design and setting this was a crosssectional analytic study in saudi arabia conducted over a period of one month study population and sampling technique all adults who were aged 18 years and above living in makkah region saudi arabia and agreed to participate in the study were eligible for recruitment the minimum sample size calculated using a level of confidence of 95 expected prevalence of 50 and precision of 005was found to be 384 for increased accuracy the studys sample size was increased to 532 to comply with the physical distancing rules in response to the covid19 pandemic convenient and snowball sampling techniques were adopted for recruitment of study participants through online invitations on various social media platforms study tool data were obtained using a predesigned online questionnaire the survey was available in both arabic and english for each participant the following information was collected sociodemographic occupational and health characteristics and relevant family history fear of covid19 scale score stressrelieving practices the authors added an additional question about practicing religious and spiritual rituals as this is expected to be of high relevance in religious communities for each statement the participants were asked to indicate the frequency at which they had adopted these practices in the prior month the questioner was tested and proved to be valid and reliable ethical considerations approval from the ethics and scientific committees of batterjee medical college was obtained before initiation of the study informed consent was obtained online from each participant the aim of the study was clearly explained and selecting the agree to participate icon was required before proceeding to the questionnaire items data were collected anonymously and the confidentiality of collected data was guaranteed data analysis the collected data were statistically analyzed using statistical package for social sciences software version 23 categorical variables were presented as numbers and percentages numerical variables were presented as means ± standard deviations testing for statistically significant differences between the subgroups was carried out comparing mean scores between two groups and more than two groups was carried out using students ttest and analysis of variance respectively the level of significance was set at p 005 results the current study included 532 participants from the western region of saudi arabia nearly twothirds of the participants were aged between 18 and 29 years the majority were females and individuals residing in cities approximately two thirds were unmarried and more than half were saudi citizens over threefourths of the respondents perceived their social level as moderate and the majority were living with their families or flatmates most of the participants had a college degree or above and were employed more than twothirds of study participants encountered minimal social engagement in daily activities most of the respondents were nonsmokers had no history of anxiety or depression had family histories of chronic conditions and did not exercise regularly variables no the majority of study participants stated that their most common method of coping with stress was practicing religious and spiritual rituals selfcare was found to be the second most commonly practiced stressrelieving strategy conversely the leastpracticed coping strategy was found to be connection with others stresscoping practices discussion the covid19 pandemic has placed an overwhelming burden on healthcare systems and economies around the world this global pandemic can provoke feelings of fear and concern among the population due to the highly contagious nature of the virus its associated health complications and the economic and psychological repercussions of the preventative measures imposed around the world 1 in this study the majority of survey respondents were females this female response dominance may be explained by the fact that females are generally more motivated to participate in online surveysthis is in accordance with similar studies in turkey and eastern europe 117 however marginally maledominant responses were found in other studies 916 although female respondents exhibited higher levels of fear than male respondents this difference was not significant on the other hand multiple studies in eastern europe israel and the usa declared that females had higher levels of fear of covid19 17 18 19 interestingly respondents aged between 30 and 49 years revealed significantly higher levels of fear than younger and older age groups this could be explained by a higher sense of responsibility in this stage of life furthermore a study by leo and trabucchi revealed heightened levels of fear among italian senior citizens intensified by feelings of isolation loneliness and loss of hope due to multiple preexisting chronic diseases demoralization and social negligence 20 however in line with religious beliefs and traditions in saudi arabia younger family members take care of the financial and health requirements of the elderly this leads to feelings of security and serenity despite the high risk of health complications among the elderly the present study found a remarkable association between married individuals and increased fear of covid19 this is in agreement with a study by fitzpatrick et al potentially indicating increased concern for the health and wellbeing of loved ones in this population 19 no significant relationship was found between fear and social level or nationality this can be attributed to the saudi governmental efforts in treating all covid19 patients equally and free of charge irrespective of their nationality or social level 21 meanwhile a study in the usa showed increased fear among individuals of certain races and citizens born in other countries additionally another study in israel revealed a higher level of fear among individuals of low socioeconomic levels 1819 additionally living arrangements seemed to have no substantial relationship with fear of covid19 people living with family may have a sense of unity and security while individuals who live alone might also feel safe due to the decreased risk of infecting family members furthermore no evident association was found between educational level and fear of covid19 among people with lower education there is a lower level of proper knowledge about the outbreak and its effects leading to a false sense of safety conversely people with higher education are more likely to be familiar with the relevant evolving information and safety protocols leading to a sense of safety the current study revealed no significant association between fear of covid19 and employment status this is in agreement with the results of a similar study conducted in china 22 one potential explanation is that employees who returned to work after the reduction of lockdown restrictions were aware of safety precautions which enhanced their psychological resilience various preventive measures were announced to the population 23 furthermore unemployed or retired individuals showed nearly the same level of fear of covid19 since they are expected to experience lower levels of social interaction during the pandemic similarly no association was found between fear of covid19 and the nature of practiced daily activities either with minimal or evident social engagement though smoking is a factor highly associated with complications from covid19 the present study showed no association between fear of covid19 and smoking habits this finding is in line with results from a previous study conducted in vietnam which revealed that smoking was a stress reliever among medical students especially during stressful times 24 the present study showed a significant association between fear of covid19 and history of anxiety and depression similarly a previous study in brazil showed that anxiety and depression can affect individuals who are most likely exposed to high rates of stress and are on the frontlines with respect to pathogens such as individuals in healthcare professions 25 additionally other studies conducted in china revealed high rates of stress symptoms and anxiety among doctors and nurses 2627 the current study demonstrated a significant relationship between fear of covid19 and associated chronic illnesses this result is supported by a study previously conducted in turkey 28 this may be anticipated especially with the emphasis of world health organization that individuals who suffer from chronic illnesses are more likely to contract covid19 with higher mortality rates 28 in addition patients who are frequently treated with immunosuppressive agents and cytotoxic drugs tend to be immunocompromised and more susceptible to infections people with systemic lupus erythematosus are considered a vulnerable population for sarscov2 infections and covid19 both systemic lupus erythematosus and covid19 have been shown to manifest multiorgan complications such as interstitial pneumonia cytopenia arthralgia myocarditis and hemophagocytic lymphohistiocytosis 129 additionally the present study revealed a significant association between lack of regular exercise and increased fear of covid19 frequent physical exercise is associated with the maintenance of good physical and mental health and is considered an effective mechanism of coping with stress 7 the present study revealed that practicing religious and spiritual rituals was the most frequently adopted stressrelieving practice among adults in saudi arabia this finding is not surprising since the study was conducted in a mostly religious community conversely a study conducted in the usa revealed that the population has directed their thoughts to extreme pessimism and hopelessness with more suicidal ideations alcohol and drug abuse during the covid19 crisis 2 moreover another significant strategy for coping with stress during the pandemic is taking care of the body by way of meditation healthy eating habits regular exercise and sleep and avoidance of alcohol and drugs this is supported by another study in india that showed how such strategies can promote the mental health of individuals during these stressful times 3 at the very least stressrelieving practices included staying in touch with friends and family members using online platforms and social media strengths and limitations this study has the strength of being the first to explore and assess the fear of covid19 and stressrelieving practices in the community of saudi arabia the nonprobability sampling technique is a limitation of the study but was adopted due to the hindering effect of lockdown during the study period the bias of this nonprobability sample was reduced by enlarging the sample size additionally the study only recruited subjects who had access to social media platforms conclusions considering the results of the present study we can conclude that adults in saudi arabia have been experiencing fear of covid19 to a considerable degree particular groups such as middleaged married those with a history of anxiety and depression subjects suffering from chronic diseases and persons neglecting regular exercise reported higher levels of fear the most commonly adopted stressrelieving practice among the study participants was practicing religious and spiritual rituals special attention is recommended for the care of the aforementioned susceptible groups and mental health education programs should be initiated for the promotion of the psychological resilience of the community spiritual aspects should be included in the construction of such health education programs a populationbased study is recommended for addressing the magnitude of the problem on a wider spectrum info all authors have declared that no financial support was received from any organization for the submitted work financial relationships all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work other relationships all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work additional information disclosures

the ongoing covid19 pandemic and its associated consequences can trigger feelings of fear concern and anxiety among the population leading to unfavorable consequences on mental health this study aimed to assess fear of covid19 and stressrelieving practices among social media users in the makkah region saudi arabiaa crosssectional analytic study was conducted among 532 adults inhabiting the makkah region of saudi arabia over a period of one month from june 15 to july 15 2020 a predesigned selfadministered questionnaire including assessments of fear of covid19 and stressrelieving practices was used for data collectionthe mean fear of covid19 scale score was 173±521 out of 35 individuals aged 3049 years and married individuals had higher mean scores 184±520 and 184±529 respectively compared to other groups p 005 additionally individuals with histories of anxiety and depression individuals suffering from chronic diseases and those who did not exercise regularly had higher levels of fear compared to other groups p 005 practicing religious and spiritual rituals was the most commonly adopted stressrelieving practice among study participants 686 adults in saudi arabia have considerable levels of fear of covid19 special attention is recommended for highly susceptible groups additionally mental health education programs are recommended for the promotion of the communitys psychological resilience in such a global crisis spiritual aspects should be included in such mental health education programs

introduction the last few decades have seen an increased focus on the concept of sustainable development 1 in operations 2 due to global restrictions legislations and customers awareness of sustainability together with a global competitive environment considerable progress has been made with the environmental aspect eg by implementing new greener technologies among the three sustainability pillars ie environmental economic and social the aspect of social sustainability has been widely acknowledged as the least developed 3 4 5 especially in the operations context the literature provides a very broad scope for the social aspect ranging from a global to a local scale sometimes without distinguishing that achieving social sustainability may require different approaches in developed and developing countries to this end solutions are sought both in the highlevel strategic sense and the lowerlevel technological implementation sense as a result it has traditionally been difficult to define an operative scope for manufacturing companies aspiring to improve social sustainability on a factory level although a distinction between traditional and emergent aspects of social sustainability has appeared in later years 6 some emergent social sustainability concerns in developed countries include demographic trends like aging populations with shortage of qualified labor as a result and the increased importance of making manufacturing a more attractive future workplace option to attract new generations of workers 7 alongside this many parallel developments drive incentives to further automate manufacturing processes particularly those that are hazardous monotonous or physically strenuous overall social impacts on operators at factory level resulting from new automation technologies and business solutions remains an important research topic there are several reasons for a manufacturing company to adopt productservice systems 8 these can influence sustainable development by extending producers involvement and responsibility to phases in the life cycle which are usually outside the traditional buyerseller relationship such as take back recovery reuse and refurbishment and remanufacturing 8 regarding environmental and economical sustainability an increasing industrial emphasis is being placed on the endoflife stage of consumer products in some countries producers of various consumer goods are tasked with the responsibility of taking care of the products once they have left the hands of customers and become waste 9 within the industry context previous research efforts 810 have addressed the environmental and economic impacts of implementing pss whereas other studies like 1112 have considered the societal impacts of it but without addressing implications for the factory operators specifically one particularly interesting form of pss is electronic waste management a burgeoning industry that turns electronic waste from an environmental threat into a resource for society according to 13 today ewaste sorting is performed mostly by humans as up to now they are the most flexible and selflearning resource available operators not properly equipped by protective devices get exposed to hazardous substances from electronics segregation however technological solutions for waste sorting and grading are on the rise apart from the advantage that automating ewaste sorting can reduce human operators unnecessary exposure to hazardous substances leaking out of ewaste materials it remains to be examined what social impacts such a development can have on human operators at factory level therefore this study aims to explore the implications of social sustainability key performance indicators in a specific case of introducing a new technology into an ewm pss this is examined by using a framework of previously established social sustainability key performance indicators as a starting point 14 2 theoretical framework productservice systems pss is a term that has been defined as a marketable set of products and services capable of jointly fulfilling a users need the productservice ratio in this set can vary either in terms of function fulfilment or economic value 15 various authors have proposed different classifications of pss 15 16 17 of which the three most distinct classification categories are productrelated services useoriented services and resultoriented services according to mont 8 from a company perspective adopting a pss can add to products value base growth strategy on innovation improve the companyconsumer relationship improve the total value for the customer by extending products lifecycle extending products function through upgrading and refurbishment and also making the product useful after its life cycle ends through recycling or reuse and also helps the company implement takeback legislations socially sustainable work systems there is no wholly agreedupon definition in literature of what constitutes a socially sustainable work system but 18 defines it as a system that has achieved a high level in three main aspects quality of work quality of the organization and the quality of connections with the environment to achieve a socially sustainable manufacturing work system that can combat the aforementioned demographic challenge it should be able to meet the needs of both current and future employees to that end it should be able to attract different societal groups as potential workers ie younger elderly women disabled and in general support greater diversity in 1419 the authors have used the key aspects of socially successful work systems from literature to develop a framework of social sustainability related kpis presented in table 1 3 method and case description method the overall research approach for this paper has been to perform a qualitative case study incorporating a literature study observations and interviews as we strived to explain a complex phenomenon under investigation 37 general data regarding the ewm case were collected mainly through semiand unstructured interviews and study visits to the ewm facility after the initial studies the aforementioned framework of social sustainability kpis from 14 was employed as a structured interview with a company representative who elaborated specific impacts on human stakeholders case description ewm systems challenge the ideas of traditional business models both by adding value to something previously considered worthless and in this particular case by the fact that their system components are accessible partially as a product and as a service this case studies the refind company which has developed and introduced a new automation technology called the egrader to sort grade and recycle ewaste using optical sorting 38 the egrader is available both as an equipment for rent and as a service where customers send spent ewaste to refinds facility for sorting and grading into useable fractions in other words the egrader itself is a pss being implemented into another pss in a nested fashion according to 13 the egrader is able to distinguish much more rapidly than human workers which products are suitable to reuse refurbish or recycle during waste sorting data regarding the products type brand model year to market etc are recorded automatically other data fields can be added based on the companies specific needs by contrast todays manual ewaste sorting cannot store workers knowledge and weee items data into a structured data management system fig 1 the egrader an automatic equipment solution for ewaste sorting and grading developed by 38 the environmental and economic aspects of the egrader were the main drivers for its introduction as a solution for ewm systems some major motivations for automating the extraction of repurposable fractions from ewaste are described in greater detail in 39 and include the presence of valuable and rare earth materials in the ewaste products minimizing human and environmental exposure to hazardous substances that can damage health and increased manufacturer responsibility for addressing the endoflife phase of their products findings and analysis this section presents and qualitatively analyses interview data from the case company each topic heading reflects its corresponding indicator from table 1 and words in cursive signal the relationship of findings to specific kpis labour code of conduct for the sake of their health and safety operators need to be carefully protected from exposure to dirt and toxic substances which are typical for the manual electronics segregation process of ewaste handling introducing the egrader to the system will reduce the exposure of operators to acidresistant substances however the operators need to be prepared and trained in terms of safety procedures and health issues regarding the new equipment eg safety implications from loading unloading turning it on etc these tasks are not considered to be highrisk operations in general but if the operators are not welltrained incidents and accidents may occur the effect on absenteeism numbers is twofold the rate of absenteeism related to health and safety issues will depend on the training level of operators as discussed above numbers might even increase if training is not sufficient and accidents occur however since the new technology will affect the employees satisfaction level and happiness and worklife balance it could also reduce absenteeism due to the new technologys positive impacts on process efficiency the company margin is expected to increase moreover the operators will perform higherskilled tasks therefore the operators salary and the monetary incentives can be affected in positive way personal development talent management and career development as described in 32 adding the egrader to the ewm process results in knowledge and intelligence being added to the sorting process this can unlock more opportunities for personal development of the people working with the system because the system stores and aggregates statistics on the sorted fractions once the data and different dimensions of it become accessible the operators can explore the dataset understand the statistics make forecasts and control their cash flows when operators use their brain as opposed to simply handling waste managers have an opportunity for talent management by recognizing good ideas from workers and incentivizing them work design currently the manual tasks performed by operators are monotonous tasks introducing the egrader to the system opens up for more diverse tasks and therefore more possibilities of job rotations moreover people that work with the data management part are called to understand these data and map them properly therefore the job becomes more stimulating for them compared to pure materials handling at the same time the operators may experience more participation and empowerment as they are expected to independently come up with ideas reports findings and conclusions based on used electronics statistics as the system adapts to new specifics within regulations and recycling schemes or market changes operators will also learn new skills and will be personally developed which can lead to more satisfied employees worklife balance the implementation of the egrader can affect worklife balance due to the shift in the operators responsibilities but will also make some of the tasks locationindependent and selforganised particularly the tasks which pertain to analysing the data this means that operators could take care of some nonloadingrelated tasks remotely decreasing the need to spend time at the sorting facility which will affect the worklife balance employee turnover and satisfaction management right now manual ewaste handling suffers from very huge turnovers not only due to the menial work in itself but also due to the very low salaries introducing the egrader and new tasks is expected to reduce the turnover because of higher job satisfaction and higher salaries caused by more profit job security implementing a technology that can replace several operators might affect the number of jobs in a negative way on the other hand as operators become more knowledgeable they will become more important assets for the company also since the new technology can make the company more profitable these two impacts can secure the operators jobs in a positive and more sustainable way discussion and conclusion methodical approaches to examining social impacts of pss remain scarce but this case study indicates some promising first steps towards their development the social sustainability kpis suggested by 14 made an efficient inquiry possible into social impacts of introducing a technological innovation to an ewm pss in this particular case the framework clearly highlighted the advantages and disadvantages for operators of implementing the technology this case also suggests that this pss may have potential to support proactive aspects of social sustainability something that is argued as very important in 14 based on the interview results the authors note that some additional conditions that the technology itself cannot not provide need to be secured by the organization implementing the egrader in order to ensure a socially sustainable implementation • education and training must be provided to employees using the equipment to prevent injuries and to make sure that the aggregated data is exploited well • workers must be made aware that new responsibilities are expected of them such as analyzing the data and coming up with new ideas in order to gain the advantage of more varied and meaningful work increased participation and empowerment • tradeoffs between number of job opportunities and meaningful work content must be managed by companies in conclusion the previously established list of social sustainability kpis provided a helpful framework for inquiring about social implications in the implementation of a technological innovation in an ewm pss as demonstrated in this case

this paper examines the social implications of introducing a new technology into the productservice system pss of electronic waste management ewm using a previously established set of social sustainability key performance indicators kpis targeting the operations level ie impacts on ewm operators social implications are examined in a case where a specific innovative new technology is introduced to replace manual sorting of ewaste into reuse refurbish and recycle fractions the social sustainability kpis were applied to the case as a structured interview guide the results showed that the kpi framework provided a good basis for examining the social impacts and also stimulated discussions about potential business impacts based on the human resources in the system the framework showed that the implementation supported proactive social sustainability but some additional conditions need to be addressed by the customer organization to make sure that potential risks identified in the interview are mitigated

introduction in recent years with the exception of how the police mistreat harm and kill black people perhaps no other issue around racial justice and inequities has received as much attention and scrutiny as the crisis in black maternal health 1 this is due in large part to the organizing and scholarship by black women and birthing people who through their own lived experience research and communitybased efforts have exposed the racism that has resulted in the extant racial health inequities impacting black families 2 regardless of good intentions racism impacts the health care environment the health care providers practice and the participantpatient experience 23 many wellintentioned healthcare institutions this time of increased consciousness around perinatal health inequities and systemic racism is a crucial opportunity to provide needed training tools and support to all staff in the maternal child health workforce 7 antiracism initiatives have begun in healthcare institutions however one overlooked health services agency with a key role in the perinatal landscape for black birthing people in cities like philadelphia is wic data reveal that more of the lowest income wic participants are disproportionately black and indigenous families who have significant financial need and corresponding higher incentive to utilize wic services 8 while improvements are necessary in how demographic data are collected at wic particularly around racial identity 9 nationally the majority of wic participants identify as white or nonblack hispanic people contrasting to national demographics of participants in 2017 almost 75 of all pennsylvania wic participants were black which is equal to or lower than the proportion in philadelphia 10 blackled advocacy groups as well as the national wic association view racial biases as malleable and suggest training staff on racial inequities antiracism and bias 11 12 13 yet neither clear guidelines nor a standard approach for antiracism training targeting wic staff exist this lack of antiracism training has significant implicationsas of 2017 nationwide eligibility for wic included more than 24 million nonhispanic black people 14 indicating that a substantial number of families could be impacted by racism in the wic program while there are promising models being developed for antiracism trainings such as crawford bias reduction theory training 15 and 5rs of cultural humility 16 there is not yet a specific antiracism methodology or training identified in the literature as having demonstrated consistent significant and sustained effectiveness or widespread implementation and dissemination however recent metaanalyses 1718 reveal several characteristics associated with effective diversity and bias trainings that are likely to translate to antiracism trainings as well opportunities for social interactioninperson sessions disseminated practice employermandated attendance and trainings as one part of larger institutional equity efforts these same studies also recommend strategies to deal with biases that include supporting metacognition active debiasing and practicing within the framework cultural humility while there are critiques of implicit bias training efforts in healthcare 1920 this seems to be a risk if the approach only focuses on awareness of ones bias and not concrete tools to recognize and manage the impact of the bias on others 20 informed by this evidence in 2019 we developed and implemented an antiracism training for philadelphia wic staff tailored to nutrition professionals who have the role of counseling all wic participants to the best of our knowledge this report is the first describing an antiracism training for wic staff and delineates the training framework design and key training components and evaluation including results from 6 months posttraining this work was determined to be nonhuman subjects research by the institutional review board at temple university methods training framework informed by the lessons from the literature on effective bias trainings we chose cultural humility as our trainings guiding framework first developed in the late 1990s by melanie tervalon and jann murraygarcía to help address health disparities and institutional inequities in medicine cultural humility is currently conceptualized as the ability to maintain an interpersonal stance that is otheroriented in relation to aspects that are most important to the person 21 p 354 key principles of cultural humility include a lifelong commitment to selfevaluation reflection and critique a willingness to right imbalances in power for respectful partnerships and a recognition of the need for institutional accountability 22 according to masters et al 16 the practice of cultural humility helps promote empathy mitigate bias and allows providers to recognize the individuality of the person in their care using a cultural humility framework inherently brings more awareness into clinical encounters and incorporates skills identified as reducing biases in healthcare such as perspectivetaking metacognition and partnershipbuilding 2324 all of which are equally germane to encounters in health service agencies like wic design and key training elements between march and august of 2019 our training team of an afrolatinx hospitalbased midwife and antiracism educator and a white communitybased midwife with experience in public health research and bioethics developed the foundational didactic 3h antiracism training in preparation we held a focus group with wic staff to elicit their feedback on the training content including interactive scenarios based on their workplace experiences our intention in developing the training was to increase awareness and provide skills to reduce experiences of bias prejudice and racism at wic as well as to make wic visits more meaningful and less stressful for participants and staff the five core components of the training are described below 1 identity web reflection exercise we chose to begin the training with an identity web reflection exercise to help participants consider how their identity shapes their worldview and an introduction to the concept of cultural humility this exercise asks wic staff trainees to draw a circle around their name in the middle of their paper put their most important identities with at least three identities being ones they did not choose in five circles around their name reflect on questions like has belonging to one of these groups ever cost you either personally or professionally and are there identity groups to which others assume you belong partner with a colleague to share responses considering which answers offered new insights and discuss with the group about ifhow having more awareness of their personal identities can help them find common ground with one another as well as with wic participants 2 definitions and concepts in the context of wic philadelphia and perinatal health data we intended to ground antiracism work in the specific context of philadelphia the role and functions of wic and national and local perinatal health data framing these sobering statistics from a place of empathy acknowledges that wic staff are being asked to do more with less just as families experiencing poverty and health inequities are we then planned to define racism privilegewhite privilege white supremacy implicit bias and cultural humility as well as introduce a multilevel framework based on the socioecological model of behavior change examining individual interpersonal and institutional influences on interactions at wic 3 workplace scenario and debrief based on focus group input we prepared an interactive group discussion and debrief about how knowledge of health inequities and socialstructural determinants of health impact the care given at wic using a very busy day at wic… scenario wic staff trainees were asked to apply a cultural humility framework to consider what they would say and do the same or differently in this scenario and to think through how their response may be impacted by their personal identity and positionality in the workplace as well as if the wic participant in the scenario was for example white versus black or a muslim person in garb versus a spanishspeaking participant 4 review of a model for healing repair and disruption building on this increased awareness of cultural humility in their interactions with wic participants andor other staff we decided to follow the workplace scenario with a simple effective model for healing and repair which deconstructs the different roles people play in social interactions especially during conflicts 25 in order to offer some specific avenues for taking action we briefly reviewed the 5 ds of bystander intervention drawn from the violence prevention and community safety literature 26 but applied to situations involving racism and bias at wic 5 care card action tool we chose to conclude the training with the introduction of a novel action tool the care card intended to be visible at ones desk at wic as a reminder that this work is ongoing and lifelong the doublesided laminated card is designed to prompt wic staff to be mindful and culturally humble in their interactions with participants and each other rather than a linear checklist the back of the card provides a visual of the individual interpersonal and institutional level framework we revisit throughout the session it is a very busy day at wic a participant walks in 45 minutes late for her appointment with her 4 kids she checks in at the front desk and asks how long is this going to take the staff person at the next desk remarks to you depends is she pregnant again once the nutritionist sees her she finds out she is pregnant and asks the front desk to make a pregnancy intake appointment for her the front desk person remarks i knew it i told you she was pregnant assessment of the program to evaluate the antiracism training we developed a series of 13 questions to assess wic staff trainees knowledge of core concepts awareness of their own identity biases and privilege and understanding of the role of racism in the us healthcare system during implementation we asked wic staff trainees these questions at three timepoints we additionally created questions for trainees to rate their confidence to identify and address interactions that perpetuate racism at the individual interpersonal and institutional levels using a 5point likert scale for responses where 1 was not at all 2 was a little bit 3 was somewhat 4 was quite a bit and 5 was extremely confident we framed our training and assessments in the context of the socioecological model for behavior change as this model is often utilized by healthcare institutions and health service agencies to understand the many influences on health outcomes and it is familiar to wic staff right after the training we additionally queried wic staff trainees for feedback about each component and the training overall assessing usefulness via a 5point likert scale for responses where 1 was not at all 2 was a little bit 3 was somewhat 4 was quite a bit and 5 was extremely useful along with offering opportunities to give qualitative feedback surveys were available via a redcap link to be completed by smartphone with paper copies available onsite for those who preferred that method responses were collected anonymously managed using redcap electronic data capture tools and summarized as meansfrequencies we did not link individual trainee responses at each timepoint limiting the examination of data to the cohort level only therefore we used twosided 1 3 ztests for independent proportions to compare responses before the training to responses immediately after training as well as responses at baseline to 6 months posttraining sas version 94 27 was utilized to carry out all analyses while all wic staff trainees completed the 3h training session we acknowledge there was attrition in the response rate for the posttest immediately after the training as well as in the number of responses we received at 6 months posttraining results we implemented the training in august 2019 on the required bimonthly education day for philadelphia wic nutrition professionals at agency headquarters our team provided lunch administered a preassessment and established community agreements before beginning didactics among 42 wic staff trainees the mean age was 30 years 55 selfidentified as white 32 as black or african american 9 as asian 4 as other 91 were female and 74 had no prior antiracism training forty percent had worked at wic for less than 1 year 30 between 1 and 2 years 12 between 3 and 5 years 9 for 610 years and 9 greater than 10 years eightysix percent of staff trainees were wic nutrition professionals according to management at north inc there were approximately 44 nutrition professionals employed across all philadelphia wic offices at the time of the training thirtysix nutritional professionals attended the training which is approximately 82 of the group required to attend before the training 48 of wic staff trainees felt quite a bit or extremely aware of the role of racism in the us healthcare system this increased to 91 immediately after and remained high at 6 months at baseline only 56 of trainees reported being quite a bit or extremely aware of their own biases and privilege this increased to 91 immediately after the training and remained above baseline at the 6month posttraining assessment while nutrition professionals reported increased confidence in identifying and addressing interactions that perpetuate racism at the individual interpersonal and institutional levels immediately after the training their confidence in identifying and addressing interactions that perpetuate racism decreased at 6 months posttraining at all levels table 2 summarizes feedback immediately after the training about the usefulness of each program component as well as key qualitative feedback about each component when queried about how their practice might change as a result of attending the workshop wic staff reflections included learning to pause and think about my own implicit biases and try to be even more understanding of the participants situations and i hope that i can have more mindful moments where im taken back or surprised by participants who suffer and have such diverse experiences at 6 months posttraining onethird of wic staff trainees felt quite a bit or extremely confident that the workshop content led to real changes in their interactions with wic participants discussion these findings suggest that a 3h antiracism training grounded in cultural humility can change attitudes and awareness as well as confidence among wic staff in identifying and addressing interactions that perpetuate individual interpersonal and systemic racism wic staff reported sustained increases in awareness of systemic racism and of their own biases and privilege for at least 6 months post didactics similar increases in confidence identifying and addressing interactions that perpetuate racism were achieved immediately after the training although the magnitude decreased by 6 months while wic staff trainees reflections indicated they could see making changes to their practice as a result of the content presented and onethird reported that the workshop led to changes in their interactions with wic participants we did not objectively assess whether changes in provider behaviors occurred or query patients on their experiences our results are aligned with those from a newly published paper implementing a graduate medical education antiracism workshop at an academic university in the southern usa 28 similar to our training content covered microaggressions colorblindness tokenism stereotypes levels of racism the impact of racism on health and antiracism concepts a majority of participants who completed the posttraining assessment reported they could apply knowledge to their work and found the workshop useful over twothirds reported being able to better identify disparities and better identify and communicate about racism after the workshop 75 thought differently about the healthcare impact of institutionalized racism while simpson and colleagues did not assess participants at 6 months posttraining many participants requested a longitudinal curriculum to build and sustain momentum around culture change the consistent drop in wic staff trainees confidence to identify and address interactions that perpetuate racism at 6 months posttraining in our study further validates this need for disseminated practice in antiracism efforts despite the fact that wic staff trainees found the core training components in our study quite a bit or extremely useful the workplace scenario and debrief elicited a wide range of responses and feelings among wic staff trainees including defensiveness trainees pointed out the competing priorities of accommodating challenges that participants face while still meeting agency expectations to follow protocols and rules eg allowing participants who arrive late due to issues beyond their control such as public transportation challenges to still be seen on the same day versus following agency protocol to reschedule if more than 30 min late this highlights how institutional level policies influence interactions between wic participants and providers as well as among wic staff 29 further demonstrated by the wic enrollment process until the covid19 pandemic accelerated the passage of waivers at the federal level to allow for remote enrollment and issuance of benefits 30 the bureaucratic and protocol driven nature of wic meant there had not been institutional acknowledgement of how the life context that positions families in need of wic benefits may work against them having the agency time and skills needed to physically produce what is required 31 however remote enrollment has been an antiracist institutional change that took wic participants social context into account and reduced the opportunity for wic staff implicit and explicit biases about the person applying for benefits therefore it felt significant that wic staff trainees recognized the need for an integrated approach linking individual interpersonal and institutional efforts toward equity not solely placing the onus for change on individual staff members working on their biases or addressing interpersonal racism in the workplace in order to address confidentiality concerns we did not link individual trainee responses at each timepoint limiting the examination of data on changes in attitudes awareness and behaviors to the cohort level only therefore we could stratify by neither demographic variables nor the impact of higher baseline competencies in the areas covered to determine which trainee characteristics were associated with attrition or survey completion further while our original intention was to do an annual core training with three quarterly followup sessions due to pennsylvania wic transitioning to electronic benefit transfer cards in the fall of 2019 followed by the onset of the covid19 pandemic plans for ongoing sessions were indefinitely suspended this could explain why confidence in addressing interactions that perpetuate racism at multiple levels was not sustained at 6 months lastly evidence reviewed earlier in this report describes antiracism training as most impactful in the context of larger institutional efforts to advance equity which is not yet happening in a comprehensive manner at philadelphia wic despite limitations the initial findings from the training remain promising and indicate further work is needed to study if and how these demonstrated changes in wic staff trainees attitudes actions and awareness translate into improved care experiences for wic participants as such these findings can inform institutionallevel changes at philadelphia wic including implementing antiracism trainings for all staff at philadelphia wic creating a confidential means for wic participants to give feedback about their experiences that can inform both the agencys policies and antiracism work and advocating as an agency for inclusion of wic staff in legislation that mandates antiracism training for perinatal providers in this seminal moment of attention to black maternal mortality and systemic racism we believe offering ongoing antiracism training is a valuable step toward building the capacity of wic staff to improve the participant experience and advance a culture of health equity data availability data is available upon request author contribution cs mcf gl and mj participated in the training design cs and mcf implemented the training cs and sh participated in the acquisition and analysis of data cs mch and sh participated in the drafting of the final manuscript all authors participated in the critical review of the manuscript all authors have given final approval to the manuscript consent to participate not applicable consent for publication not applicable conflict of interest the authors declare no competing interests publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations springer nature or its licensor holds exclusive rights to this article under a publishing agreement with the author or other rightsholder author selfarchiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law

introduction women infants and children wic nutrition professionals serve as frontline providers for black families who disproportionately experience poor perinatal outcomes with racism driving inequities we developed an antiracism training tailored to wic this report describes the training framework design components and evaluation methods in 2019 with feedback from wic providers we created a 3h antiracism training for philadelphia wic nutrition professionals that included an identity reflection key concept definitions workplace scenario and debrief a model for repair and disruption and an action tool we implemented this training in august 2019 and surveyed wic staff trainees awareness of racism and skills to address bias before immediately after and 6 months posttraining comparing responses at each time point results among 42 wic staff trainees mean age was 30 years 56 were white 91 female and 74 had no prior antiracism training before the training 48 felt quite a bit or extremely aware of the role of racism in the healthcare system this increased to 91 immediately after and was 75 6 months later similar increases in confidence identifying and addressing interactions that perpetuate racism were achieved immediately after training although the magnitude decreased by 6 months onethird felt quite a bit or extremely confident the training improved participant interactions at the 6month timepoint qualitative feedback reinforced findings discussion results suggest antiracism training may improve wic nutrition professionals attitudes awareness and actions and could be valuable in efforts to advance health equity more work is needed to examine how changes translate into improvements for wic participants

introduction in 1986 john friedmann published the world city hypothesis an article in which he elaborated on the concept of world cities and put forth seven assertions about the relationship between the worlds large cities and globalization this seminal article served to crystallize a line of inquiry that had begun several years earlier but since then has flourished in social science theory and empirical research scholars working on cities and globalization have subsequently concentrated on this world city concept and the related one of global cities from the perspectives embedding these concepts organizational ties across cities and the flows of capital information and people between cities have interconnected the worlds great cities the most pivotal world cities in this network are followed by less central cities that nevertheless articulate among large regions of the world economy the image that emerges from this body of scholarship is that of a hierarchical worldsystem of cities from its inception world city research has focused on identifying this network of global cities and relating it to processes of global transformation since the late 20 th century while the conceptual work on world cities and global cities is rife with hypotheses and casebased observations on the socialstructural concomitants of a citys place in the global network globalization scholars have been reluctant to engage in systematic research on how cities global centrality positioning affects the social structures within them this paper fills this lacuna by exploring one of the key claims about global cities the claim that by virtue of their hierarchical place in the global system of cities cities nearer the top of the hierarchy are correspondingly more socially polarized from mapping the network to the effects of network position locating cities in the global network since about 1995 world city scholarship has included an increasing number of empirical representations of the world city hierarchy most of which are based on relational data linking cities through various flows between pairs of cities or through the organizations sited in those cities this body of work has located specific cities within global networks of cities usually identifying cities by their degree of centrality in the network at a particular point in time more recent research has become more nuanced today we have studies that show how cities relative positions in the network change over time studies that focus on the degree of integration within the global city system and changes therein and studies that analyze the extent to which the global city system has become independent of the system of nations in which the cities are located the research reported here uses one global city mapping procedure to assign global centrality scores to cities consequences of world city network location in his seminal piece on the world city hypothesis friedmann connected cities locations in the global hierarchy of cities to social patterns within cities he very clearly articulated that social outcomes within cities were related to cities positions within the global hierarchy of cities 1 the form and extent of a citys integration into the world economy and the functions assigned to the city in the new spatial division of labour will be decisive for any structural changes occurring within it friedmann also expected that cities that were more central to the global system would be more socially polarized 6 world city formation brings into focus the major contradictions of industrial capitalismamong them spatial and class polarization sassen too expects that cities social structures will depend on the nature of their role in a global network of urban places in much of her writings on globalization her focus is on the global cities at the very top of the hierarchy these are the global control centers of the international economy in which she argues social polarization is especially pronounced however she also argues for similar but less pronounced tendencies farther down the global city hierarchy the purpose of this paper is to empirically assess these claims by examining data on large us cities in 2000 we first review the literature bearing on global cities and polarization then we describe the data that this paper brings to bear on the matter followed by a presentation of the data analysis we end by discussing the implications of our findings relative to the specific hypotheses as well as the larger literature literature review polarization and professionalization in world cities polarization for both sassen and friedmann the mechanisms that link cities global centrality to polarization emanate from structural concomitants of the economic roles that they play in the world economy class polarization in these cities is characterized by large income gaps between transnational elites and lowskilled workers largescale immigration from rural areas or abroad and structural trends in the evolution of jobs in cities atop the world city hierarchy production is more capital intensive leading to an ecology of jobs defined by small high wage professional technical and managerial workers and the destruction of jobs in the high wage unionized sectors high wage professional occupation growth creates demand for lowwage jobs in consumer and personal servicesjobs often filled by women and immigrants similarly sassen argues that key globalization processes including global economic restructuring and international migration fuel social polarization first the rise of producer service industries as the leading edge of the global economy has created an increasing proportion of veryhighincome positions in top global cities while also generating more demand for lowwage workers at the same time manufacturing has been spatially decoupled from leading cities in core nations resulting in a decline in relatively wellpaid lowskilled and semiskilled jobs in this sector the increasing numbers of workers in producer services requires an army of lowwage workers these workers fill an astonishing array of jobs including residential building attendants dogwalkers housekeepers for the twocareer families workers in the gourmet restaurants and food shops french hand laundries and so on because these lowskilled jobs are often filled informally they attract immigrants many of whom lack the documentation necessary to acquire formal sector employment thus a key feature of globalization is manifested disproportionally in more globally central cities which are home to capitalintensive firms as a growing highincome service sector exists alongside an expanding lowincome service sector with little growth in the middle of the income distribution sassen argues that there is …a dynamic of valorization at work that has sharply increased the distance between the devalorized and the valorizedindeed the overvalorizedsectors of the economy producing global cities that are highly polarized in terms job opportunities incomes skill levels and housing patterns sassen claims that the expansion in the number of lowwage jobs in the manufacturing sector is due to three important factors 1 the social reorganization of the work process notably the expansion of sweatshops and industrial homework 2 the technical transformation of the work process that has induced a downgrading of a variety of jobs and 3 the rapid growth of high technology industries that are characterized by a large share of lowwage jobs in production again these processes are more extreme in more globally central cities due to their roles as loci of global power and control hamnett disagrees with some of sassens contentions but he broadly agrees on the topic of polarization he states that the downgrading of the manufacturing sector has led to a decline in unionized shops in addition wages deteriorate while sweatshops and industrial homework proliferate some of the aspects of globalization that scholars see as contributing to polarization include the rise of information technology the absence of institutional regulations and the rise of informal sectors in cities like london and new york although a voluminous research literature exists on the topic of increasing socioeconomic polarization in advanced national economies very little of it focuses on world cities in particular professionalization the world citypolarization hypothesis first developed by friedmann and then further elaborated by sassen has attracted a fair amount of criticism in recent years hamnett argues that polarization remains conceptually underdeveloped in the literature and that while occupational polarization may be occurring in some global cities the more significant secular occupational trend in western urban economies is professionalization hamnett and others also accuse sassen of overgeneralizing from tendencies in primarily american cities and others underline this critique pointing out that many specific historical cultural and political conditions are more important in shaping the nature and degree of polarization across the worlds major cities empirically nørgaard and hamnett have found evidence refuting sassens polarization theory nørgaard examined the new york metropolitan area and found that the employment structure…has become more similar to other areas in the united states in the period between 1970 and 1990 specifically while wages are clearly distributed very unevenly this pattern of inequality was already established by the beginning of the study period nørgaard asserts that the specialization in producer services that sassen claims has occurred in global cities like new york does not have an empirical basis instead nørgaard found evidence of a trend toward more generalized job structures a transformation that is hardly confined to the most globally central cities in spite of such important critiques of the world citypolarization thesis the matter has hardly been settled it seems to us that the real tension in friedmanns and sassens arguments that empirical research can should begin to address is whether cities higher up in the global hierarchy of urban places are different with respect to social polarization in the ways the thesis suggests than cities lower in the hierarchy testing this thesis suggests a comparison of cities along a continuous measure of position in the global urban hierarchy this is not to say that critics objections to the world citypolarization thesis are not valid first we would be surprised if culture history and politics did not affect forms of polarization in cities second the professionalization objection to the thesis needs to be more seriously considered empirically the global economy could really be generating more equitable employment opportunities on average across the world city hierarchy finally there are plenty of reasonable people scholars and pundits alike who would argue that the polarizing effects of globalization are ubiquitous not at all confined to the top levels of the global city hierarchy if so we would not expect to see evidence that polarization varies with the degree of cities global centrality thus the fundamental question remains does position in the global urban hierarchy contribute to an explanation of polarization within urban places an important theoretical wrinkle in the world citypolarization argument bears upon the significance afforded by scholars such as sassen to the role of immigration in the processes of global city formation for sassen immigrants constitute a global labor supply system that arises from a set of global dynamics that push migrants from lessdeveloped countries and pull them toward developed countries and specifically toward global cities on the push side structural adjustment policies and global capital flows in lessdeveloped countries generate conditions that exacerbate emigration they tend to displace traditional forms of production feminize the labor force and uproot large segments of the population while laying the organizational and institutional infrastructures that facilitate the international movement of labor on the pull side the growth of advanced producer services in developed countries the downgrading of the manufacturing sector and the casualization and informalization of employment have produced a significant demand for lowwage labor which has been filled predominately with immigrant labor although the push and pull dynamics promoting international migration are typically considered to be analytically distinct sassen treats them more holistically contending that they are both associated with an integrated process of global economic restructuring the same set of basic processes that has promoted emigration from several rapidly industrializing countries has also promoted immigration into several booming global cities recent work has found empirical support for her arguments linking emigration from lessdeveloped countries to economic globalization indeed there is strong theoretical rationale for believing that the effect of a citys global embeddedness on polarization will depend on the extent of immigration into a city at the most basic level immigrant workers are useful to global city employers because the ways of controlling them are much simpler cheaper and more straightforward than with other groups sassen asserts immigrants especially in the united states are often employed in firms where the system of control rests not on techniques of production and elaborate organizational arrangements but on the powerlessness of the workers control is not structural but immediate and personal employers can respond to workers dissatisfaction complaints and rebellion by firing them given these means of controlling workers the powerlessness of immigrants is particularly significant of course this applies to immigrants in low skilled occupations who are less likely to be fully documented and less likely initially to be fluent in english more broadly higher levels of immigration might exacerbate the polarizing effects of global centrality because the expansion of the highskill service sector so characteristic of social structures in global cities is predicated on a sufficient supply of lowskill labor which is most often fulfilled through immigration indeed the growth of these two labor markets is intrinsically linked as both advanced producer service firms and their employees consumption patterns generate strong demand for lowwage service labor the expansion of the highincome workforce in conjunction with the emergence of new lifestyles have led to a process of highincome gentrification that rests in the last analysis on the availability of a vast supply of lowwage workers all of these trends give these cities an increasingly sharp tendency toward social polarization methodology ideally we would conduct our analysis on major cities in the world as a whole however the citylevel data for many of the variables necessary to test this hypothesis across cities in most of the worlds countries are not readily available there are advantages however to restricting the analysis to cities within one country the most significant of these advantages has to do with the effects that national policies are likely to have on the degree of polarization of cities if we had an international dataset we would certainly need to control for variation in these nationlevel differences with data from only one nation this problem is eliminated as all of the cities in our dataset share the same national policy context of course there may be some variation in state and local policies that affect income distributions directly but probably only in very minor ways compared to national level policies we also note that in studying us cities alone we are considering only cities in the core of the worldsystem so we do not need to control for variation in worldsystem position this is important since previous research has shown that worldsystem processes contribute to different income distribution patterns across nations much of our data come from the us census 2000 the data are available at various levels of agglomeration we use urbanized areas because they are the geographic units within which urban social polarization occurs that is polarization is replicated within urbanized areas not within city limits it is also the unit that the census uses to make much of our data available in contrast to metropolitan areas we restricted the analysis to large urban areas with populations that exceeded 750000 in 2000 thus our dataset includes 57 cities hypotheses following sassen and other proponents of the global cities and world cities theses we hypothesize that cities that are higher up in the global hierarchy of places those more central to the global network of cities will have higher levels of social polarization thus we expect that our measure of centrality will have a positive effect on polarization we use two indicators of polarization income polarization and occupational polarization 1 using two indicators of polarization as outcomes in the analyses captures multiple dimensions of polarization and allows us test the sensitivity of our findings to alternative measures we note that polarization is conceptually distinct from overall inequality increasing overall inequality could occur as a result of a number of different redistribution patterns as long as three or more percentiles are involved in the calculation polarization however occurs when the relative sizes of both the high and low segments of the particular distribution are relatively large while the world city literature does not always clearly distinguish between overall inequality and polarization sassen is quite clear that more globally central cities are polarized especially in terms of increasing shares of the labor force at both the bottom and the top of the occupational ladder data and measures the most theoretically interesting variable in our analyses is the global centrality of cities measuring this concept involves estimating cities relative positions in an urban hierarchya global urban hierarchy in this case there is a long history of estimating the location of cities in urban hierarchies and until recently this was accomplished by comparing key attributes of cities that were assumed to be related to their dominance in a given system of cities for example population size of cities or the number of fortune 500 headquarters sited in cities was used to measure a citys place in an urban hierarchy however for the past twentyfive years researchers working on mapping the worldsystems city system have increasingly turned to network analysis of relational data to accomplish the task this is hardly surprising since most theorizing about systems of cities has always been about network relations but the methodological tools for modelling the actual networks have not been available until fairly recently now global city networks are routinely mapped with relational data using some form of network methodology and the data employed include airline passenger flows intrafirm networks across cities internet backbone linkages and scientific collaborations linking researchers located in different places in principle many other sorts of relational data could be used including commodity flows migration flows and telecommunication flows however so far estimates for these other flows across cities are not available we use flows of air passengers travelling to and from other cities to generate our measure of global centrality operationalizing global centrality with air passenger flow data is well established in the literature our measure is derived from a unique data set that provides information on individual passenger flows in 2001 this socalled midtdatabase is described in detail in derudder and witlox and reference should be made to this publication for further details here we only provide a brief summary of these data this database has been used for a number of publications on global city hierarchy and relative position of cities in the world system of cities and is similar to but more inclusive than the data set used by smith and timberlake which has also produced a number of complementary studies the midt database contains information on bookings made through global distribution systems such as galileo sabre worldspan topas infini abaccus and amadeus gds are electronic platforms used by travel agencies to manage airline bookings hotel reservations and car rentals using a gdsbased database therefore implies that bookings made directly with an airline are often excluded from the system and therefore the data however in 1999 just two years prior to our data 80 of all reservations continued to be made through gds thus although our information source may give a slightly biased picture of airline connections there is no reason to assume that the overall pattern of reservations made by direct bookings differs fundamentally from that for reservations made through a gds the the midt database over other airline data sources it contains actual origindestination information which minimizes the problem of overrating of the connectivity of airline hubs and firsttier world cities is minimized earlier air passenger data sets also covered only international flights and had to be supplemented with data from particular countries in order to include flights among cities within countries the midt data cover national and international flights it provides truly transnational data with the cooperation of an airline we were able to obtain a midt database that covers the period from january to august 2001 and contains information on more than 500 million passenger movements this database was used to measure the total number of od passengers for us cities for the period under investigation to achieve this we relabelled the airport codes into city codes this was necessary to compute meaningful measures because a number of cities have more than one major airport arraying the resulting data in an inflowoutflow matrix we used formal network analysis to generate measures of betweenness indicating the relative position of each of our 57 us cities within the worldwide hierarchy of cities cities with higher betweenness scores are more central to the global system of cities than those with lower scores hanneman and riddle explain the concept of betweenness as follows betweenness the third reason that actor a is advantaged in the … network is because actor a lies between each other pairs of actors and no other actors lie between a and other actors if a wants to contact f a may simply do so if f wants to contact b they must do so by way of a this gives actor a the capacity to broker contacts among other actors to extract service charges and to isolate actors or prevent contacts the cities in our analyses cover a wide range of the us urban hierarchy with betweeness scores ranging from 6009 to 394875 dependent variables our primary interest is in estimating the effects of global on two different indicators of social polarization we construct our dependent variables using us census data on income using the distribution of the households into the extremes of the national income distribution and occupations using the distribution of service occupations into categories related to skill we compute polarization measures for each income polarization is based on the balance of households concentrated in the highest and lowest quintiles of the national household income distribution 2 incpol abs where incpol is the index of the extent to which the distribution of income is polarized hinc is the census estimate of the percentage of a citys adult population that is concentrated in the highest overall national income quintile loinc is the census estimate of the percentage of a citys adult population that is concentrated in the lowest quintile by taking the absolute difference between the high and low categories our measures of polarization guards against mistaking monopolarized distributions for true bipolarity 3 again income polarization is measured using census data that provide estimates of the percentages of households falling into each quintile of the national income distribution 4 for example these data include the percentage of each citys households that is at or above the national average for the highest income 20 of the population we use this and the percentage of a citys households at or below the national lowestearning quintile of families thus these are relative measures of the income distribution based on comparing each city to the national average we use highest and lowest income quintile estimates to produce an index of income polarization according to the formula above thus cities are more polarized to the extent that their households fall relatively equally into the lowest and highest national quintiles of the household income distribution for our cities the income polarization scores range from 2078 to 3984 we also use estimates of overall inequality in some of our models recognizing that this a more familiar measure of inequality 5 however we have no expectation about the correlation of our measure of polarization with the measure of overall inequality because the polarization measure is about both ends of the income distribution it will not necessarily sort cities in the same way as the gini for example the medianranked cities in terms of polarization among our cities are san diego and baltimore however in terms of the gini index they are ranked 20 th and 37 th respectively the world cities literature also discusses occupational polarization the growth in highly skilled jobs in finance insurance real estate and legal services for the global economy and the growth in low skilled jobs such as personal services food services and custodial occupations thus we also estimate models of occupational polarization using data from the us census 2000 summary file 3 aggregated for urbanized areas occupational polarization is measured according to a formula comparable to that above where hisvc the percentage of a citys employed workers falling into the highskilled occupational categories and losvc the percentage of a citys labor force employed in the lowskilled occupations in addition to estimating models that examine the effects of global centrality on polarization we also examine its effects on the high and low components of each polarization measure we do this to test for the possibility that the global cities thesis is halfright that is more globally central cities may indeed have greater concentrations of employment in highend service occupations but not in lowend service occupations and vice versa if so this would be consistent with hamnetts professionalization thesis a critique of sassens line of reasoning control variables given the important role of immigration in explanations of polarization in global cities we include a control variable for immigration because most versions of the global city hypothesis focus on recent immigration we include the percentage of the population that immigrated within the five years preceding the us census as our measure to test whether the effect of global depends on the level of immigration in a city we include an interaction term in the appropriate models outside of the global cities literature variation in the degree of polarization across cities is not welltheorized thus aside from hamnetts professionalization thesis the factors for which our analysis ought to control are not clearly identified in an empirical literature on crosscity polarization our analyses do however include several control variables that related research suggests are theoretically important in explaining polarization in cities or that are important to the way in which social scientists think about aggregatelevel social inequality for example in testing for the effects of global city centrality on occupational polarization we control for aspects of cities population age distribution because school and collegeage residents are more likely than older workers to be employed in occupations quite different than those that they will hold after training or education we control for the percentage of cities populations that are in the age range of 1728 when we estimate the effects of global on income polarization we use a measure of the income distribution that is based on the relationship of the city household income distribution to national averages this requires that we take into account variation in the cost of living across cities we do this by controlling for median rents this measure is comparable given our regression models to the quintile estimates of cities relative income distributions produced by berube and tiffany that is their estimates were based on national figures that are standardized on regional cost of living adjustments for each city based on housing costs estimates in order to take into account hamnetts professionalization argument we control for the possible effects of the percentage of the employed population in professional occupations this measure is based on a broader set of professional occupational categories than hisvc because we are not trying to match it with the highend producer services occupations that are the focus of sassenss thesis because including profsn is redundant in the occupational polarization models we do not include it there similarly we include the level of education measured as the percentage of the adult population with college degrees in the models examining occupational polarization following the logic of the spatial mismatch argument the degree of blackwhite residential segregation should be associated with the lowincome component of our bipolarization measure an important part of this argument is that poor minority group members are residentially segregated in areas of the city that make it more difficult for them to find work we therefore include a measure of segregation in the model in order to control for such an effect on income polarization our measure of segregation uses dissimilarity index scores for urbanized areas available through the us census the research by volesho and fullerton dawkins et al and madden suggests controlling for employment in government and manufacturing employment both of which should ameliorate polarization by providing higher wages to lower skilled workers thus where appropriate the models include respectively slgov fedgov and mfg finally we include a dummy variable for cities located in the south in order to control for the historical and cultural heritage of race and class polarization that characterizes southern places 6 findings table 1 presents the descriptive statistics and simple bivariate correlations for the variables in the analyses there are a few descriptive findings worth discussing briefly first global is more closely related to gini inequality than polarization moreover the bivariate correlations suggest that global is associated with higher proportions of the population in the top categories of income and service occupations but with lower shares of the population in bottom categories of income and service occupations thus more globally central cities might have more inequality associated with relatively larger shares of the population in the top income and occupational categories but we do not find correlational evidence to support the hypothesis that more globally central cities have relatively high shares of their populations in both the top and bottom of their income or occupational distributions which would be indicative of polarization second our outcome measures allow a conceptually broad test of the world citypolarization hypothesis as they are not strongly correlated with each other gini inequality is only moderately correlated with income polarization and it is particularly distinct from occupational polarization similarly the two measures of polarization are themselves conceptually distinct from one another as they are inversely related of course while the simple correlations are suggestive adequate tests of the global city thesis require multivariate analysis table 1 about here using ols regression we estimate the effect of cities degree of global centrality on various measures of income and occupational distributions net of the control variables table 2 presents results for the analysis of income polarization and inequality and table 3 presents results for the analysis of occupational polarization overall the key finding is that we find mixed empirical support for the global city hypothesis on the one hand we do not find strong evidence that centrality is associated with higher levels of income polarization or occupational polarization nor does it affect the components of income and occupational polarization on the other hand the results demonstrate that the effect of global on income polarization depends on the level of immigration which supports the notion that the polarizing effects of centrality are conditioned by larger influxes of immigrants into more global cities a key tenet of sassens version of the global city hypothesis moreover the results show that global is associated with higher levels of gini inequality we detail these findings below 7 model 1 estimates the effect of global on income polarization net of controls global does not have an effect on income polarization although the sign is positive which would be consistent with the global city hypothesis to assess more specifically whether global affects income polarization we estimate models of the high income quintiles and low income quintiles again the coefficient for global is positive but it is not statistically significant we then test for whether the effect of global centrality depends on the level of immigration in model 4 by including an interaction term here we find evidence that centrality and immigration combine to exacerbate income polarization as the coefficient for the interaction term is positive and significant that is it appears that global centrality by itself is not associated with income polarization but instead global centrality coalesces with immigration to produce more highly polarized income distributions this is an important and theoretically interesting finding that is consistent with sassens version of the global city hypothesis but has not been empirically documented in a multivariate analysis finally we estimate the effect of global on gini inequality in model 5 to assess whether global behaves differently on income polarization and inequality we find that global is positively associated with gini inequality net of all controls this finding too is theoretically interesting given our null findings for income polarization in models 13 it appears that more globally central cities have higher levels of gini inequality however again this is a measure of the unevenness in the distribution of households into national income quintiles also noteworthy we find evidence that immigration is positively associated with gini inequality table 2 about here hamnetts critique of sassen argues that she mistakes polarization for professionalization in global cities thus we include the percent of the labor force in professional occupations in these models 8 model 1 indicates that contrary to the professionalization thesis professionalization has a negative effect on income polarization moving to models 2 and 3 it appears that professionalization is associated with higher proportions of the population in the high income quintiles and lower proportions of the population in the low income quintiles which suggests that professionalization results in higher median incomes in cities but not income polarization per se this finding also casts doubt on the assumption in sassens version of the global citypolarization thesis suggesting that higher wagelevels associated with professional occupations generate a larger lowwage sector we also find that blackwhite residential segregation exacerbates both income polarization and overall inequality it is not farfetched to suppose that both income polarization and overall inequality in american cities are largely racialized matters as suggested in abulughods critique of the global city hypothesis based on her study of new york chicago and los angeles surprisingly our control measure for the percentage of the labor force employed in state and local government has a positive effect on income polarization this variable is not welltheorized in the crosscity literature on inequality but we expected government employment to work against income polarization by increasing opportunities to attain middle incomes instead we find that cities with higher shares of the population employed in state and local government also have levels of income polarization associated with a smaller high income population segment and a higher low income segment at the same time the relative size of federal workers as a share of the labor force has no significant effects in any of these models our estimate of the relative cost of living was not significantly associated with income polarization but its strong effect on the relative size of the top and bottom income quintiles indicates that it is indeed an important factor to control in these models in general our models fit the data relatively well with adjusted r 2 measures ranging from 035 to 085 as a sensitivity test and to further test the professionalization thesis we estimate models of occupational polarization and present the results in table 3 again we do not find empirical evidence that global is associated with occupational polarization the coefficient is not statistically significant in any of the models as we did in the analysis of income polarization we estimate models on the high and low ends of the distribution for occupational polarization neither of the models demonstrates that global affects the relative sizes of either the professional labor force or the lowskilled service labor force in model 4 we include an interaction term for global newim to test whether the effect of global might depend on the level of immigration but again the coefficient for the interaction term is not significant table 3 about here the percentage of the population that is collegeeducated is positively associated with occupational polarization raising the proportion of the population in the professional service labor force and lowering the proportion of the population in the lowskilled service labor force no other variables have consistently significant effects on occupational polarization and with the exception of model 2 the explained variance is lower relative to our models for income polarization suggesting the need for more theorization of crosscity variation in occupational polarization the degree of blackwhite residential segregation increases occupational polarization the size of the manufacturing sector lowers the share of the workforce in both highend services and lowend services but it does not affect occupational polarization immigration and the population age structure have no bearing on occupational polarization 9 conclusions the literature on world cities and global cities is extensive and growing for example taylor and his gawc associates identify a citys prominence in the world city network on the basis of only the largest producer services firms and alderson and beckfield measure centrality in terms of fortune 500 corporations in fact the gawc network is based on firmcity relations ranking cities in terms of how important they are as locations of headquarters of producer services firms and as locations of three levels of decreasingly important branch offices we use the midt measure because it has more coverage of cities in the united states while the alderson and beckfield data would allow more coverage a number of us cities that they identify as globally prominent have low face validity as world cities ranking high only because they are home to one very significant global firm headquarters moreover some of their cities are embedded within larger urbanized areas and are too small geographically to encompass the polarization processes on which we focus two avenues for future research seem especially fruitful on the basis of our findings one avenue will be to further explore the relationships between international migration globalization and global city processes international migration has been overlooked as a key globallevel dynamic as scholars have devoted more efforts on other important factors including trade relations and movements of investment capital yet we demonstrate that international migration works with global dynamics in this case global centrality to produce higher levels of social polarization and inequality in us cities international migration can be investigated at the national level but cities are particularly well suited for systematic study of the types of processes that drive contemporary global social change because these processes are often centered on urban areas because the majority of the worlds population is now urban and most importantly because global social processes occur at levels above and below the nationstate thus we need to better understand how global processes are associated with international migrations directed toward urban areas specifically studies that examine the relationship between cities global centrality and immigration rates are particularly warranted on the basis of our findings a second avenue will be to expand the coverage of cases to include cities in other countries obviously this requires that we begin to build an international database of cities that goes beyond indexing cities with respect to the global urban hierarchy their population sizes or other such attributes previous studies of what it means for urban residents to live in a global city have relied on case studies or limited comparative case studies only a few of which have been deliberately systematic such studies have certain advantages over quantitative studies such as ours however those advantages do not include careful systematic tests of the hypothesized relationships found in the world cities literature as a final note while the practical significance of research on the effects of global city status on urban life might seem limited it is clear that powerful interests operating within cities and within nations on behalf of particular cities frequently mobilize global city rhetoric to marshal support for efforts to push their cities up the global hierarchy we believe it is worthwhile trying to understand some of the social consequences that may follow from these efforts we also conducted a comparable exercise using a measure of educational polarization with similar results to those for occupational polarization they are available upon request 2 our operationalization of polarization could be more appropriately termed bipolarization which for the sake of simplicity we avoid using bipolarization is the appropriate operationalization of the hypothesized social structural effects of world city centrality according to the literature that has inspired this effort 3 for example without taking into account the absolute difference between the relative concentration in the high and low categories city a in which the low percentile was 10 and the top percentile was 40 would have the same score as city b in which the high and low percentiles each had 25 clearly city b is bipolar in a manner consistent with the polarization hypothesis and city a is not our measure gives city a a polarization score of 20 and city b a score of 50 4 direct measures of the income distribution are not available from census for all of the cities in this study this leaves us with an unconventional income distribution measure but it seems to us to be justifiable measure of one aspect of polarization for our purpose of comparing cities in terms of the concentration of residents in bottom and top of the income distribution that is we have a measure of bipolarization at the city level that is standardized by the overall national income distribution account for the possible confounding effect of population on polarization including population size in the models does not change the substantive results we report here moreover population size was an insignificant explanation of polarization which is consistent with neals study that reports a decoupling of population size from other indicators of global centrality among us cities beginning in about 1940 and continuing to the present 7 we tested for whether spatial autocorrelation was present in our key dependent variables using morans i the data were geocoded using latitude and longitude values for the central city there is no evidence of spatial autocorrelation in these variables so we do not correct the standard errors for spatial autocorrelation 8 moreover in table 3 we provide a direct test of hamnetts critique by estimating the effects of global on employment in highend services 9 we have more regression results available that will provide further confidence in the results we present in the paper and we are glad to make these available upon request testing a world city hypothesis does the location of us cities in the world system of cities explain levels of social polarization within them

social polarization is perhaps most evident within the worlds large cities where we can easily and often observe stark contrasts between wealth and poverty a world city theoretical perspective has emerged that associates large cities importance in a global network of cities to the degree of internal polarization within these cities the research reported here locates 57 large us cities within this world city hierarchy and then empirically examines the hypothesized positive association between global centrality and social polarization using a multivariate crosscity analysis the findings are mixed with some evidence that global centrality increases income polarization but only in the context of higher levels of immigration there is no evidence that a citys centrality affects occupational polarization we conclude by suggesting implications for the world city literature and future research

introduction the social network microblogging site twitter has played an increasingly important role in communication during disasters both on the side of the public and of institutions involved in disaster relief and response in parallel the literature on functions of twitter during disasters is growing with different disciplines examining unique aspects of its use in hazardous events research shows that it is most heavily used as a platform to disseminate information quickly through a population to a lesser extent as a source of information from people who are witnesses to an event and as a way for the public to contribute to efforts in generating awareness through retweeting of relevant information 1 2 3 4 5 as our knowledge continues to develop about how twitter is used during emergencies and how its purposes can be expanded users continue to innovate on its functions before during and after a disaster this paper contributes to current knowledge by showing how the content of twitter during and after a global humanitarian event evolves over time from a channel of information dissemination about a storm and its impacts to a venue for mobilizing relief and response on a global scale to a place to where emotions are shared content analyzed twitter messages related to haiyan over the course of 20 days suggest that the issue attention cycle 6 on twitter for this global humanitarian crisis began to wean after 9 or 10 days unlike much of the existing work in this area we analyzed retweeted messages and nonretweeted messages separately allowing for a differentiated view of the sites functions for those who compose original posts and those that are widely shared across the network which often are from official sources and key information hubs this way results are not heavily skewed toward the types of messages that are most often shared and the voices of ordinary twitter users who are not often retweeted are not drowned out in the analysis results indicate that there are meaningful differences in the content and sources of tweets that are the mostretweeted and the ones that emanate from the broader audience while there has been interest in the use of twitter during crises 78 this paper contributes to this growing body of work by focusing on how attention cycles operate in social media platforms and identifies the voices and messages that drive attention and conversation twitter data were collected the day before supertyphoon haiyan and for 18 days afterwards haiyan was a trending topic on twitter for over two weeks with activity coming from many countries this was the strongest typhoon to ever make landfall in recorded history 910 severely damaging areas of different countries in southeast asia it directly hit the middle of the philippine archipelago which is comprised of a group of islands decimating the city of tacloban in leyte province and flattening many other municipalities along its path while both local and international relief efforts were quickly mobilized from outside the province it took several days for help to reach the affected areas for over a week little was known about the extent of the damage the situation on the ground where survivors were and how many were killed delayed access to the site also perhaps lengthened the attention cycle on social media and traditional media as information about damage in tacloban was slow to reach the press because of difficulties in reaching affected areas the international media were on site as soon as transportation systems allowed broadcasting to the world images of devastation stories of loss and as days passed with no help arriving criticisms against the national governments efforts rose twitters functions during disaster events while twitter was not originally conceived for use in emergency response situations and disaster events the public and institutions are increasingly turning to it for gathering and disseminating information 11 the growing empirical work on twitters functions in relation to disasters shows that it is a valuable channel of information for both official institutional sources such as government agencies and news outfits and witnesses on the ground close to the event who are able to post updates as texts and photos its use has been studied in relation to the 2011 tohoku earthquake 12 the red river valley flood threat 4 the pakistan floods 1 the waldo canyon wildfires 13 the australian floods 14 and several others twitter contains features that are particularly useful for disaster reporting and monitoring realtime posting shortburst message style default public settings when posting multimedia capacities hyperlinking presentation of posts in reverse chronological order and easy retweeting or forwarding of messages to followers and the public twitter space informal networks on social media are used for different purposes including information transmission emotional expressions activity reporting media content sharing and collective sensemaking 111516 during emergencies twitter functions as a backchannel source of information 17 a means of rapid information dissemination 8 a venue for information sourcing to enhance situational awareness 18 and as a channel for sharing opinions and experiences 1920 there may be other functions as yet understudied following palen et als 4 observation that twitter and other social media serve various functions depending on the type of user and type of event a number of studies have closely examined various aspects of twitters use as an information source and channel for dissemination during disasters in addition to being a place to find and share information people also use it to share personal experiences crack jokes express concern and ask questions 19 information sharing is done often through retweeting of links with a larger portion of links coming from news websites rather than official government sources 212223 for many studies of twitter messages during disasters the main finding is that over half are informationrelated and contain links to websites the platform functions largely as a broadcasting medium during emergency events and other nonroutine situations 24 in response to its institutional use as a broadcasting medium people or audiences use the site to actively seek out informationa more common behavior than starting an online conversation or other similar forms of interactive strategies 25 publics are drawn to the site by active information seeking because in crisis situations affected populations seek out explanations to reduce uncertainty information hubs 2627 tend to be official sources with announcements and situation updates dominating the most retweeted messages and reaching the widest audiences a content analysis of twitter messages posted by international organizations involved in the response after haitis earthquake revealed evolving use of the medium over time 28 from that of information dissemination to expressions of support to fundraising the earthquake was a trending topic on twitter for several weeks throughout breaking news fundraising organizing of events and updates on response on the ground 29 engaging through twitter as a response to disasters and crisis situations is motivated by a felt need to contribute and by doing so better able to cope with the enormity of the situation 17 a study of people who tweeted about haiti found that their reasons included connecting with others for a common cause promoting relief efforts and personalizing their own activities in response to the disaster 30 from an organizations point of view nonprofits and media institutions craft messages on twitter to motivate citizen response 31 this in turn generates greater interest in taking action like donating money or contributing to relief efforts in light of these previous findings we coded for many different types of content using the twitter posts during and after haiyan these include information about the typhoon and its damage posts about disaster relief as reported from the ground reports of different disaster relief efforts from those who are initiating them posts of emotional response supportive messages and posts about politics this will allow for a detailed view of the makeup of twitter posts overall throughout the issue cycle of haiyan and changes across the days in terms of content global interest in disasters the impact of haiyan was hardest on a handful of islands in the philippines but the interest in the typhoon the damage it created and the recovery of hardest hit towns like tacloban was international in scale a day after the philippine president aquino declared a state of calamity and formally accepted international assistance on 11 november 2013 the united nations declared a level 3 humanitarian response and triggered relief operations from international governments and ngos 32 countries like japan the us australia and the uk pledged billions of dollars in aid funds and sent valuable disaster experts and military personnel in disaster response humanitarian agencies descended on the small city with emergency supplies bringing their own transportation communication and fuel closely following the responders were international media such as cnn nbc and other television networks in the us the bbc of the uk the wires and many others from different countries sentiments on twitter came from around the globe with messages conveying support emotion and sharing of efforts to contribute to the relief operations this was an event that held the attention of many people in many countries similarly with other global humanitarian crises like the haiti earthquake the japan tsunami and the pakistan floods global interest in local crises may be more common in the age of online social networks following the predictions of castell 26 information flows in the digital world now reflect structures of networks organized around communication hubs and nodes communication hubs function as main exchangers coordinating elements in the network while nodes become the bases for locally initiated activities content can be generated by any person or organization and shared to or by any entity on the network this communication structure enabled by twitter allows local citizens to broadcast worldwide and allows the world to respond during haiyan information flows with such patterns was evident for many days photos of hardhit areas were being tweeted by relief workers on the ground and then shared across the world the global public posted messages of support and in some cases used the platform to coordinate response the 2010 haiti earthquake in many ways brought into global focus the capacities of twitter for disaster outreach and fundraising 31 scholars have pointed out how humanitarian agencies recognized the significance of twitter for aid mobilization in the context of haiti 3334 one organization successfully designed a communication protocol to have mobile sms systems and twitter messages work together to make donations to haiti relief efforts convenient the ngo arc used a 5digit number to text if a person wants to donate and then used twitter to publicize the mechanism for donating in a fixed 10 amount 35 in eight days 305 million was raised 2836 as humanitarian agencies continue to develop innovative social media approaches to fundraising and response they will become a greater presence in twitter traffic during and after disasters murthy and longwells 1 examination of the uses of twitter during flooding in pakistan suggests that there is a globallocal divide in perceived legitimacy of information while most links shared by twitter users emanated from traditional media with social media trailing far behind social media sources were more often linked to among those tweeting from pakistan moreover messages from pakistani sources were conferred more authority status during the floods a manner of communication from sites of disasters that were previously unavailable in events of global interest social networking sites are now members of the larger media ecosystem that operates during disasters of global implications they have become an important part of the communication system used to inform organizations and citizens 37 in a communication environment where online social networks no matter how transient provide an always on firehose of news and information from many places to many places certain types of events like disasters will find its way more easily to global consciousness when information sources are as diverse as they are on twitter the source becomes an important heuristic in sorting out good information from bad official information sources like governments and news organizations would be the entities with the widest reach and following 2238 as their status confers credibility onto information tweeted language matters as well primarily as an indicator of where the source is located and who their main audience is locallanguage tweets may have different content from englishlanguage tweets intended for a global audience local users may produce and seek out particular content from their media especially for those in the disaster zone in contrast englishlanguage tweets may be written with a global audience in mind and express solidarity through more general language the evolution of content dominant sources and volume of twitter traffic postdisaster is reflective of an issue cycle for similar events on the social network site communities that form are informal and loosely knit together those who are part of the haiyan community are held together by a series of hashtag terms most of these connections disappear eventually several days following an event it is posited that this issue cycle the one that will be found for haiyan would be similar with what one would find for any largeimpact disaster event that finds a global audience gaps in the literature and research questions the growing literature on twitter use during disasters paint a consistent picture of its value and function as an expeditious way of disseminating information information often emanate from official sources mostly news organizations many of these studies however do not examine changes of tweeted content over time although there are those that offer observations of overall declines in information sharing as days pass since retweets comprise a large portion of overall twitter traffic during disasters this means that keeping the retweets and original posts together will obscure noninformational types of content that regular citizens may be posting the analysis in this paper separates these two categories of messages and compares patterns between them we expect that by coding for other message content that are not purely information namely posts about disaster relief emotion support personal experience and political commentary a more detailed understanding of the various functions of twitter during such events can be discussed to illuminate whether and how content evolves over time and the potential alternate forms of content that are posted we ask rq1 how do volume and content of twitter messages about a disaster evolve over time rq2 are there differences in message content between the most widely shared messages and original posts on twitter following research on the news issue attention cycle a longitudinal analysis of the rates of increase and decrease of various types of messages about haiyan on twitter should provide valuable information on parallel issue attention cycles in relation to global disasters coding for other types of content like emotions and supportive messages may reveal differing patterns from informational posts when examined through the days postdisaster to provide a more nuanced understanding of the networks behavior regarding reception and sharing of certain types of messages features of the most retweeted messages were analyzed for content and source to determine characteristics of the most retweeted messages rq3 which types of content are most shared what types of messages and sources act as the most effective communication hubs on twitter during disasters method tweets were collected using a twitter api at the spritzer level between november 7 and 27 2013 this means that 1 of all tweets posted are made available by twitter to the api for collection the tweets were filtered to include messages that contain the following keywords bagyoph rescueph floodph tracingph reliefph typhoonhaiyan haiyanph haiyanph haiyan typhoon typhoon haiyan haiyan typhoonph mindanao visayas samar leyte these include both the international and local name of the typhoon names of places in the philippines that were hit common hashtag words for the typhoon and official hashtags used by the philippine government over twitter in addition to the message tweeted the data included user location for a subsample twitter handle time zone of the user hashtags time the tweet was posted whether the tweet is a reply to a message and whether a tweet is a retweet all twitter data collected for this study are publicly available and can be collected by anyone in the same manner as it was collected here the data collection was conducted in compliance with the terms and conditions stipulated by the site the fields included twitter usernames alone which are publicly viewable and dates of the post data collected did not include any identifying information or geolocation tags there are no data protection committees in the philippines that may be consulted but data collected were not shared with anybody outside of the authors and research assistants named in this paper during large natural disaster events much of the circulating information are retweets from media and other official sources these predominate the universe of tweets and are often the focus of many published studies since the contents of retweeted messages are considered the most influential this research focuses as well on the content of unique messages being tweeted to provide greater visibility in the data toward individuals that post thoughts and information the public as it were thus the dataset were first filtered of retweets this was done in an automated manner that removes all messages beginning with rt the most retweeted messages were analyzed separately after the automated filtering which excluded a large proportion of the total twitter data two undergraduate students manually scanned the dataset to delete duplicates that did not have rt tags messages that were not in english or filipino and messages that were not related to haiyan these deletions comprised 35 of the dataset without rts the process yielded a dataset that reflects original comments by different sources and represents 195 of the original set of tweets from the twitter feed api collection from the cleaned dataset a random sample of 1000 tweets was drawn per day resulting in a final sample size of 20000 two graduate students coded the sample for a number of variables that indicate the content of tweets krippendorffs kappa was calculated for each variable to test for reliability with each round of reliability testing done with a sample of 500 tweets from the full dataset minus retweets acceptable reliability levels according to de swert 40 are 80 and above with a minimum of 67 for exceptional circumstances the majority of coded variables reached the 80 acceptable threshold with a few exceptions variables with reliability coefficients between 67 and 79 had low incidence rates and were therefore very sensitive to each disagreement the table reports percent agreement and incidence for these variables the coding scheme was designed so that all content variables could overlap no restrictions were placed for mutual exclusivity that is a single tweet could contain typhoon information emotional expressions and a comment about climate change and would then be coded for each of the three in making decisions they were instructed to read the body of the text as well as all the words with hashtags some tweets would have contentrelevant words in hashtags for instance a tweet with heartbroken or sad would be coded under negative emotion the most retweeted messages were coded in an identical manner for each day of data collection data were ranked according to the number of times a message was retweeted the top 100 most retweeted messages for each day were compiled and coded using the same coding scheme and by the same coders sources of the most retweeted messages were also coded into categories that included news media philippine government sources international aid organizations and media celebrities measures appendix a contains all content variables coded their definitions subcategories examples and reliability coefficients two background variables were coded language and source since the research team has the capability to comprehend the top 2 languages used in the dataset during haiyan these were tagged for purposes of comparative analysis of content by language these languages were filipino or tagalog and cebuano source was coded in a centralized manner a list of all unique twitter handles was generated and a graduate student did researchbased determinations of whether the handles belonged to private individuals entertainment media celebrities heads of institutions politicians aid organizations and local or international media the remaining content variables fall under the following general categories information expressions of support emotion disaster relief and aid and political expressions each category has a number of subcategory variables defined and described below information these tweets contain information about the typhoon its impact and where to help with monetary donations although solicitation of information does not happen often these were coded as well there are a number of subcategories of information coded to allow for disaggregation in the analyses when there is an interest in specific types of information typhoon information is tweets containing information about the weather phenomenon of haiyan itself including trajectory strength time of landfall or place of likely impact class suspension was coded separately these are simple announcements about suspension of school and work as a result of the typhoon and its damage damage information are messages that describe the extent and type of damage number of deaths places hit or scale of the impact fundraising information are shared details about drives to raise money to send to victims of the storm requests for information include queries about current situation or specifics like whether an area was hit whether a street is flooded or whether electricity has been restored disaster relief in the aftermath of the typhoon institutions and individuals undertook massive relief and recovery efforts tweets that were about disaster relief were coded in several subcategories personal relief are activities of any relief effort a tweeter has provided to the affected populations these include monetary and nonmonetary aid relief of others is those that report efforts of other people and institutions relief coordination is messages that contain actionable information pertaining to the provision of aid for example tweets that say what a community needs or where one can go to volunteer or messages containing logistical information reporting on the status of aid distribution specific calls for help contain specific information like place where help is needed and what kind of help is needed foreign response many tweets report on the pledges of support from countries and international aid agencies even individuals in places outside the philippines these were coded into a separate category and include news about monetary or nonmonetary assistance provided by any entity that is not based in the philippines foreign response may overlap with disaster relief and in those cases the tweets would be coded positively for both the distinction would reveal when the event reached and sustained international attention personal information messages that contain personal reports and questions were tagged these include messages that ask for information to help finding people specific local information about impact or status of the storm reports of direct personal loss of people or material possessions personal information is separated out as its own category to try to distinguish tweets from those who were directly affected or witnesses from those that are general information from institutions such as government and media emotions the literature on use of twitter suggests one of its main functions is for users to tell others how they feel emotions were coded into three broad categories negative positive and expressions of gratitude messages of thanks were pervasive over some days and thus were coded separately from other forms of positive emotions however in the end positive emotions were not reliably coded since there are only few instances of positive emotion tweets the reliability tests were extremely sensitive to even the slightest disagreement however since we were coding for negative emotions it would be inappropriate to not code for positive ones results for positive emotions should be interpreted with caution negative emotional statements included expressions of shock sadness grief and anger among others expressions of positive emotions included having hope feeling inspired expressions of support haiyan was a global phenomenon both as a weather disturbance and after it hit tacloban as a humanitarian crisis we coded for messages that expressed calls for safety and prayers a separate category on other supportive messages was coded but did not achieve reliability and are thus excluded in the analyses politics discussions and news about politics and government were common in the days after the storm hit related to relief and recovery operations these were primarily criticisms related to the slowness of response to statements made by public officials and news and commentary about fights between political factions positive and negative messages were coded in separate categories to capture valence the data were examined longitudinally to reflect changes in functions over time simple descriptive summative statistics are used to provide an overall picture of the types of messages that are posted related to haiyan byday distributions of variables are presented to examine longitudinal patterns bygroup and byday differences presented are statistically significant a result that is more readily attained since the sample size is large results the first research question is about how volume and content of twitter messages about a disaster evolve over time fig 1 shows the number of tweets collected by day through the api since these are a fixed percentage randomly selected sets of tweets from the collected data it is assumed that the volume changes per day in the sample reflect volume changes per day among all collected tweets tweets about haiyan started off november 7 with low frequency shooting up to 5 times its volume the on november 8 the day the storm hit tacloban at 5 in the morning while the storm was happening and the day it made landfall there was little information coming out of the hardest hit areas towns were isolated from any communication and transportation for close to 48 hours reflected in a slight dip in tweet volume following november 8 tweets increased again starting november 11 peaking on 12th tweets during these days were about the scale of the damage the press had arrived on site and descriptions photos and videos were being circulated to the public the rate of decline in tweet volume was equally steep in the following two days thus from this example the issue attention cycle peters off after about 17 days the vast majority of tweets were retweets a manner for individual citizens to share information they see on the platform the solid line in fig 1 illustrates volume after all retweets are excluded showing a much flatter line although an increase in original content posting is also evident following the same dates as the line including retweets differences in patterns of overall twitter traffic and posts that exclude retweets reflect the platforms use as an effective dissemination channel through communication hubs and social networks information can be retweeted any number of times much of the available literature on twitter posts during disasters find that the majority of content being posted is information by a large margin with other forms of posts lagging far behind in frequency the second research question asks whether there are differences in message content between the most widelyshared messages and those that are original posts fig 2 shows general content category distributions for both the most retweeted messages and messages without retweets while 59 of the most retweeted messages contain information about the typhoon a smaller portion of the general twitter messages contains information still the overall pattern is that information about the typhoon and about disaster relief dominates twitter we argue that the vast majority of original posts are from ordinary citizens or the general public results show that these tend to contain more messages with emotions personal information and commentary about politics although these do not occur frequently among the original tweets 10 of messages have content about emotions compared to a smaller 4 among the most retweeted messages personal information in general does not get tweeted often however given the scale of twitter 41 even small proportions could be consequential there are more instances of personal information tweets from original posts compared to the retweeted messages of note is a dearth of messages related to politics according to an international comparative study by pew research center 42 while social media enjoys relatively high use rates in the philippines its use for posting content related to politics is low compared to other developing countries this is reflected in the content coding done here where political posts comprised very little of the total twitter traffic on haiyan this could be specific to the country however and it would be interesting to do further crosscountry comparisons of twitter use during global humanitarian crises to determine if the lack of political discourse postdisaster varies by location over the course of several days tweets with informational content about the typhoon and its damage declines sharply for both retweets and nonretweeted messages these are replaced by messages with information about disaster relief and foreign response as a proportion of total tweets these two categories comprise the vast majority of posts emotions are shared across all the days for tweets of the general public peaking at 168 of tweets the day the storm hit with the lowest values at 5 at 20 days posttyphoon for retweets emotions do not comprise a substantive proportion of messages hovering around 3 for the days around the typhoon and then peaking 8 days after at 10 informational tweets among the general public are comprised of 18 information about the typhoon 8 about fund drives 4 questions asking for information and the vast majority 75 information about the damage and impact of the typhoon the volume of informational tweets decreases over time but always stays above other forms of content in terms of proportion of total tweets of interest are tweets about disaster relief as these have not been examined as a separate category in existing research on the functions of twitter during disasters of the total sample of tweets from the general public that were classified under disaster relief 12 reported on personal acts of disaster relief 67 reported on the relief activities of others 8 were solicitations of specific kinds of help and 54 are coordinative in nature twitter therefore not only acts as a channel to disseminate information about the typhoon and the disaster relief activities that go on it also is used as a platform to coordinate and mobilize relief efforts to share personal stories helping and to share information about help being extended by others retweets are mostly information messages for more than a week after the typhoon comprising 85 and 90 the day of the typhoon and the day before it respectively these are messages with news about the intensity and size of the storm its trajectory and where it will make landfall there are large increases in news about the foreign humanitarian response to those affected starting at 15 only 2 days after and rising to 53 of the most retweeted messages one week after disaster relief messages that circulate among the most retweeted messages are usually about large fundraising campaigns these began in earnest the day immediately after the storm the day that information about the size of its damage started appearing on the news by november 12 50 of the most retweeted messages were about disaster relief staying at around that level until the end of data gathering there are slight bylanguage differences in the overall distribution of content types tweeted by the general public filipino language tweets which comprises 11 of the sample have higher rates of messages with emotions support politics and information english language tweets have higher rates of messages about disaster relief and foreign response locallanguage tweets represent sentiments of people who are closer to the site of the disaster and therefore are either directly or indirectly affected as opposed to the rest of the world on twitter who are spectators to the event as it unfolds the international community responded through disaster relief and this is evident in the higher proportion of disaster relief messages in english the most retweeted messages are often from news sources media celebrities and aid organizations involved in disaster relief fig 5 shows the progression of how different sources of tweets dominate in different stages of the issue cycle interestingly while we coded for philippine government agencies and key officials these were not substantive sources of popular information on twitter in the initial days when circulating messages are comprised mostly of information about the storm and the extent of damage local news sources played an important part in circulating critical safety messages their influence over the network began to decline as soon as news about the scale of the damage became public international news organizations started covering it as a global event foreign news sources had more retweeted messages than local news sources two days after the storm and continued for a week local news became more prominent again beyond november 16 when local news outfits carried a story about the empire state building having been lit up as a tribute to those killed by haiyan the most influential communication hubs are clearly celebrities most of whom are nonfilipino celebrities table 2 lists the top most retweeted messages each day and for most days the top are from celebrities harry styles liam payne and alicia keyes the current pope francis head of a state and a religious institution we argue has celebrity status given his high visibility in international media celebrities clearly have an inordinate amount of influence over circulating information on the network particularly during disasters when they are active in publicizing fundraising efforts aid organization are also a prominent source of the most retweeted messages these are mostly fundraising drives and are aided in turn by the activities of interested celebrities to answer research question 3 even more so than news organizations media celebrities act as the most effective communication hubs for disseminating across the network if we define discussion and conclusions this research sought to provide an overtime examination of the various functions of twitter reflected by the types of messages that are posted how these message types gain dominance and then decline in frequency the main communication or information hubs in the network and how their posts differ from those of the general twitter public by examining these throughout a 20day period between the day before haiyan a predicted weather event to the days when rescue and relief were in full force we hope to show a more nuanced picture of the issue attention cycle on the twitter network this is shown in the context of a global weather event that turned into a humanitarian crisis since it hit a developing nation as the biggest storm in recorded history hit the philippine island of leyte killing more than 6000 people with a 20foot storm surge twitter users posted information retweeted and engaged actively in the relief effort consistent with findings of studies that examine social media use during disasters posts related to haiyan were comprised mostly of retweeted informational content 843 about 80 of the total traffic in the 20day span were retweets of messages from media sources celebrities and philippine government agencies as a proportion of tweets retweets comprised the largest portion of messages on the day the storm hit and 5 days afterward when news stories become available users take it upon themselves to retweet throughout their network the steep curve of information dissemination on twitter suggests that users are not just relying on the site for news but also have a sense of engagement enough to retweet stories that are of interest changes in volume of retweets indicate the public and news engagement with the issue which declined sharply on the 5 th day and then slows even more over the next few days this we propose is a typical news issue cycle on twitter and with similar studies of other global disaster events may be reflected in other instances an events presence on the site may not be as extended for disasters that do not have international attention as much of this attention was sustained by disaster relief efforts by organizations that are not in the philippines without the retweets in the dataset the content analysis reveals that original tweets coming from ordinary people are of only a slightly different character in terms of content type distribution ordinary people are more likely to tweet emotional expressions reports about disaster relief efforts and personal information while the differences do not appear large compared to the retweets and the proportions are at or below 10 the massive scale of twitters traffic 41 means those even low proportions could translate to tens of thousands of messages these types of messages have not been examined thoroughly in the literature possibly because retweeted messages usually are included in sample codings drowning out alternative types of messages being posted by the regular users the exception is chew and eysenbach 19 but their study is in the context of a global pandemic and its interest is more in twitters use as an alternative source of statistical information for a diseases spread in the case of global disaster events such as haiyan which evolves into a humanitarian crisis the types of posts from ordinary people and their changes over time indicate twitters functionality as a space to express solidarity and work through emotions significantly it is also a space where people share information and activities about disaster relief done by those outside of the philippines such information sharing and locally organized fundraising and volunteering carry great potential for government and humanitarian agencies to widen their pool of potential volunteers and donors the role that twitter plays as a functional communication tool for disaster preparedness emergency response crisis communication and relief provision continues to grow as institutions and individuals innovate on the various ways it can be used to deploy and gather information disaster relief messages comprised a substantial portion of both the retweets and general public messages the retweeted messages are mostly announcements and retweets of celebrities that publicize fundraising drives of aid organizations however other tweets that are not among the most retweeted contain actionable coordinative information these include things like calls for volunteers to a specific location to help with packing goods for delivery to affected sites calls for volunteers with cars to drive relocated individuals to places where they can stay and lists of supplies needed in specific locations these are important logistical coordinative functions that may spur greater involvement among those who are active on the twitter platform beyond the functionality for publicity during fundraising activities twitter may also effectively improve upon disaster response and relief delivery from volunteers and aid groups insofar as it brings together into conversation engaged and interested actors twitter amplifies voice creating a potentially wider audience greater mobilization efforts and greater attention from the aid community at large as disaster events capture global attention more easily now than before nevertheless we recognize that it is important to also assess the impact of twitter in relation to how affected people themselves accessed and used twitter and benefited from any campaigns organized through the platform research on affected communities own uses of social media suggest a disconnect between global initiatives with experiences on the ground 44 the evolution of posted content moves from a predominance of information about the typhoon to disaster relief messages and reactions and stories about foreign response the news cycle media sources writing stories about the storm and its aftermath sustains attention at a high level for several days this signals the relevance of official information sources in providing the original content that generates interest in the network as it is retweeted at scale attention spreads throughout different countries bringing the event to international importance this high level of attention indicated by the volume of retweets in the early days creates a community of followers of hashtags about haiyan which in turn serves as the main audience for all other noninformational posts that follow in the days of response and relief as members of the twitter public contribute to relief efforts in various ways they post about their own and others efforts extending issue interest in the network and potentially creating a sense among followers of the hashtags that a large public is directly involved which may in turn create a perceived social normative pressure to contribute 45 celebrities had a central role in acting as information hubs and key entities in the network that would increase attention and then sustain it through time specifically harry styles and liam payne members of a musical group called one direction with a large international fan base showed up in the results as being central information hubs for disaster relief drives there are many other celebrities that appear among the top sources of retweeted messages highlighting the importance of information hubs in creating wide networks of followers for issues even the twitter fan pages of celebrities often appear as top sources of retweeted content on certain days the scale of this effect is large and a systematic empirical network analysis of the size and speed of information diffusion from celebrities is in order to clarify exactly the depth and breadth of this influence this research is limited by some key constraints first the spritzer level access to twitter data and the opacity of the selection of tweets the platform supplies limits the ability of many studies like this to show the real scale of attention and content diversity however this does not threaten the validity of the distributions and relationships examined here second the content analysis can only be done for english language and filipino language tweets excluding many messages that were posted in other foreign languages that are a substantive portion of the international attention third the sheer volume of even sampled content made coding of sources difficult to complete as information is not available for every twitter account that was sampled this limited our ability to draw inferences about the relationship between content types and sources for the nonretweeted messages use of twitter during and after disaster events spans a variety of functions including information dissemination disaster relief and response coordination fundraising and emotional expression the distribution of content in the network evolves in the days following a disaster event particularly one that becomes a global humanitarian issue as what happened in haiyan various sources play important roles as information hubs that either generate original content or in the case of celebrities amplify the reach of messages to new publics that would otherwise be less engaged and aware the issue attention cycle on twitter taking into account key sources and hubs and the evolution of content provides important information for strategic communication crisis communicators from government can apply what is learned here to widen the audience base for messages aid organizations doing fundraising drives should connect with effective amplifiers of messages such as entertainment celebrities to improve collections smaller microvolunteer networks in local areas can use it to broadcast needs and coordinate effective response news outlets can use twitter accounts to sustain attention on the issue by continued postings of new information constantly even if the information base changes from details about the event to details about the response it would be of empirical and theoretical interest for future research to examine whether the issue attention cycle on twitter is different from that of other media outlets or even for that matter from facebook unfortunately global weather events that lead to humanitarian crises are a constant threat and will continue to happen periodically efficient and targeted use of available communication channels such as social media networks can make a real difference in preparing communities for disasters and transforming response and relief into larger and more effective efforts information regarding data access using the twitter api is available in the supporting information files

when disaster events capture global attention users of twitter form transient interest communities that disseminate information and other messages online this paper examines content related to typhoon haiyan locally known as yolanda as it hit the philippines and triggered international humanitarian response and media attention it reveals how twitter conversations about disasters evolve over time showing an issue attention cycle on a social media platform the paper examines different functions of twitter and the information hubs that drive and sustain conversation about the event content analysis shows that the majority of tweets contain information about the typhoon or its damage and disaster relief activities there are differences in types of content between the most retweeted messages and posts that are original tweets original tweets are more likely to come from ordinary users who are more likely to tweet emotions messages of support and political content compared with official sources and key information hubs that include news organizations aid organization and celebrities original tweets reveal use of the site beyond information to relief coordination and response

introduction approximately 65 million adult women in the united states have a current substance abuse or dependence disorder research has identified gender differences in the course and pattern of substance use disorders including the vulnerability of women to negative consequences of substance use and the likelihood that women with substance abuse problems have experienced prior sexual or physical abuse and continue to be exposed to violence women with substance use disorders are more likely than their male counterparts to have cooccurring psychiatric disorders including depression anxiety and posttraumatic stress disorder it is estimated that up to two thirds of women in treatment for substance abuse may have a cooccurring undiagnosed mental illness this cooccurrence is clinically significant because as compared to treatment concepts of social support and social networks using a personal social network conceptual framework this study sought to understand how women in substance abuse treatment describe their network members supportive and unsupportive behaviors and attitudes related to recovery the term social network refers to a set of individuals and the ties among them the study of personal social networks examines the relations surrounding a focal person in this case a woman enrolled in a substance abuse treatment program social support as defined in this study follows the empirically derived definitions of gottlieb and barrera and ainley verbal andor nonverbal information or advice tangible aid or action provided by social network members or inferred by their presence which has beneficial emotional or behavioral effects on the recipient social support consists of a variety of types of helping behaviors and has typically been categorized into three primary types of support informational support emotional support and concrete support a social support network refers to a set of relationships that provides nurturance and reinforcement for efforts to cope with life on a daily basis such as sobriety support to maintain recovery and tangible help not all social networks are social support networks nor do all social networks reinforce prosocial behaviors our study aimed to further social support research by building understanding of how women in substance abuse treatment view the behaviors of network members as either supportive or unsupportive of recovery such specificity may help treatment programs to more precisely design and match social network interventions to sustain recovery previous research on women substance use and social networks impact of substance using and other negative network members on recovery substance using network members often maintain a presence in the networks of women in recovery complicating efforts to maintain sobriety boyd and mieczkowski reported that women in their study stated that their friends mothers or sisters were the most likely people in their lives to help them become sober nearly 30 of the women however stated that they knew no one who would help them stop using drugs in studies of women offenders mandated to substance abuse treatment falkin and strauss and strauss and falkin reported an average of 9 supporters and 3 drug associates women in their sample had some support some enablers and some network members who did both using qualitative techniques trulsson and hedin examined the social support of women in the process of giving up drugs and found that divisions occurred within their networks between those people who supported recovery and those who primarily blamed and criticized the womans previous substance using lifestyle elbassel chen and cooper found that among women in methadone treatment 10 of their network members had provided them with drugs and 18 had used drugs themselves focus group discussions with men and women with cooccurring schizophrenia and substance use disorder revealed that the most commonly cited extratherapeutic factor that helped people stay substancefree was the emotional and practical support supplied by family members andor friends in fact substance abusers with cooccurring mental disorders as with substance users in general frequently cite social reasons for using drugs while social support has been recognized to have beneficial impacts on individuals wellbeing and physical health there are potential harmfuldetrimental risks embedded in interpersonal relationships the obligation to reciprocate may be stressful and lead to reluctance to use social network resources particularly for low income women with few resources to share ribisl and luke found that the negative impact of substance users within the social network exerted a greater influence on recovery than positive family supports for treatment criticalness hostility and overprotectiveness of spousespartners can reinforce continued substance using behavior and lead to increased relapse rates sun reported that interpersonal conflicts with intimate partners family members and service systems were perceived by women with substance use disorders as major triggers for relapse to occur one contributing factor to interpersonal conflicts and negative emotions was found to be delayed or undiagnosed psychiatric disorders that interfered with interpersonal communications and relationships social networks and treatment outcomes social network members can either support or undermine participation in treatment and recovery from drug use both peer support within the treatment setting and social support outside of treatment appear to be significant factors in treatment progress and outcome studies have examined the contribution of the characteristics of pretreatment social networks to extent of alcohol use retention in treatment and treatment outcome there is some evidence that interventions to build or mobilize supportive relationships in treatment and recovery are best matched to the nature and composition of clients pretreatment networks other studies indicate that positive abstinenceoriented social networks following treatment may be more predictive of treatment outcomes than are pretreatment social networks the importance of recoveryoriented social networks and nonusing social network ties has been stressed in maintenance of sobriety treatment adherence and relapse limitations of previous studies in summary research on social networks and substance abuse suggests a critical role for personal social networks and socially supportive relationships in ones participation in treatment treatment outcomes and maintaining outcomes following treatment in fact the national institutes of health has set forth a research agenda regarding the process by which social networks link individuals to health providers and how network members influence patterns of health and risk yet few studies have examined social network resources of women with substance use disorders including what specific elements make up the experience of different types of social support and how women experience network members who are not supportive of recovery methods measures psychiatric disorders were assessed using the computerized diagnostic interview schedule all of the women in the study completed the following mental disorder sections of the cdis generalized anxiety disorder depression dysthymia posttraumatic stress disorder and maniahypomania the cdis has demonstrated reliability and validity and is based on criteria from the diagnostic and statistical manual for mental disorders fourth edition this measure provides a dsmiv compatible diagnosis and distinguishes current from lifetime disorders substance use disorders were determined from the results of a structured computerized intake assessment instrument a uniform assessment tool developed for the county in which this study took place it is administered on intake and yields a dsmivcompatible diagnosis authorization to use this previously collected information was sought so that study participants would not have to complete an additional substance abuse assessment demographic information was collected from the demographic section of the cdis as follows age racialethnic identification educational level marital status number of children and employment history over the past 12 months this information along with substance use and mental disorder status is reported in table 1 qualitative research questions following the generation of a list of social network members positive and negative aspects of womens social networks during treatment and recovery were assessed via the following openended questions which of the people listed in your network have supported you the most in your current recovery efforts what does each person do to support your recovery which of the people listed in your network make it hard for you to work on recovery what does each person do to make it hard for you to work on your recovery thinking back to when you last used drugs or alcohol which of the people listed in your network had something to do with your substance abuse what did each person have to do with your using drugs analytic strategy the first three authors conducted the data analysis responses to openended questions were transcribed and entered into a word processing program and later into atlasti where data could be coded and merged analysis was an iterative process consisting of documenting initial impressions invivo coding merging and organizing codes and developing axial codes and themes this process was guided by the constant comparison method analysts read participant responses independently guided by ideas from taylor and bogdan initial impressions were documented in the form of memos for later discussion based on these impressions and previous research on support networks an initial codebook was developed by the first and second authors each analyst independently coded participant responses the codebook was used as a guide allowing flexibility for invivo coding several new codes emerged from this process atlasti was used to merge and organize coded data the first and third authors identified and discarded redundant codes in cases where more than one code was used for a response discrepant codes were discussed and only mutuallyagreed upon codes were kept in cases where agreement could not be reached the second author served to help reach a consensus all three analysts met several times to discuss axial codes and themes each presented hisher ideas on the meaning of the data and relationships between codes reliability was established through these discussions and through a mutually agreedupon presentation of the results themes and corresponding data elements are presented below resultspart 1 positive support helpful to recovery the following are the resulting themes and corresponding data elements regarding positive support that was helpful to recovery emotional support numerous data elements were coded as general emotional support for example supports me shes been an all around support support mentally talks to me and he supports what i am going through also seven more specific subcodes emerged under the axial code of emotional support namely encouragement caring and concerned communication being there making sure praise and recognition of success for hard work and positivity these are discussed below encouragementone of the most frequently discussed forms of emotional support was encouragement women reported support in the form of general encouragement she encourages me to do my best and not give up tells me to keep up the good work and encouragement specifically related to treatment and recovery he told me i can do this that i can stay sober and clean she encourages me to stay in treatment no matter what and encourages me to go to na and aa meetings encourages me to stay clean and talk with my sponsor finally womens reports of network members encouraging comments suggested that they felt inspired encourage me that i can overcome anything and assured tells me i would be alright and …talked about my problems that im not alone caring and concernwomen in the present study spoke of network members as caring which they perceived as supportive of recovery cared enough to get me into the program is very caring …they really care they also reported that network members were concerned about them she is concerned about me further caring extended to checking on women checks on me and calls to see if im ok women also commented that supporters provided comfort he comforts me and hugs me one woman expressed that network members cared by stating that they took care of me communicationtalking and listening in person through correspondence and telephone were highlighted by the majority of women in the study talking with women during treatment and the recovery process was a predominate form of emotional support for the many of the women in the present study comments revealed that having someone to talk to was important talked to me she talks to me whenever i need it long talks and talk on the phone also women specifically reported that it was helpful to their recovery to talk with network members about their problems she talks to me when i feel down and he always talks to me about whatever im having a problem with of particular interest many women reported that they valued talk that was direct honest and held them accountable for their behaviors told me things i didnt want to hear about myself honest wme in my journals gentle but direct talks to me telling me my attitude and behavior need to change tells me what i need to hear not what i want to hear corrects me when im wrong helps me stay focused and lets me know when im slipping he gives me that extra kick in the butt when i want some weed or something these comments suggest network members were valued for their willingness to talk directly to the women about their difficulties and the need for change in their lives listening was also an important aspect of emotional support for the women in the present study supportive network members were identified as good listeners good listener when im upset as someone that listens when women have problems she listens when i have problems and as individuals that will listen and give opinions and moral support she listens gives her opinion she listens and gives feedback and she listens and gives me moral support being therewomen frequently commented that network members being there for them was viewed as supportive of sobriety is always there shes always there no matter what she is the reason i am still here supported me when they were going to put me out hes just there for me and hes always there to talk to me and give me advice hes always there to give money for personal things consistency was also reported as supportive helped save my life shoulder to cry on through good and bad times making sureresponses revealed that network members who helped keep these women on the right track were viewed as supportive of treatment and recovery for example kept asking when are you going to treatment every day and tells me off if im going to use stays with me every day to make sure im not using revealing a quality of consistent support that was initiated every day comments also revealed that network members often were perceived as making sure women have what they need makes sure i have what i need making sure they remain in treatment and keep appointments my counselor made me stay when i didnt want to be here if it werent for her i wouldnt be here makes sure to get to my appointments and meetings and also maintain their recovery makes sure i take care of my body and stay sober finally making sure extended to important daily life activities such as work makes sure i stay on top of my jobs making sure and being there reveal that some network members provided consistent emotional support to women in recovery from addiction praise and recognition of success for hard workanother category of emotional support that emerged in the present study was women in recovery reporting that network members gave them praise for their hard work and told them that they were happy or proud comments such as happy that i am sober she notices the changes tells me shes proud of me and stood up for me told me how proud she is reveal that women valued the recognition that they received from network members for their efforts to get better in treatment also women reported tells me how glad they are shes happy im here and shes happy that i am doing good revealing that women found it supportive when network members revealed their happiness gladness and joy to women in recovery positivityfinally women found it helpful to their recovery when network members were simply positive comments such as was always positive gave positive feedback tells me i look good tells me beautiful things and talks to me in a positive way support the importance of network members being positive to assist these women in the recovery process tangible help many forms of tangible help including child care a place to live and money emerged as concrete support that impacted the experience of recovery from addiction for example women reported that network members taking care of their children supported their recovery she babysits when i go to aa meetings keeps my child when i get stressed given my kids food going to buy them shoes and winter coats she takes care of my kid keeps them well and gives me information on how they are doing shelter or a place to live was also reported as important to the process of recovery let me stay with her and got me off the street put me in a hotel until i could get a place here she provides me with a place to live and grateful that she didnt put me out if it werent for her i would be using today each of these data elements reveals that women often were in need of housing while battling addiction and comorbid mental illnesses money was also reported as critical to recovery money to help with recovery was utilized in many ways giving me money to pay rent took me to dollar store and bought me personal items helps me pay my bills helps buy things for baby like diapers buys stuff for the baby pays for babysitting and bus fare finally women reported that help finding employment was important to their recovery tries to get me jobs and job search bringing personal itemsanother tangible support theme that emerged was the importance of bringing things to women while they were in treatment various items were mentioned by multiple women for example clothes blankets shoes cigarettes stamps envelopes a bible and food to name a few while many of these items were necessary to keep up personal hygiene bringing an item in and of itself was perceived as supportive many women simply stated brings me things or brings me things i need this suggested that the action of taking the time to bring things to them was an important aspect of support for the women in this study keeping in touch throughout treatmentan additional tangible support code was the importance of maintaining contact during treatment women reported that network members supported their recovery in the following ways calls and checks on me we call each other every day calls me daily and always call me every day also visiting was repeatedly endorsed as a way to maintain contact with support network members he comes to visit me and visits me at hc contact through written correspondence was a tangible support women mentioned he writes me sends cards writes encouraging letters and he writes me letters seeing her face every day is the way one woman described how a network member provided support for her recovery doing for and doing withsome data elements within tangible support were coded as doing for participants or doing with participants as both processes were suggested in the data doing for included two codes namely the frequently coded does things for me and takes care of my personal business does things for me included packed things for me when i was moving tries to do as much as he can does things for me taken me to the store took me to dollar store and bought me personal items helps me with the household chores goes to court with me arranges activities that help to distract me and she did all of my christmas shopping for me also many women commented that network members took care of their personal business particularly when they were spending time in their treatment program check my mailbox take care of my personal business for me given my kids food going to buy them shoes and winter coats and hes going to help out with my dad helps me pay my bills helps buy things for baby like diapers helps watch baby drives me to grocery store and back home and she handles my business doing with included codes such as do things together and takes me to meetings women reported that doing things with network members such as watches movies with me about recovering people and do fun things together was supportive to their recovery also doing things with women that directly supported their recovery were often mentioned such as go to aa meetings together and took me to meetings introduced me to sober people these data highlight that support network members played a key role in womens treatment process these actions also provided women support as they felt an emotional connection to individuals that did things for and with them helps me get into servicesdata specifically illustrated that network members worked on behalf of and with respondents to help them get into services shes wonderful she helped me get connected cared enough to get me into the program and they talked to a lady in their church and she told them about h c and directed me to different services informational support womens responses also focused on informational and cognitive support including teaching educating advice giving and criticism teaching specific to the disease of addiction teaching coping skills and sobriety support were part of informational support described below teaching specific to diseaseinformation about the disease of addiction and how to fight it was reported as supportive to womens recovery examples of womens responses were that network members makes me aware of what the disease does to you taught me disease of addiction how to live life without use of drugs she gave me the knowledge about drugs and alcohol and taught me how not to use on a daily basis and she teaches me how to stay clean every day teaches about bad consequences teaching coping skillswomen in the present study perceived that network members also taught them how to cope with the emotions thoughts and behaviors that surround recovering from addiction data elements suggest that social network members helped women identify deal with and express emotions helping me identify my feelings sharing about their recovery teaching me to meet life on lifes terms deal with anger …we have oneonone talks she teaches me to express my feelings and help me get in touch with my feelings okay to feel and talk… network members were also perceived as supporting women through helping them cope with their thoughts helps me with my thoughts being helped with identifying behaviors related to these difficult thoughts and emotions was important as well sort things out help me calm down when im stressed and helps me avoid triggers sobriety supportsupport specific to maintaining sobriety was commonly mentioned when discussing what helps women with their recovery women frequently endorsed this type of informational support when discussing supportive network members three codes were subsumed under sobriety support supports sobriety and doesnt support use does not use around me and helps me follow treatment program data suggests that network members communicated information that did not support substance use and endorsed the idea that staying sober would lead to a better life told me to do the right thing stay sober tells me to stay away from drugs dont useshe tells me to leave those drugs alone so you can get your baby back and encourages me to stay sober so that when he gets out we can be together sobriety support was also discussed as occurring through actions such as helping women make new contacts with people who were also in recovery introduced me to sober people and coming back into their lives when they were actively sober she stayed away while i used but shes back now that im clean shes back in my life women reported that substance using network members avoided use around them she wont drink or use weed around me anymore not using around me and doesnt drink around me this suggests that for these women having had network members that were sensitive to avoid use in their presence helped them fight their own addiction lastly helping women follow their treatment program was an important dimension of sobriety support women perceived that network members helped them follow the 12 step program helps me through my steps and keeps me sober and shes helping me through the 12 steps and pointing out to me where i need to change more generally network members provided support for treatment helps me follow my case plan read na books and counseled me counseling reading and working with women on their treatment plans were perceived as supportive to sobriety adviceinformational support in the form of advice and lecturing was reported by many women she gives me advice he gives me lectures and she gives feedback on issues more specific advice was reported by women about staying away from people that use stay away from her nephew and more generally stay away from people who use finally advice was given to women to get myself together so i can take care of my kids educatingeducating was also discussed as supportive to women gives me a lot of education lets me know what school is like and shows me things illustrates things resultspart 2 negative support harmful to recovery nearly all women described networks that included relationships that were in some ways harmful to recovery the following are the resulting themes and corresponding data elements regarding such negative support excessive worry about others while women mentioned their children as important support network members they also discussed that extensive worry about their children was not helpful when they were working on their recovery one woman reported just everything that you have to do with your kids raising them and guiding them makes it hard on your recovery because you have a full scale day they also give support another woman stated …harder to work on my recovery because im worried about my son women experienced difficult emotions knowing that they were not with their children in addition to their children women reported worrying about others in their support network more generally and how much other people needed to do for them while they were in treatment shes got so much responsibility i worry about her tangible supports harmful to recovery many of the tangible supports discussed above were also discussed as negative support that enabled women to continue using for example in regard to child care she kept my kids watched my daughter and took care of my kids while i was using and shelter supplied the place to get high and gave me place to use these situations were identified as harmful to recovery money and avenues to attain money such as prostitution were reported as harmful to recovery tricks money to use men that i tricked with and gave money to use which was a phrase reported multiple times by the women in this study unsupportive messagesinformation women reported that network members criticized them and sent messages experienced as unsupportive to their recovery some examples of critical remarks were makes me feel down and less than them putting me down…makes me feel bad about myself and negative asking why i couldnt just get a job said i could quit without coming to this program women perceived some network members actions as discouraging makes me feel i have no chance in staying sober blames me for not staying clean and not enough trust afraid of relapse afraid of my past finally one woman reported people in projects criticize you dont want you to have anything better than them… which suggested that some participants heard criticism in the communities they returned to after leaving treatment unsupportive relationships women discussed dimensions of relationships with network members that made recovery from addiction more difficult for example male network members some of whom were boyfriends come around when they were not supposed to and invited others to use with them id be not thinking about getting high hed say come on lets go even though he knew i was trying to stay straight he said if you love me youll do this and he tries to come around when he is not supposed to he is not supportive he has said he wishes i would relapse also women discussed how female friends or partners also invited using and not staying in treatment shes always calling me and asking where she can get some weed and she wanted me to drop out of my drug rehab program support network members also engaged women in remembering their traumatic pasts sometimes when they did not want to he wants me to live in the past he keeps bringing up my past my past relapses he thinks im going to fall back into the same pattern and not enough trust hes afraid im going to do the wrong thing afraid of relapse afraid of my past thus relationships with individuals that do not allow for future change may make recovery increasingly difficult for women to realize women also spoke eloquently about how network members lack of understanding made recovery difficult she is just stuck in her ways…she is angry and doesnt understand the disease not understanding why im doing this hes selfish and thinks its about him when its not and constantly come around when they know i am in recovery…they dont understand so i have to shut them out finally women discussed how relationship conflict was difficult to manage while in recovery exboyfriend…he likes to argue and puts pressure on me father of child argues with me makes me feel i am not doing my best and takes my focus we argue too much community of use data from the present study revealed that women exist within a network of complex support relationships and a dense community of drug users the data clearly illuminate the potential barriers to sustained recovery for lowincome women for example comments such as we got high together used with me mother gave me my first drink my first drug my first hit of marijuana cousin she took me out and we went to bars she be using bad makes me feel funny seeing someone else do it when im trying to recover drug associate introduced me to crack person i got high with they would drive me to get the drugs exboyfriend would come around do drugs was a dealer old boyfriends they would buy drugs for me and dad smoke with him highlight the complexity of attempting to maintain sobriety when close family and friends are engaged in substance abuse behaviors for many of these women family members and old friends in their social networks were still using another difficulty of returning to a community of use was articulated by women through statements about easy access to drug dealers and exposure to drug users in the community women reported that drug dealers came around offering to sell drugs come to my house ask if i want to buy anything and because they are close to where i live close proximity to dealers may make maintaining recovery all the more difficult women also reported that network members made it hard to work on their recovery because they allowed contact with individuals that were using he lets his weedsmoking friends come over and the dope guys come onto the pizza shop and he wont make them leave drug dealers and people using in the community make it difficult for women in recovery women also reported that network members gave them a place in the community to use gave me place to use and supplied the place to get high this revealed that women had relationships with network members that could easily provide them with a place where they could use drugs together finally women reported that within their social network and the larger community individuals were not helping them quit but instead were urging them to use for example one woman stated about a network member talked to her about using when they got done with the treatment program frequently urged me to use others reported he let me use when i was pregnant urged me to use put ideas in my head even when i was trying to stop he parties himself and so he doesnt help me much he doesnt push me much to do what is right and sister would urge me to try one line and things like that recovery from the physiological and psychological pull of addiction is difficult without these added layers of temptation which were thrust upon the women in the present study by their identified social network members discussion results of the present study extend classic social support concepts such as emotional tangible and informational support by contextualizing these types of support to the experiences of a group of women in treatment for substance use disorders further additional themes emerged in this dataset that expand our thinking about personal social networks within the context of women who have struggled with addiction and within communities associated with their addiction consistent with previous literature on social support the women in this study clearly described supportive actions of their network members that fall into the categories of emotional informational and tangible support yet some elements of support as narrated by these women appear to be unique and best understood in the context of being embedded in a community of substance use for example while emotional support was reported as consisting of the expected supportive behaviors of encouragement listening caring and consistency in relationships being there and making sure were also viewed as emotionally supportive in some ways these socially supportive behaviors can be thought of as combinations of types of support descriptions of being there and making sure combined elements of tangible informational and emotional support talks to me which was a frequently reported component of emotional support also involved giving direct advice and information further some forms of informational support such as teaching coping skills combined the giving of advice and information with recognition and validation of emotions some forms of tangible support such as took me to meetings combined elements of information and advice findings from this study are consistent with previous research documenting the positive and negative aspects of personal social networks of women in treatment and the potential roles network members may play in both use and recovery some network members and specific forms of support they provided such as tangible support were described as simultaneously helpful and harmful to recovery for example network members both took care of children while mothers used and helped care for children while mothers attended treatment programs further offering a place to stay was perceived as something that may help get someone off the streets or give them a place to use money was also a tangible type of support that was helpful to recovery as was noted above but also enabled women to use the money to get high and she gave me money to get drugs this dual role of some forms of network support highlights a potential reason it may be difficult for women particularly low income women to maintain their sobriety the data also reflect the negative impact of substance using network members and the difficulties created by conflictual relationships as suggested by lincoln for example some supportive people also created emotional strain such as excessive worry informational support in the form of criticism was described as harmful to womens recovery resulting in difficult feelings women also discussed many dimensions of unsupportive relationships and messages that were harmful to recovery negative relationships with some network members could potentially add additional stress to the process of maintaining sobriety overall these findings highlight the fact that network members actions can fulfill multiple functions and differing forms of support for women in treatment and that a variety of network behaviors are important to assess and evaluate while research has typically focused on the potential for sobriety support or overall levels of support that influence treatment outcomes recent research has begun to examine the differential impact of types and sources of support for example lewandowksi and hills study of the impact of emotional and material support on womens drug treatment completion found that social support could have positive or negative effects depending on the type and source perceived emotional support from family members was more predictive of treatment completion than material support from family members partners or government assistance programs women reporting higher levels of emotional support from friends were also more likely to complete treatment more research examining the differential impact of various types and sources of support could be helpful in informing network interventions the findings of this study suggest that we expand our thinking about the categories of social support and begin to gain a deeper understanding of the particular ways in which network members help in terms of practice implications that might be drawn from the above findings social work practitioners given their personinenvironment focus may relate to the finding that substance abusing women are often embedded in networks that help and harm them at the same time reducing contact with network members who continue to use or who are not supportive of sobriety is viewed as difficult to achieve in the context of recovery particularly when they may be family members or partners who provide other essential types of support such as child care andor transportation tangible supports like a place to use money to use and child care were discussed by women in this study as help that enabled them to continue their addiction one approach may be to incorporate strategies for helping women cope with their inevitable return to a network and community of use practitioners could routinely ask women questions about their social networks to more clearly assess what network members do to either help or hinder the treatment process another strategy may be to integrate social network members into treatment program modules in order to build on positive aspects that are supportive of sobriety while many substance abuse treatment programs find it difficult to engage family members in womens treatment the women in this study suggested a number of simple tasks such as brings things doing for and doing with that may contribute to feeling supported given the often important social functions of substance use these findings are reflective of the fact that social functions served by substance using networks need to be replaced if women are to stop use and maintain sobriety the women in this study also revealed how some network members facilitated their access to and use of helping services and encouraged them to remain in and complete their treatment program this is consistent with the networkepisode model and the crucial role of network and community ties in pathways to services talking and listening were important aspects of support for women in recovery in this study network members who were viewed as supportive of recovery were valued for their willingness to talk directly to the women about the latters difficulties and the need for change in their lives based on these findings network members might benefit from interventions in order to enhance their ability to provide support for recovery kidorf et al conducted an intervention to involve significant others in a methadone maintenance program and found that 78 of the clients who participated in the social support intervention achieved at least four weeks of abstinence women in this study responded more favorably to this intervention than did the men litt kadden kabelacormier and petry reported positive outcomes for a social network intervention in a randomized control trial their findings indicated that network support treatment to change the network from one that supports drinking to one more supportive of sobriety could significantly contribute to improved outcomes over a two year period tangible help was also valued as supportive of recovery help with child care transportation to meetings and taking care of personal business allowed women to focus on their treatment program it may be beneficial for treatment programs to facilitate such help either through incentives for family members to help in these ways or through volunteer services in a similar vein contact and keeping in touch during treatment were viewed as supportive of treatment visiting the women while in treatment was frequently mentioned as a way to stay connected with family members as well as demonstrating endorsement of the women being in treatment treatment programs might consider how best to maintain open access for family members while a woman is in treatment the women in this study reported a number of barriers and constraints in their lives in regard to maintaining sobriety upon return to the community thus a relapse prevention curriculum that considers the context of womens lives could be meaningful and relevant to their recovery study limitations the practice implications suggested above are best viewed in the context of the studys limitations these data were not analyzed to determine if dual disorder status influenced perceptions of support networks or the types of support exchanged nor were the data in this study analyzed in terms of which network members provided which types of support therefore another limitation is not being able to parcel out or distinguish support provided by family and friends versus professional counselors or therapists additionally the data were derived from a cross sectional study and therefore it was not possible to determine the ways in which support networks may change over time or the manner in which networks may contribute to treatment outcomes further generalizability is limited to women enrolled in treatment programs from one midwestern city sarason and sarason summarized the gaps in our knowledge of social support in stating that no one definition is clearly agreed upon and that the mechanisms by which social support exerts its influence and the factors that moderate its effectiveness are not fully understood future longitudinal research therefore should examine changes in social networks and social support over time in relation to a variety of outcomes in addition research should examine types of support including multiple or blended forms of support provided by different network members and be able to identify differences in support provided by informal and professional helpers more intervention research is needed on the sequence and intensity of social network interventions including the method and timing of delivery such research could identify and examine differential outcomes of various types and sources of support we also need more information on whether network interventions need to be matched to the stage of treatment or stage of change for example perhaps certain types of support may be found more or less helpful depending on the stage of treatment or recovery in spite of these needs the nature of the qualitative data collected do offer us a more nuanced reflection of categories of social support and direct our attention to practice approaches that may lead to optimal community integration and a more enduring recovery for women with substance use disorders note numbers of disorders do not add to 100 because women may have had more than one disorder conclusion appendix a 1 conceptualization of data for views of social support for women in recovery

using a personal social network framework this qualitative study sought to understand how women in substance abuse treatment describe their network members supportive and unsupportive behaviors related to recovery eightysix women were interviewed from residential and outpatient substance abuse treatment programs positive and negative aspects of womens social networks were assessed via openended questions analysis was guided by grounded theory techniques using three coders the findings extend classic social support concepts such as emotional tangible and informational support practice implications are presented in light of the potential roles network members may play in substance use and recovery

paradox family firm literature review contradiction innovation entrepreneurship learning succession the paradoxical nature of organizational life has been widely discussed in business and management since the mid1980s and paradox remains an important source of management insight paradox is generally understood as contrary or even contradictory propositions which are driven by apparently sound arguments organizational paradoxes include a wide variety of contradictory yet interwoven elements perspectives feelings messages demands identities interests or practices that arise from actors attempts to make sense of an ambiguous world unlike theoretically simpler kinds of organizational problems which disappear after an appropriate solution is implemented paradoxes cannot be made to vanish even to try would be counterproductive because it would suppress the gains that result from appreciating both sides of an enduring contradiction instead managing paradoxical tensions involves acknowledging complex links between opposing forces this gives meaning to apparent contradictions and allows people to cope with them indeed coping reflects the original meaning of management rather than the modern connotations of planning and control all firms family and nonfamily are subject to these contradictions but combining the features of family and business two unlike systems makes family firms more difficult to manage early researchers noticed this for example tagiuri and davis and stafford et al who pointed to family firms bivalent attributes which lead to both advantages and disadvantages moores and barretts 2002 book learning family business paradoxes and pathways broke new ground in its focus on the paradoxes that aspiring successors confront when learning to lead family businesses they discussed not just what paradoxes arose from combining family and business but how these differences created special learning paradoxes that those seeking family firm leadership needed to cope with the value of paradox for understanding family business has persisted indeed family business review the preeminent journal in the field was founded with the aim of better understanding the paradoxes faced by the owners and managers of family enterprises nevertheless so far as we know there has been no systematic literature review since moores and barrett that would give a comprehensive picture of the paradoxes inherent to the nature of family businesses and the paradoxes of managing them the key contribution of this paper is thus a systematic literature review of 203 items informed by the what and the how of family business paradox in the 17 years since then this commentary is structured as follows first we briefly recap the 4ls framework then explain the method used to review the literature the results concerning each items geographical context its basic approach and what it said about paradox are available at appendix 1 we then present the two broad themes our review revealed paradoxes arising from the nature of family firms ie what paradoxes and the paradoxes of managing them ie how paradoxes we link both themes to the 4ls model often confirming it but sometimes showing where it is deficient the next section examines new and interesting research questions which arise from looking inside the model and looking outside it moores and barrett developed the 4ls model via a qualitative study which sought to understand how leaders of family firms learned to manage the special complexities of family firms analysis of 17 such cases in australia across a variety of industries showed how combining family and business led to unique paradoxes in what future ceos must understand and do to become competent to lead family firms findings were summarized in four sequential learning phases the 4ls in brief l1 learn business in l1 future leaders acquire skills to develop the firm a difficult task if undertaken only inside the family firm they need to gain experience outside it to view it critically and demonstrate to themselves and family members that they are capable businesspeople its paradox encountering change reveals tensions between old and new moreover successors who leave the firm may create a satisfying career outside and never return threatening the incumbents goal of keeping the business in family hands finally choosing a leader from the family means a much smaller talent pool compared with nonfamily firms its priority business proficiency both personal and technical is the l1 priority personal skills of discipline selfawareness and selfmanagement are even more important than the technical skills of business and the pathway through it gaining outside experience is so important that successors go outside anyway l2 learn our family business in l2 future leaders learn our business the special qualities of this particular family business this is the obverse of l1 l2 often starts very early via stories passed down from earlier generations so its lessons are reinforced by emotion however they can also create dangerous inertia its paradox l2 demands that future family firm leaders appreciate the special qualities and broad strategies of the family business but do so critically and with an eye to necessary change so the l2 paradox is to continue differently its priority l2s priority is to perpetuate values that is create a sense of continuity so that despite change family members and customers see the firm as the same family business it often turns out that family firm values also have market value another paradox its pathway the pathway through the continue differently paradox is to keep the businesss principles and philosophies and discard outdated detail l3 learning to lead our family business family firm leaders need to take a helicopter view of the firm and understand its position in its lifecycle with growth it is often necessary to professionalize the firm its paradox professionalizing the family firm requires formal informality to manage lewiss paradox of organizing simultaneous demands for control and flexibility unlike nonfamily firms leaders must preserve the family qualities of commitment and trust while gradually introducing more formal controls its priority family firm leaders need perspicacity to balance formal and informal controls its pathway the pathway through the informal formality paradox is to professionalize the firms strategy structure and systems using a light touch l4 learning to let go l4 is often difficult because it can mean loss of identity and purpose for the incumbent while realigning organizational goals it occurs more rarely than in nonfamily firms and is more likely to include ownership as well as management transfer letting go creates a belongingness paradox whereby the incumbent must help the successor to do things differently partly by getting out of the way …its paradox learning to let go is paradoxical because family firm leaders must anticipate what the firm will need when they are no longer leading it in short they lead in order to leave its priority the priority of the l4 leader is prescience anticipating their own future needs and smoothing the successors pathway to leadership its pathway to carve a pathway through these tensions family firm leaders develop a timeline for retirement create management development systems then stick to the plan figure 1 presents these phases at their simplest place figure 1 about here our identification of distinctive paradoxes that prevail in the context of the learning journeys for aspiring family business leaders now calls for a review of the subsequent literature to distil the nature and form of family firm paradoxes especially those associated with successor development method to explore current state of the field following tranfield et al we first defined the topic and corresponding keywords articles and other items were sought where family business family control family firm family led or family own appeared in the title abstract keywords or references these terms were combined with paradox or contradict and learn appearing anywhere in the text adding asterisks to the search terms caught variations such as family owned and family businesses we sought peerreviewed items including articles research notes working papers books conference papers and full papers we also wanted to see how nonacademic sources such as the business media and management blogs have treated paradox so we added these source types we achieved a broad search by applying this protocol to the proquest central database which searches six different databases and the sage database which covers several journals important for family business research not covered by proquest central including family business review and entrepreneurship theory and practice items in languages other than english and duplicate items were excluded each items abstract and full text were read to ascertain their topic fit their references were also checked and promising items read because moores and barretts book was published in 2002 we included results from 2003 onwards we sought out the most recent research by checking the citations of key articles and researchers publication lists the first author evaluated all the items sending the other author a written summary of each including a justification for including or excluding the item we discussed any disagreements and negotiated a consensus applying this method yielded 203 papers we collated the items basic method and geographic focus to give an overview of the type of study and because knowing the cultural context of a piece of research aids in understanding the findings we then coded the items via a content analysis for each item we noted what topic or problem was linked to paradox for example innovation firm reputation succession governance tax law and so on there were numerous such topics and problems these will be discussed in the next section despite their variety we could readily classify them into two broad categories paradoxes arising from the inherent features of family firms which are sources of tension coded as what paradoxes and paradoxes that were apparent in how families seek to cope with or manage these paradoxical tensions coded as how paradoxes themes emerging from the literature review ingram et al was particularly influential in our analysis of themes emerging from the results the authors focus on innovation in family firms in the context of family firm paradox endorsing schuman et als view that three broad paradoxes characterize family firms tradition versus change family liquidity versus business growth and founder control versus successor autonomy they use the family business and organizational paradox literatures to develop measures of paradoxical tensions and paradoxical thinking in family firms applying these measures in a multistage exploratory study revealed that paradoxical tensions may stymie innovative behavior but leaders paradoxical thinking is positively related to innovative behavior ingram et als finding that paradoxical thinking enables positive behaviors and paradoxical tensions reduce them resembles our twoway grouping of what paradoxes and how paradoxes nevertheless their assertion that there are only three broad family business paradoxes seemed surprising given the large number of apparently contrasting paradoxical topics and problems that emerged in our analysis accordingly we compared our what paradoxes and how paradoxes with both the 4ls and the three basic paradoxes of family business discussed in schuman et al and ingram et al see what is paradoxical about family business table 1 shows that the three paradoxes finding of schuman et al andingram et al has some justice our what paradoxes all map onto one or more of their three basic paradoxes for example litz discusses the paradox of conformity vs nonconformity the doublebind message sent out by family business owners to their children entrepreneurial ideology encourages children to make their own way in the world but family business ideology often encourages subservience and obedience hjorth and dawson refer to the same paradox as the impossible gift of succession these papers and many others are commensurate with ingram et als founder control vs successor autonomy paradox the paradox of entrepreneurial success discussed by wasserman and zhao et al arises in family firms because founders typically have long tenure and are likely to develop a strong commitment to existing strategies a possible source of strategic inertia again the likely result is that family firms will tend to maintain tradition and resist strategic change similarly the initiative paradox was originally discussed by campbell in the nonfamily firm context but has been applied to the family complex by marler who studied personality incongruences between ceos of family firms and successors a typicaland nonparadoxical personality incongruence arises when a proactive incumbent has difficulty persuading a more passive successor to take over family firm leadership but a paradox arises when the incumbent and the likely successor have similar proactive personalities proactive leaders expect their followers to have expanded role definitions and to take initiative as they would themselves proactive individuals tend to define their roles broadly and proactive aspiring successors may take on roles beyond their formal job descriptions incumbents may see this as too much initiative leading them to actually reduce the successors discretion despite wanting to hand over leadership again the likely result is less strategic change consistent with the tradition vs change paradox lin and wang who studied the speed with which serial entrepreneurs start new ventures following failure suggest that the embeddedness paradox1 might explain why family involvement does not expedite reventuring the embeddedness paradox refers to the riskaversion created in successors by highly entrepreneurial founders successors fear that if they take risks they may waste the resources the founder built up for the famiy 2 fear of wasting these resources would encourage family firms to keep to their traditional products and methods consistent with the tradition vs change paradox and reluctant to grow as predicted by the family liquidity vs business growth paradox several authors discuss the ability vs willingness to innovate paradox notably casprini chrisman et al de massis et al and de massis et al it refers to the finding that family firms have superior ability yet lower willingness to engage in technological innovation causing differences in behavior and performance between family and nonfamily firms as well as among family firms family firms have superior ability to direct resources towards innovation given their personalized control low levels of formalization and bureaucracy longterm investment horizons patient capital altruism and interest alignment between owners and managers however innovation also entails significant risk requires a strong commitment of resources takes time to produce tangible outcomes and can lead managers to operate in domains where results are unpredictable and the need for external resources is greater accordingly family firms are typically seen as less willing to innovate through riskaversion lack of the requisite skills within the family and reluctance to share control with nonfamily managers who do have the skills they have a particular comparative disadvantage for more radical innovations because reflecting the paradox of entrepreneurial success they may be overly committed to their traditional products and prefer to minimize the need for external financing the ability vs willingness to innovate paradox thus aligns with all three of ingram et als basic paradoxes thus far we have discussed the what paradoxes revealed by our literature review that is paradoxes arising from the idiosyncratic features that result from combining family with business each leads to reinforces or at least resonates with one or more of ingrams three basic paradoxes however the how paradoxes those that concern how leaders cope with these paradoxical features are not so readily reducible we identified many how paradoxes some such as the roots and wings paradox were related to learning and successor commitment and competence others deal with managing chaos innovation and perpetuating values they present ways of managing the what paradoxes the tensions or contradictions that make family businesses complex and hard to manage we first consider how paradoxes that link to management learning frameworks or concepts then frameworks from nonlearning fields such as institutional logics and innovation strategy how to manage family business paradoxes a paradoxes from management learning frameworks garcia et al present a pathway through litzs paradox of conformity vs nonconformity if they are to persuade nextgeneration members to join the family firm parents must embrace the classic roots and wings paradox simultaneously imbuing in their offspring a feeling of belonging and the confidence to fly independently deep roots without wings cause a lack of selfconfidence that binds nextgeneration members to the family firm but equally strong wings with shallow roots encourage them to fly away from their family firm the roots and wings paradox resonates with l1 successors must go outside yet appreciate the special qualities of the family firm enough to return garcia et al theorize the indirect influence of perceived parental support and psychological control on nextgeneration engagement through the mediating variables of selfefficacy and commitment to the family business dhaenens et al suggest that mentoring particularly by a family member produces the necessary affective commitment and sometimes even normative and continuance commitment mentoring helps potential leaders move from l2 to l3 by increasing their willingness and competence to lead the family firm in addition successors are likely to be attached to a family business mentor when they go outside as part of l1 learning business preparing them for l2 learning our business the chaos creates continuity paradox comparatively few researchers explicitly discuss paradox in successor learning but there is evidence of the informal even chaotic way family business management is learned that supports moores and barretts findings that the process is highly paradoxical konopaski et als study of 18 respondents from canadian family businesses shows how continuity is created by chaos continuity involves balancing tradition and change through a learning process that is uneven nonlinear and unpredictable despite this dealing with one problem after another by combining past and present knowledge creates continuity a clarifying pathway which enables family members to cope with a welter of prevailing paradoxes continuity is achieved by continuing differently at l2 and informal formality at l3 professionalizing the firm while preserving the informality of family coparticipation the paradox of formal international business education while much l2l3 learning inside the family business could be expected to be chaotic and subject to paradox one would expect formal international study of business outside the family to be less paradoxical firm owners often nudge their offspring to study in fields relevant to the family firm hoping they will equip themselves with relevant technical skills it is common in korean singaporeanchinese taiwanese and pr china firms that aspiring successors undertake formal business training overseas not necessarily in western universities alone korean chaebol owners have sent their offspring to prestigious japanese universities due to the colonial economic and cultural links with koreas former colonizer zhao et al explored the extent to which the international education of successors of publiclylisted family firms in pr china a transitional economy equips them with a different cognitive outlook compared with their predecessors and whether international education influences the level of strategic change important in a transitional economy in a postsuccession firm they found that strategic change was likely following succession and that successors with international education undertook greater strategic change than those without few founders had any international education experience in contrast to most successors of these some had graduated from elite universities and others from lower status institutions strategic deviation in postsuccession firms was significantly positive when the successor had received education from a foreign elite university but successors with an elite domestic university or general university experience abroad made less adventurous strategic choices thus less welleducated successors appear more conservative and more cognitively embedded in local kinship networks than their nominally better educated counterparts there was a significantly negative relationship between strategic change and financial performance in the two years following succession echoing findings in oecd contexts that foundermanaged firms frequently outperform family successormanaged firms this might have been because two years was not long enough to determine the eventual effects of strategic changes or a result of the continuing influence of founder strategies in addition some senior executives are overconfident which especially when combined with undue optimism lowers firm revenue growth in contexts of high environmental dynamism and is associated with higher firm failure rates most importantly from a 4ls perspective elite internationallyeducated successors may become relationally disembedded from valuable local networks which are vital assets in transitional and emerging economies zhao et al warn against essentializing tendencies in much family firm research perspectives such as agency theory and sew which often overlook the effects of the cultural and institutional context on family firm behavior less wealthy chinese successors including those in rural areas increasingly use online business training resources to supplement their informal learning this would prevent international business training from interrupting relational onthejob business learning it would be paradoxical if chinese successors to top firms through elite international training actually ran more risk of disrupted learning than their counterparts in china and elsewhere zhao et als results remind us that the 4ls model should be used with due attention to the cultural and institutional environment blancomazagatos et al examine formal human resource practices in family firms both skillenhancing and motivationenhancing they wanted to know whether the two types of practices differentially affected family and nonfamily employees organizational human capital their study of 707 unlisted spanish family firms showed that skill and motivation practices enhanced the ohc of both types of employee however only motivationenhancing practices not skillenhancing practices continue to enhance family employees ohc over successive generations the authors posit that in a family firms early development family members are motivated to obtain skills to further family goals even without skillenhancing or motivationenhancing practices with succeeding generations however entering the family firm becomes more competitive amongst family members because there are more of them and because the firm does not need to hire them all this makes skillenhancing practices attractive to family members but only until they enter the firm after that the easier criteria for compensation or promotion for family employees compared to nonfamily employees mean family employees tend to receive these benefits without acquiring further skills the effect of motivationenhancing practices for family employees is not eroded over the generations in this way the training reduces learning paradox the study reinforces the value of the formal motivation and skillenhancing hr practices that according to the 4ls are part of l3 professionalization however unless the firm avoids bifurcation bias that is treating nonfamily employees less favorably than family employees skillenhancing practices will be less effective with family employees than with nonfamily employees particularly over successive generations if formal entry requirements also apply to potential successors formal hr practices strengthen the 4ls norm that leaders gain business and personal proficiencies before they take their first inside role the family vs human capital paradox ahrens et al touch on successor learning via an investigation of the impact of human capital on postsuccession firm performance they examined the apparent contradiction between empirical findings that predominantly document inferior performance of family ceos postsuccession and the theoretical literature that predicts positive effects of family involvement in their study of postsuccession performance in 804 german family firms of between 30 and 1000 employees they disentangled the family member attribute of the ceo from other attributes such as ceorelated human capital factors positively linked with postsuccession firm performance included the ceos business education industry experience age leadership experience and use of a business plan during the succession furthermore successors who rejected the status quo had better postsuccession firm performance their results support the idea that family business leaders whose firms perform well postsuccession follow the 4ls development trajectory particularly l1 to l3 acquiring businessrelated knowledge through outside experience coincides with the l1 priority identifying familymember attributes that grant access to specific knowledge values identity and vision is consonant with l2 the finding that firms whose successors reject the status quo perform better suggests that successful family successors not only learn from prior generations but continue the firm differently two recent empirical studies of family social capital sanchez et al and herrero and hughes investigated its paradoxical nature that is its capacity to have both positive and negative effects family social capital refers to the internal bonding resources available through family linkages both studies looked at the differential impact on firm performance of nahapiet and ghoshals three dimensions of fsc structural fsc relational fsc and cognitive fsc using configuration analyses of two large samples of us family firms sanchez et al found three clusters of family firms firms with instrumental identifiable and indistinguishable fsc successors in firms with the highest level of fsc had significantly enhanced outside experience compared with successors in firms with lower fsc the instrumental fsc cluster had the highest levels of all three types of fsc but had less structural fsc than cognitive and relational fsc the value of fsc seems to lie primarily in its relational and cognitive dimensions herrero and hughes support this tentative conclusion they examined the effect of the three dimensions of social capital on the roe of spanish family firms in the manufacturing sector relational and cognitive fsc significantly enhanced family firm financial performance but structural fsc increased financial performance only up to a threshold then decreased it these findings resonate with the 4ls at high levels structural fsc can trap the family firm in its established networks blocking the entry of new knowledge to counter this potential leaders need to go outside andor their leadership preparation must include outside networks moreover the positive effect of relationship fsc reinforces the pathway through l3 informal formality ie informal practices that promote familybased trust and communication finally the positive relationship between cognitive fsc and firm performance is consistent with l2 valuing values of the family business and family members shared understandings the manage chaos with simplicity paradox this is the obverse of the chaos creates continuity paradox pieper et al examine a salient source of family firm complexity even chaos the presence of at least two unrelated founding families if combining one family with business adds management complexity we would expect firms run by two or more unrelated families to be even more complicated the authors studied five multifamily businesses of between 200 and 5000 employees which had persisted for two three or four generations instead of managing complex problems through complex structures and processes the firms used simple rules imprinted by the founders the simple rules related to executive formation and decisionmaking boundaries executive formation comprised two principles a family member skills and b openness to outsiders as leaders the decisionmaking boundaries rule meant broad decision parameters not detailed planning or reliance on consultants in 4ls terms the executive formation rule reflects commitment to developing successor competence in l1 l2 and l3 requiring family members to have either extensive outside experience or divisionlevel leadership experience echoes the l1 pathway go outside only divisionlevel internal experience which would require external networks can replace outside learning staying open to outsiders as leaders also brings external knowledge into the firm finally broad parameters not detailed planning echoes l2 pass on principles and philosophies not the details the innovation through tradition paradox erdogan et als study of eight longlived turkish family firms found four ways to manage the willingness vs ability to innovate paradox the legacy of previous family generations imprints two different approaches to both tradition and innovation the preservation approach to tradition denotes firms where the family is committed to the founders values beliefs and craftsmanship conversely the revival approach to tradition characterizes firms where some elements of familial tradition have faded over time regretting this firms recover past elements to revive tradition concerning innovation firms may adopt a segregation approach distinguishing iconic products from new products and processes or an integration approach protecting the essence and reinterpreting traditional products through innovation all four approaches resonate with our l2 pathway keep the philosophies and principles but innovate by discarding outdated detail the perpetuating values damages the firm paradox kidwell et al also focus on the imprinting process passing values from earlier generations to later ones however they sound a darker note drawing attention to the halo effect around organizational learning the authors argue that excessive parental altruism and early imprinting of values of such as entitlement and a sense of injustice create negative damaging behaviors this reveals a gap in the 4ls we like many researchers tended to overlook the downside of learning organizations and perpetuating values how to manage family business paradoxes b paradoxes from institutional theory and innovation strategy the what paradoxes of family business include willingness vs ability to innovate mazzelli et al working from an institutional theory perspective present ways of managing this paradox which are themselves paradoxical their study of the product innovations of spanish manufacturing firms between 1998 and 2012 found unexpectedly that family firms showed higher levels of innovation output than nonfamily firms when the decision to introduce new products was perceived as socially desirable that is when their peers were doing the same family firms desire to preserve social wealth leads them to follow this conformityindistinctiveness rationale in contrast to nonfamily firms which seek positive recognition from distinctivenessinconformity paradoxically then the desire to conform to norms fuels innovation in family firms other articles positing ways to manage the ability vs willingness to innovate paradox include gómezmejía et al who challenge the assertion that family firms are riskaverse they reframe the concept of wealth to include socioeconomic wealth a frequent feature of family firms to preserve sew family firms may be riskwilling and riskaverse at the same time their study of 1237 familyowned olive oil mills in southern spain confirmed avoidance of sew as these firms primary reference point to avoid such losses family firms accept a significant risk to their performance yet simultaneously avoid risky decisions that might aggravate that risk this study confirms the l2 pathway keep the philosophies and discard detail the successor commitment or successor competence paradox richards et al use institutional theory to explore another type of ability vs willingness paradox for incumbents finding a family successor who is both highly committed and highly competent commitment to continuing the family business is limited because a career in family firm leadership competes with other attractive options outside equally not all potential successors are equally competent finding a family member who meets both requirements is often difficult requiring the incumbent to compromise richards et al examined reactions from 1060 family firm incumbents to a case vignette to see whether their relative exposure to two different institutional logics family logic and business logic shifted their preference for a successor lacking either high competence or high commitment the vignette manipulated firm performance half the incumbents imagined that their firm was performing below the industry average and half that it was performing above average a priori incumbents preferred a family successor but had no clear preference between competent and committed successors however their relative exposure to family or business institutional logic and their perceptions of higher or lower firm performance shifted their preference towards a highly competent successor and a highly committed successor results for cultural embeddedness were not clearcut but appeared influential incumbents from italy which places strong value on family would not forgo benefits from competence but preferred a committed successor much more than incumbents from frenchspeaking regions where familial preferences are lower the successor commitment or competence paradox echoes the l1 paradox going outside may turn into an attractive career which means the successor never returns our l1 pathway go outside anyway focused on the successor richards et al broaden this by examining the incumbents view of the l1 paradox research focused on hybrid organizations and industries suggests still other explanations of how family firms manage the paradoxical outcomes of competing institutional logics for example yan et al examine socially responsible investing in the asian financial sector particularly how financial logic both provides the means to found novel socially responsible financial ventures and enforces profitmaximizing financial ends the outcome is that the founding of sri funds has a curvilinear inverted ushaped relationship with the prevalence of financial logic in society alternative logics those of unions religion and green political parties moderate these effects by applying the 4ls with due attention to prevailing cultural and institutional logics future researchers could examine how shifts in the strength of financial institutional logic affect how leaders shape family firm goals over time eg regarding the balance between economic and socioemotional wealth de massis et al developed the familydriven innovation framework highlighting the need for consistency between a family firms idiosyncrasies and its innovation strategies paradox is apparent in that the family firms idiosyncrasies yield continuity in the form of innovation strategies osnes et al also consider how paradox generates strategies they consider a range of choices arising from the ability vs willingness to innovate and founder control vs successor autonomy paradoxes safety or loss of attachments a stable notion of self or grasping new opportunity own drive or dependency on others using interviews with family members and nonfamily employees of firms in a range of countries they show how strategy formations such as succession cluster ownership stewardship and new business models are negotiated pathways to further research extending the 4ls model our literature review shows that the 4ls are confirmed by or at least resonate with many family business debates and findings the how paradoxes in contrast to the what paradoxes are not reducible to a small number of basic paradoxes they echo our insights into the paradoxical aspects managing family firms and point out new ones some broadly confirmatory findings nevertheless suggest modifications to the original 4ls pieper et als finding that holding a divisional leadership role can offset lack of external experience and ahrens et als finding that both external and internal experience enhance family ceoled postsuccession firm performance indicate that the l1 pathway needs expanding go outside could be partially replaced by developing outside networks however relying on family networks alone to source outside knowledge is inadequate our literature review results also suggest how the 4ls model might be extended one kind of extension to a model or theory arises when revisiting its components suggests their potential might not have been fully exploited another type arises when a model points beyond its primary construct to suggest linkages with other areas frameworks or issues that are strictly outside it but lie adjacent to its domain linking the model with adjacent frameworks may suggest new mutually informative research questions advancing the conceptual development of both models or suggesting ways to test them empirically yet another way is to consider possible modifications required by different cultural or institutional environments we do all of these in the following sections looking inside the 4ls 3 learning between phases in the 4ls successors encounter a specific paradox within each of the models four developmental quadrants and learn to manage it thus the 4ls model implicitly locates successor learning only within the four phases the arrows in figure 1 point simply to the theoretical sequence in which successors can be expected to encounter and learn to manage a specific paradox however table 1 suggests that learning also happens between successive developmental phases enabling innovative action suggests moving from merely acknowledging tradition and the need for change towards implementing paradoxical strategies at l3 at l3 the leader exercises informal formality maintaining informal family controls while establishing the formal controls needed in contemporary contexts the family liquidity vs business growth paradox may also appear when the leader moves between l2 and l3 and a similar bothand approach is needed while reinvesting profits enables more aggressive growth leaders must also accommodate some family members needs to receive dividends finally family business leaders often struggle to move between l3 learning to lead and l4 learning to let go founder control vs successor autonomy tensions are played out when leaders stay and inhibit the next generations autonomy specific examples of learning pathways between not only within the 4ls phases include mitchell et al who developed the construct of successor discretion to test how likely successors were to exercise entrepreneurial agency following succession their results present a pathway through founder control vs successor autonomy specific successor characteristics tolerance of ambiguity locus of control cognitive complexity professional aspiration power base and political acumen increase their discretion whereas a successors commitment to an existing course of action or a former incumbents attempts to maintain control hinder it business factors including wealth preservationbased inertia and familiness that is the unique bundle of firm capabilities and resources created by family involvement familiness is paradoxical it can affect the firm both positively and negatively according to mitchell et al preservationbased inertia and familiness reduce successor discretion and heighten the negative effect of successor commitment in line with its paradoxical nature however familiness could be expected also to increase successor discretion by magnifying the positive effect of a successors political acumen we could test both mitchells propositions and the 4ls model by investigating whether a successor who had developed confidence selfefficacy and legitimacy as a result of going outside the firm andor previous seniorlevel involvement in it has higher successor discretion evidenced in their undertaking more adventurous strategic change following succession combining learning phases combining learning phases into larger units also yields new insights and questions consider figure 1 again combining l1 learning business with l2 learning our business suggests an apprenticeship learning phase cognitive apprenticeship theorists refer to socialization as a process of acquiring skills and values relevant to ones society or profession combining the longterm focus common to l3 learning to lead our business and l4 learning to leave our business suggests a stewardship phase much has been written about family business stewardship but less about apprenticeship an exception is le bretonmiller and miller who show how apprenticeship learning lays the foundation for stewardship in 4ls terms l1 l2  l3 l4 another way to combine the elements of the 4ls is to consider what all four mean cumulatively theories of expertise and its acquisition have been developed in fields from sports to creative arts to medicine we know for example that experts are better problem solvers than novices because they hold a large amount of organized domain knowledge that reflects deep understanding experts organize their knowledge around core components in contrast to novices who organize knowledge as a list of facts formulas or heuristics the expertise acquisition literature suggests that progressing through the 4ls l1l2l3l4 is like attaining expertlevel understanding for example novices rely on lists of facts and textbook heuristics and often display anchoring biases in their efforts to master the information that their inquisitive but laborious searches unearth experts develop through progressive problem solving and experiential learning eventually enabling very fast decisions that proceed from expert intuitions between these two extremes successors develop insights and apply them via innovative processes figure 2 illustrates the extensions to the 4ls that arise from combining its elements in new ways place figure 2 about here however even experts are subject to error eg through contextual effects and other sources of cognitive bias the benefits of expertise are less pronounced when solving problems with higher initial structure experts make some types of error more than novices when factors that supported their expertise such as good eyesight decline the expertise literature suggests many analogous research questions to extend the 4ls for example we could ask what types of contextual bias reduce incumbents expert intuitions and insights what prompts incumbents to reduce their involvement in daytoday firm tasks and what business problem structures benefit most from former incumbents input looking outside the 4ls we now look outside the 4ls linking it with some adjacent frameworks suggested by our review effectuation and new venture creation bases of successor commitment and strategic narratives linked with institutional logics just as when we looked inside the 4ls we consider the compatibilities of these outside concepts with our model and generate new research questions effectuation and new venture creation for nearly 20 years sarasvathy has examined how expert entrepreneurs think when they create new ventures her research has led to a new process view of entrepreneurship effectual reasoning dew et al found that the thinking processes of mba students and expert entrepreneurs differed starkly compared to novices expert entrepreneurs used more effectual reasoning specifically they placed more emphasis than novices on  transforming means at hand into new outcomes  beginning with a given set of means and focusing on generating new ends  choosing projects according to what they could afford to lose  building partnerships early  opening themselves up to surprises hayton et al found that family firms consistent with their reluctance to innovate their conservative approach to debt and the entrepreneurs embeddedness in a family are somewhat more likely to follow effectuation processes and significantly less likely to follow causation processes during new venture creation their new ventures are less likely than those of nonfamily firms to arise from a sudden stroke of insight possibly reflecting the more limited knowledge available via family networks nevertheless pwcs latest global market survey indicates that 25 percent of next generation family business members also started their own company and our review found many items about passing on an entrepreneurial legacy these empirical and conceptual links suggest that the 4ls and the adjacent issue of new venture creation by family businesses are at least mutually informative investigating whether successors with longer outside experience use more radical strategies could test hayton et als contention that relying on family networks reduces family firms propensity to create ventures based on new insights sharma and irving in an influential conceptual paper posit four commitment mindsets which prompt people to join their family businesses namely  affective commitment individuals perceive an alignment between family business opportunities and their personal identities and career interests  normative commitment individuals feel obliged to join the family firm out of a sense of loyalty  calculative commitment individuals join to avoid perceived financial andor social opportunity costs  imperative commitment individuals join the family firm through a perceived lack of career alternatives bases of successor commitment one could investigate possible links between the bases of successor commitment and an individuals preceding or subsequent engagement with the 4ls phases individuals who join their family firm out of affective commitment ie a sense of personal identity and anticipated job satisfaction could be expected to be intensely involved in the l1 l2 and l3 phases but to have difficulty at l4 learning to let go imperative commitment by contrast could arise from failure to engage in l1 outside learning we saw earlier that having family members mentor potential successors heightens successors leadership competence and commitment especially affective commitment so we could also examine how mentoring by family members produces affective commitment and whether different types of commitment are mediated by successors perceptions of their own competence richards et al discussed the compromise between commitment and competence the incumbent has to make if an ideal successor is not available but we also know from dalpiaz et al that wouldbe successors use specific narratives to sway the incumbent and other stakeholders in their favor their repertoire may include narratives aimed at changing stakeholders perceptions of unfavourable institutional logics and firm performance successors strategic use of narratives also suggests a test of the relationship between political acumen and successor discretion wouldbe successors whose narratives changed stakeholders views could be expected to show more political acumen those whose narratives failed would show less returning to the bases of commitment we could ask how normatively influenced but still reluctant potential successors use narratives strategically to reduce incumbents desire to appoint them successors strategic narratives and institutional logics in table 2 we suggest some of the many possible paradoxinspired research questions we see emerging from our what and how themes especially those motivated by extensions to the 4ls whether from inside the 4ls framework or from adjacent frameworks place table 2 about here as our literature review showed the 4ls align with how rather than what paradoxes and this is reflected in table 2 however the what paradoxes also generate a plethora of new research questions some arising directly from an inherent feature of family business others focusing on how to manage them conclusion our review and ensuing commentary followed established good practice for conducting systematic literature reviews by adhering to these procedures and defining keywords carefully we are confident that it encompasses the literature from 2002 to the present and shows the progress of family firm research on family firm paradoxes since our first book briefly revisiting the original 4ls reminded us of its paradoxes priorities and the pathways successful ceos devised to cope with them subsequent conceptual and empirical research confirmed our original model of how members of family firms manage the special nature of family business and revealed some deficiencies both confirmations and deficiencies suggested how the 4ls could be extended whether by looking again at its internal components or looking outside it at adjacent frameworks and concepts further research questions emerged from this we are reminded of the paradox of knowledge the more we know the more there is to know we invite future researchers to join us in continuing to use paradox to critique and expand current ways of understanding the 4ls and other models of family business including via the research questions in this paper doing so will help us learn more and create more to know figure 1 the 4ls of family business source adapted from moores and barrett learn to lead our business learn to let go business learn business learn our business learning between phases what learning happens between successive developmental phases how do family business leaders at l3 innovate and manage paradoxical opposites when moving from acknowledging tradition and the need for change successor discretion what specific forms of strategic change are associated with greater successor discretion how likely are successors to be able and willing to exercise discretion through entrepreneurial agency following succession how likely are successors who have developed confidence selfefficacy and legitimacy from going outside the firm andor previous seniorlevel involvement to display higher successor discretion evidenced by more adventurous strategic change initiative and embeddedness what are the consequences of the initiative and embeddedness paradoxes in family firm successions how do families cope with these paradoxes maintain tradition change or adopt paradoxical thinking and continue differently development of innovation strategy what individual and firm abilities are needed to foster willingness to innovate how do families cope with the uncertainty and time demands of innovation for example are family firms longterm investment horizons and patient capital used to manage the time needed to produce tangible outcomes from innovation how can the continuity qualities of family firms be used to develop more radical innovations expertise what novicelike behaviors do aspiring leaders display as part of their inquisitive forms of learning what expertlike behaviors do family business leaders exhibit what decision types or errors trigger l4 learning eg incumbents recognize the need to step back from daytoday tasks how are inquisitive forms of learning used to transcend novicelike behaviors at l1l2 how do problem solving and experiential learning eventually enable very fast decisions proceeding from expert intuitions at l4 how can the expert insights of former incumbents be used to assist successor learning outside 4ls effectuation and new venture creation which venture creation strategies are used more by successors with longer outside senior internal experience than by less experienced successors how are effectuation and causation principles absorbed during each of the 4ls bases of successor commitment what is the relationship between the bases of successor commitment and an individuals preceding or subsequent engagement with 4ls learning how and when does mentoring by family members produce affective commitment to what extent are different bases of commitment to joining the family firm mediated or moderated by successors perceptions of their own competence institutional logics which institutional logics shape the formation of family firm goals over time how do shifts in the strength of financial and other institutional logics affect how successors shape and implement competing family firm goals eg financial and socioemotional wealth strategic narratives which narratives of aspiring successors aim to change stakeholders perceptions of institutional logics andor firm performance which narratives of reluctant successors aim to discourage incumbents from appointing them how are successors use of narratives and their political acumen related firm structures which structures are distinctive features of family firms how are firm structures used to manage aspects of family firms internal and external environment how are family firm structures linked to simple rules for managing complexity do some simple rules lead to complex rather than simple structures and processes

the purpose of this article is to review and comment on the literature on family business paradox against the backdrop of moores and barretts 4ls learning framework this framework outlined the learning paradoxes priorities and pathways that successful family business ceos identified and coped with in their learning journeys a what and how theme emerges from our literature review 203 items where we identify both confirmations and deficiencies in the 4ls framework deficiencies that suggest future research opportunities research directions are distilled in the form of questions that extend the 4ls by enhancing the model both within it and by connecting it with adjacent areas

mental health of homeless adolescents although prevalence rates of psychological disturbance vary widely among samples of homeless adolescents it is well documented that this population is at higher risk than the general adolescent population for many mental health issues in fact about twothirds of homeless adolescents have at least one psychiatric disorder meeting dsm ivr criteria specifically about onethird of homeless adolescents have had a depressive disorder and about onefifth have had an anxiety disorder at some point during their lives sleegers et al 1998whitbeck et al 2004yoder longley whitbeck hoyt 2008 additionally about 36 percent of homeless and runaway adolescents meet lifetime criteria for posttraumatic stress disorder though this rate varies widely based on gender with females presenting with higher rates than males female homeless adolescents also have significantly greater rates of depression and other psychological disorders than their male counterparts while some studies indicate that africanamerican and latino homeless adolescents are at higher risk for depression than their white counterparts others have found no significant association between race and depression homeless and runaway adolescents are six times more likely than the general american adolescent population to meet criteria for two or more mood disorders thus many homeless adolescents experience a high degree of comorbidity of psychological symptoms furthermore homeless adolescents may also suffer from low selfesteem suicidal thoughts suicide attempts and selfinjurious behavior while there are multiple possible etiologies of depression at play in this population having an abusive family history has a direct effect on depressive symptoms even after controlling for gender race and other relevant variables depressive symptoms frequently cooccur with substance use conduct problems and dangerous sexual encounters and have been associated with higher odds of arrest the high prevalence of these psychological conditions can severely impact homeless adolescents wellbeing and life outcomes the impact of social connection and isolation on adolescent mental health in the general population of adolescents peer relationships exert great force on individuals mental health and wellbeing for the average american teen being sociallyintegrated improves psychological outcomes while social isolation worsens them teens who are socially isolated demonstrate higher rates of depression sociallyisolated teens also tend to think about suicide more than teens with friends some scholars have challenged the notion that purely having relationships is always beneficial and that social isolation is not necessarily a risk factor for poor mental health instead they posit that the type and quality of the relationships can produce differential results in individuals for instance lincoln suggests a need to examine the multidimensional nature of social support as the negative interactions resulting from some relationships can potentially be more harmful than the benefits derived from the support provided in those relationships research on adolescents also indicates the need to conceptualize positive and negative relationships as distinct constructsaffiliation with a peer crowd can protect against psychological disturbances such as social anxiety while negative peer relationships can have detrimental effects including an increase in depressive symptoms in fact adolescents who feel socially isolated have higher odds of suicide attempts lower levels of selfesteem and higher rates of depressive symptoms countervailing influences of social environment on homeless adolescents among homeless adolescents exists a complex web of influences one that is difficult to disentangle in hopes of isolating specific factors leading to better or poorer mental health and life outcomes some literature indicates that social support can improve mental health outcomes and reduce risky drug and sex behaviors other studies support an alternative hypothesis homeless adolescents social networks typically do more harm than good since they are largely comprised of other homeless adolescents many of whom come from problematic backgrounds and engage in risky andor deviant behavior when social networks are comprised largely of deviant adolescents the risks associated with living on the streets are magnified for individuals operating within those networks additional support for this model can be found in subsequent studies however others have found that the social networks of homeless adolescents are more heterogeneous than previously thought networks are comprised not only of other street youth but also include relationships from adolescents home communities including family members friends and nonrelated adults furthermore various dimensions and characteristics of heterogeneous social networks have differential effects on homeless adolescents homeless adolescents social networks can and do include prosocial relationships that contribute to positive outcomes for the individual prosocial peer relationships reduce homeless adolescents risk behaviors and antisocial behaviors the longer adolescents are homeless the less likely they are to have prosocial peers and the more likely the proportion of antisocial and risktaking peers in their networks increases moreover the social location of the relationship contributes to adolescents risk behavior for homeless adolescents who retain prosocial homebased peers are less likely to engage in highrisk behavior modern social networking technologies such as email cell phones and social networking websites are facilitating connections to prosocial homebased ties for homeless adolescents homeless adolescents report connecting to a wide array of streetbased family and homebased ties with such technologies despite being homeless and profoundly resource poor most homeless adolescents get online at least once a week and rely heavily on free access points such as public libraries and youth service agencies even homeless adults who are less culturallytied to social networking technologies than adolescents are utilizing mobile phones and the internet to connect to a wide array of social ties from both on and off the streets thus existing research provides some evidence supporting the utility of investigating the multidimensionality of the social connection of homeless adolescents and how communication technology may facilitate homebased social ties however existing studies have not sufficiently examined the effect of these various relationship characteristics on homeless adolescents mental health outcomes since homeless adolescents have aboveaverage rates of mental health issues and these issues often contribute to a higher risk of poor life outcomes an improved understanding of the positive and negative elements of social network composition will help to inform identification of and service provision to this highrisk population the aims of this paper are to examine how social isolation influences depression and anxiety and how integration into street and homebased networks differentially affect mental health outcomes among homeless adolescents methods a convenience sample of 136 adolescents was recruited between june 19 and august 21 2008 in hollywood california at one dropin agency serving homeless adolescents all clients ages 13 to 24 years receiving services at the agency during the period of study were eligible to participate in 2008 the agency saw 1860 individual adolescents who visited a total of 30575 times adolescents were asked if they would like to participate in the survey at the same time they signed up to receive services at the agency only 14 adolescents declined to participate a consistent set of two research staff members were responsible for all recruitment this was to prevent adolescents from completing the survey multiple times signed voluntary informed consent was obtained from each adolescent with the caveats that physical or sexual abuse and suicidal or homicidal feelings would be reported informed consent was obtained from adolescents 18 years old and older for minors loco parentis consent was obtained from an agency staff member who was not part of the research team and informed assent was obtained from participants interviewers received approximately 40 hours of training including lectures roleplaying mock surveys ethics training and emergency procedures procedures all surveys were conducted in a private space at the agency the survey consisted of two distinct parts in total the interview lasted approximately 60 minutes at about 30 minutes for each part all participants received a 20 gift card as compensation for their time survey items and procedures were approved by the universitys institutional review board part one was a computeradministered selfinterview by which adolescents answered survey items pertaining to demographics sex and drug risk taking behaviors living situation service utilization and mental health demographic profiles are displayed in table 1 part two was a facetoface network mapping interview conducted by a trained interviewer who collects egocentric network data from each participant first interviewers explain that they are interested in collecting information about the adolescents social network within the previous month the following text was read aloud think about the last month now i am going to draw a map of your network we are interested in the people you interact with were interested in the people you talk to people you hang outkick it withchill with people you have sex with or hook up with people you party with or drink or use drugs with next the interviewer wrote the adolescents name in the center of a large piece of white paper the interviewer then read a series of prompts to the participant to elicit network nominations after each prompt the interviewer recorded nominations on the paper in a large arc around the adolescents name the following set of prompts were always read friends family people you hang out withchill with kick it with have conversations with people you party withuse drugs or alcohol boyfriendgirlfriend people you are having sex with baby mamababy daddy case worker or agency staff people from school people from work old friends from home people you talk to people from where you are staying people you see at this agency other people you know in hollywood after adolescents finished nominating persons a series of questions about the type of ties and attributes of each nomination were then asked the interviewers were trained to ask the adolescents about each attribute of every nomination on the page and record all responses responses were then entered into a database by a research assistant and checked for quality assurance by another research assistant after the interview this technique yielded standard egocentric network data this mapping activity however provided a visual stimulus which enhanced the adolescents ability to focus on providing a large quantity of social network data while simultaneously reducing participant burden measures all demographic variables were coded from selfreported data mental health was assessed via the becks depression inventory and becks anxiety inventory both instruments are widely used and show high consistency in a metaanalysis looking at outpatients older than 18 years old becks anxiety inventory was found to have an α 091 likewise becks depression inventory has been found to have good internal consistency with adolescents who are also at risk of substance use social network variables were coded independently for each respondent based on that respondents egocentric network data total network size was coded based on the total number of nominees in the network three important attributes were collected for each of the ties whether the interaction with the tie was facetoface or via social networking technology in the prior month whether the tie was formed at home prior to homelessness or formed on the streets after the adolescent became homeless and whether the tie was considered to be a friend or not the total number of friends was coded by summing all ties reported as friends a breakdown of eight possible combinations of these three dichotomous variables is presented in table 2 analysis because egocentric network data assesses the social network of each individual respondent independently of one another it can be transformed into variables which can be incorporated into standard linear modeling techniques for this study two separate multivariate ordinary least squares regression models were run outcomes were bdi and bai summary scores because of the modest sample size not all possible social network variables were included in the final models after adding social network variables one at a time only network variables that were significantly associated with at least one outcome were retained in the final model onetailed tests were used to assess inclusion in the model based on the hypothesis that increased ties to streetbased ties has a positive association whereas increased ties to homebased ties has a negative association with increased anxiety and depressive symptoms the final model included facetoface streetbased peers and social networking homebased friends results details on the sample are provided in table 1 the mean age of the sample was 208 years the sample was 605 male and 395 female 381 african american 246 latino and 214 white twentytwo percent of adolescents reported moderate to high levels of depressive symptoms and 22 also reported moderate to high levels of anxiety symptoms turning to network composition variables in table 2 we examined three relationship types facetoface relationships social networking based relationships and a composite named all relationships within these relationship types we looked at the number of streetbased peers streetbased friends homebased peers and homebased friends friends are people specifically labeled as such peers are people who were nominated but not labeled a friend the adolescents sampled reported on average 135 ties but only 72 friends adolescents reported more facetoface ties than social networking ties reflecting proximity and affect adolescents reported the greatest number of streetbased peers followed by streetbased friends followed by homebased peers followed by homebased friends in their facetoface networks homebased peers were the most frequent nominated tie type among social networking relationships followed by homebased friends in the multivariate ols model for depression an increasing number of facetoface streetbased peers were associated with increased levels of depressive symptoms and an increased number of social networking homebased friends was significantly associated with a reduction in depressive symptoms after controlling for gender race and age for anxiety an increasing number of facetoface streetbased peers were associated with increased levels of depressive symptoms social networking homebased friends were nonsignificantly associated with anxiety after controlling for gender race age discussion there are several important findings to emerge from these results first in terms of demographic correlates of psychological disorder we found that in keeping with prior literature female homeless adolescents were at higher risk of both depression and anxiety than their male counterparts our results indicate that white homeless adolescents are at increased risk of anxiety and depression when compared with their nonwhite peers adding to the collection of inconsistent results found with respect to the associations between race and mental health among homeless adolescents second in keeping with recent research we found that homeless adolescents were connecting with both streetbased and homebased peers and that these different sources of peer support andor influence were associated with mental health our data indicate that increased numbers of streetbased peers were associated with increased depressive and anxiety symptoms this echoes whitbeck and hoyts earlier finding that increased contact with deviant peers was positively associated with depressive symptoms these data also showed increased numbers of homebased friends to be associated with reduced depressive symptoms again similar to whitbeck and hoyts findings what is unique to these data is the importance of social networking technologies in facilitating these positive connections with respect to mental health outcomes while homeless adolescents have barriers to internet access and rely heavily on free access points such as public libraries and youth service agencies these technologies are key to accessing positive support networks these data show that connecting to friends from home was accomplished primarily through these technologies and that such connections were associated with good mental health facetoface relationships with streetbased peers on the other hand were associated with both increased anxiety and depression it has long been acknowledged that street life is unhealthy for adolescents yet here we see how modern telecommunication technologies provides an opportunity for homeless adolescents to reach outside of their street networks back home to friends who can support healthier outcomes there are three important limitations to the current study first these data are not causal one cannot say that having more friends from home caused adolescents to be less depressed second these data are imprecise with respect to the use of social networking technology unfortunately these data do not differentiate among ties maintained through email social networking websites such as myspace or facebook a cell phone through texting or even a standard phone accessed at a social service agency it is possible that socializing and social support processes may differ according to the interaction media third these data are drawn from a convenience sample and are subject to the biases of such a sampling strategy data collected from homeless adolescents however are almost always drawn from convenience samples the lack of residential stability or institutional attachments inherent to homelessness make residential or schoolbased sampling strategies impossible and often convenience sampling at agencies serving youth is the only viable way to collect data from this population conclusion there are two directions for future research that stem from these findings first a probability sample of homeless adolescents that examines technology use and how social networking technology is used to maintain connections to relations that support health and mental health would be valuable second researchers should seek to understand more completely the process through which connecting to prosocial homebased peers was associated with improved mental health a more comprehensive examination of social support in this context would be a logical starting point while these data are preliminary we believe there is a straight forward programming implication for agencies working with homeless adolescents homeless adolescents could benefit from increased access to the internet and other forms of mobile telecommunication connecting to positive supportive homebased ties is made possible through these technologies and these relationships may buttress adolescents mental health communitybased and public agencies serving homeless adolescents should consider facilitating the maintenance of such relationships by providing access to computers the internet social networking websites and other social networking technologies

although social integration tends to have positive effects on the mental health of housed adolescents the role of homeless adolescents social networks is more ambiguous social network data were collected from 136 homeless adolescents in hollywood california to examine how network ties are associated with symptoms of anxiety and depression facetoface relationships with streetbased peers were a risk factor for both anxiety and depression while contacting homebased friends through social networking technology was found to be protective for depression communitybased and public agencies serving homeless adolescents should consider facilitating the maintenance of these protective relationships by providing internet access

background the hivaids epidemic in asia is characterized as concentrated the national adult prevalence of hiv is still under 1 in the majority of countries in the region but exceeds 5 in many mostatrisk populations including men who have sex with men injecting drug users sex workers migrants and sexual partners of these groups overall declines in hiv prevalence achieved in the region during the last decade are offset by pockets of high prevalence within these key populations for example while national hiv prevalence in india remains at a low 03 1 hiv rates among some marps such as female sex workers can be as high as 41 2 despite the overall low prevalence rates the large population sizes of many asian nations mean that about 48 million people were living with hiv in the region in 2010 17 million of whom were women 3 from 1990 to 2002 the proportion of asian women with hiv increased from 21 to 35 of all adults but has since stabilized and has stayed below the global level of 52 3 while the majority of women with hiv were infected by their intimate partners many are also at risk for or acquired hiv through sex work 3 substantial investments have been made in condom promotion and other hiv prevention and risk reduction programs targeting female sex workers and other women at risk for or living with hiv many of these programs have been successful in slowing the spread of hiv however attention to the other sexual and reproductive health needs of women particularly the prevention of unintended pregnancy has been largely absent from these programs like all women women living with and at risk of acquiring hiv have the right to determine the number and timing of their pregnancies and to safely achieve their reproductive intentions in addition enabling women living with hiv to prevent unintended pregnancies is an important and costeffective strategy for preventing mothertochild transmission of hiv 4 5 6 7 8 9 10 11 galvanized by public health leaders and human rights advocates the importance of better linkages between family planning and hiv policies and programs is now widely recognized by global health policymakers and donors 12 however most of the advocacy programmatic efforts and research to improve these linkages have been conducted in africa efforts to identify and address the reproductive health needs of women and men affected by hiv in asia have been scant by comparison asia differs substantially from africa in terms of the nature of the hiv epidemic health system organization and constraints culture and socioeconomic development while some lessons for advancing family planning and hiv linkages may be drawn from africa the asian context necessitates strategies tailored to the unique circumstances of the region in this paper we argue that greater efforts are needed to identify and implement effective strategies for meeting the contraceptive needs of women and couples affected by the concentrated hiv epidemic in asia drawing on englishlanguage published peerreviewed literature as well as grey literature we describe what is currently known about the use of and need for family planning among key populations affected by hiv in asia we then use this evidence to inform a discussion of the various challenges to effectively addressing the family planning needs of key populations in asia and offer recommendations for strengthening the linkages between family planning and hiv policies and programs in the region family planning needs among key populations in asia the majority of data on unintended pregnancy family planning practices and abortion among people affected by hiv in asia are from female sex workers and to a lesser degree women and couples living with hiv as a result of successful condom promotion policies and programs focused on key populations in 2009 about half the countries in the region reported that at least 80 of female sex workers used a condom with their most recent client 3 when used consistently and correctly condoms are effective at preventing both sexually transmitted infections and unintended pregnancy indeed many women at risk of or living with hiv report using condoms specifically for pregnancy prevention in cambodia 873 of the fsws surveyed reported relying exclusively on condoms for both contraception and stihiv prevention 13 in a survey of recently or currently pregnant women living with hiv in six countries in asia condoms were reported as the most known available used and preferred method of pregnancy prevention 14 however the potential for dual protection against stis and unintended pregnancy that condoms offer is often not realized despite encouraging reports of condom use with clients 15 16 17 18 19 many fsws do not use them consistently or correctly 14 15 16 and often women are forced to or will accept additional money in exchange for not using a condom 15 16 17 data from china suggests that fsws who are also injecting drug users have particularly low rates of condom use with clients 17 correct and consistent condom use with regular nonpaying partners of fsws such as boyfriends or husbands is even less typical only 135 of fsws in bangladesh 16 between 127 and 45 in china 1720 267 in hong kong 21 and between 11 and 50 in india 1819 report consistently using condoms with their regular nonpaying sexual partners additional evidence from india suggests that people living with hiv who are not involved in sex work also struggle to use condoms with regular sexual partners with onethird of men and onequarter of women reporting inconsistent use 22 use of contraceptives other than condoms by key populations in asia varies widely across countries among fsws in india and afghanistan who were not pregnant infertile or desiring pregnancy up to 53 and 65 respectively were using noncondom family planning methods 1923 contraceptive use was much lower among young or hivpositive fsws in india 19 research from cambodia also suggests use of noncondom family planning methods among fsws is low 13 information on dual method use is limited but data from india suggests it is low among fsws 2425 and women and couples living with hiv 26 although not extensively documented nor uniformly calculated existing data reveal fsws in asia have a higher than average unmet need for family planning compared to the general population for example 60 of fsws surveyed in bangladesh 16 had an unmet need for family planning compared to 168 of married women ages 1549 27 in china 47 of fsws surveyed 20 had an unmet need for family planning while only 23 of married women ages 1549 reported an unmet need 27 the evidence from china also suggests that fsw with unmet family planning need tend to be younger unmarried less likely to already have children newer to sex work and less educated 20 high rates of unintended pregnancies have also been documented among key populations in asia one study in india found that 70 of the repeat pregnancies among women living with hiv were both unplanned and unwanted 28 data from a study covering six countries in asia showed that on average 371 of women living with hiv reported their most recent pregnancy was unwanted 14 abortion is legal in many asian countries and its common use among key populations in the region provides further evidence that many experience unintended pregnancies and have an unmet need for reliable contraception recent or lifetime abortion rates among fsws in several countries in asia are often higher than the national average 131516 19 20 21 23 for example compared with the 5 of all cambodian women of reproductive age estimated to have had an abortion in 2000 more than a quarter of fsws reported having aborted a pregnancy despite 94 also reporting consistent use of condoms with clients 15 twentysix percent of fsws surveyed in india had experienced abortion 19 compared to a general rate of 31 abortions per 1000 indian women 29 analyses from vietnam also indicate higher than average rates of abortion among women living with hiv in addition knowledge of a positive hiv status has been associated with an increased tendency to seek an abortion 3031 challenges to meeting the contraceptive needs of marps a limited but growing body of evidence from the region suggests that greater attention is needed to meet the contraceptive needs of key populations at risk of or living with hiv however various political societal cultural and health system challenges converge to restrict access to family planning for these women and couples policy barriers and funding gaps restrictive laws and policies in several countries pose major barriers for key populations to access highquality contraceptive services and realize their reproductive rights for example in india women under the age of 18 are restricted from receiving family planning services in bangladesh despite recent improvements in the policies for married women unmarried women are officially prohibited from receiving popular and effective contraceptive methods such as injectables or implants these types of policies present real challenges for women such as fsws who are often young or unmarried despite the high absolute numbers of hiv infections hiv remains a low national health priority in most asian countries given the low overall proportion of the population affected as such adequate funding for programs targeting key populations continues to be problematic while programs reaching sex workers have been critically important in the regions hiv response funding for these programs has been steadily declining since 2007 3 with shrinking funds programs become less able to offer comprehensive services moreover national disparities in the allocation of funds can prevent critical resources from reaching vulnerable populations for example in india the states with high hiv prevalence also have the highest contraceptive prevalence although key populations in high hiv prevalence states may have a high unmet need for family planning the majority of the governments limited resources for strengthening family planning service delivery go to other states where the contraceptive prevalence is lowest among the general population furthermore a large proportion of hiv activities in asia is supported through external funding while the commitment to supporting family planning services for clients with hiv continues to grow among funders specific guidance on how hivaids funds may be allocated for this purpose is not always clear and program managers are often faced with difficult decisions about how to mobilize and deploy resources for integrated activities stigma and discrimination the stigmatization of key populations is distributed across the policy program and service delivery continuum stigmatization can be rooted in an overall lack of female empowerment an individuals involvement with sex work andor a positive hiv status challenges at the policy level to ensuring access to family planning services for key populations are not limited to the aforementioned restrictive laws and funding but also often involve pervasive and systematic discrimination by authorities across the health and legal system furthermore the low political importance assigned to the sexual and reproductive health of key populations is exacerbated by the criminalization of behaviors that put key populations at risk for example in countries where sex work is illegal the police may use the possession of a condom as evidence of criminalized behavior to avoid arrest some fsws refrain from carrying them 3 which could increase the likelihood that condoms will not be used during sexual encounters with clients female sex workers and women living with hiv are also routinely stigmatized by healthcare providers in mainstream health facilities through refusals of service abusive treatment or the provision of inadequate or inappropriate care 3 fsws in afghanistan have reported being less likely to visit regular health clinics due to fear of being reported to local authorities 23 in a survey of recently pregnant women living with hiv from six asian countries 416 reported difficulty finding a gynecologist to care for them during their pregnancy due to their hiv status and 18 were not satisfied with the confidentiality afforded to them 14 this type of provider bias and discrimination is a substantial barrier to the provision of comprehensive health services including family planning for key populations in a study from india physicians and clients alike reported that the family planning counseling delivered to men and women living with hiv focused exclusively on condoms with only minimal discussion of other contraceptive method options 26 this data reflects a common concern among hiv program planners that providing nonbarrier family planning methods to highrisk clients will be detrimental to or even reverse the progress achieved on rates of condom use for stihiv prevention 1314 however evidence suggests that access to or use of noncondom contraception does not decrease condom usage among people living with or at risk of hiv 3233 additional data from several asian countries suggest that women living with hiv are sometimes encouraged to avoid pregnancy or to undergo sterilization or abortion by their healthcare providers based on their hivpositive status 14 these types of limited biased or coercive fertility discussions not only result in unmet contraceptive need but also are violations of womens reproductive rights program and service delivery challenges as a result of policy barriers and stigma women affected by hiv often only access health services through targeted stihiv interventions aimed at key highrisk populations these siloed programs however often miss opportunities to address clients other sexual and reproductive health needs for example these programs promote and provide condoms explicitly for the prevention of stis and hiv they often do not directly address considerations for using condoms as a family planning method discuss the importance of dual method use offer other more reliable contraceptive method options or provide emergency contraception due to the narrow focus of sti and hiv services the providers staffing these programs may not have the required training or capacity to appropriately address the family planning needs of their clients in addition referrals from stihiv sites to mainstream family planning services are currently inadequate given the stigmatization of key populations and their general avoidance of those facilities even though family planning services may be geographically available through mainstream health facilities some women at risk for or living with hiv may be reluctant to access them due to provider biases and concerns about service quality and confidentiality lack of operations research and programmatic guidance for asia globally the evidence base for effectively linking family planning and hiv policies and services continues to grow with more data emerging that suggests integrating family planning and hiv services can improve health outcomes however little of this evidence has been generated in asia to date the integrated family planning and hiv programmatic interventions implemented evaluated and published have been almost exclusively limited to the african setting a 2009 systematic review of evidence for linking family planning and hiv interventions included an analysis of 16 studies only one of which was located in asia 34 moreover that study addressed the introduction of hiv services into standard family planning programs not the integration of family planning within hiv interventions for mostatrisk populations 34 thus the evidence base of best practices for effectively meeting the contraceptive needs of key populations living with or at risk of hiv in asia remains limited a growing number of technical materials and tools are available to guide the integration of family planning and hiv programs however strategies tailored to a concentrated hiv epidemic are rarely included while some elements of existing technical guidance on integrating family planning services into hiv programs are widely applicable some unique policy and programmatic considerations are required within the context of concentrated epidemics for example programmatic guidance for the asia region must address issues such as the systemic stigma experienced by mostatrisk groups particularly when accessing healthcare this type of stigma has implications for the design of appropriate and feasible referralbased models of integrated care where sizable investment would be needed to sensitize health care providers and foster enabling environments conclusion and recommendations many women in asia who are at risk of or living with hiv also have an unmet need for effective contraception they experience high rates of unintended pregnancy and abortion and suffer from a lack of access to comprehensive rightsbased sexual and reproductive health services strategies for addressing the contraceptive needs of women and couples with hiv are emerging from research and programs in africa 34 35 36 37 38 39 40 41 42 43 however the asian context presents a scenario requiring a tailored approach for effective integration of family planning and hiv services beyond those designed for and evaluated in an african or generalized epidemic setting advocates policymakers funders and program planners must include considerations for concentrated epidemics within the global dialogue on strengthening the linkages between family planning and hiv services based on our understanding and interpretation of both global and regionspecific evidence and information currently available we offer the following recommendations for groups of key stakeholders key population communities and other advocates advocate for the immediate removal of restrictive laws and policies which bar access to the full range of contraceptive services for key populations increase the expressed demand for comprehensive sexual and reproductive health services including family planning from clients visiting targeted stihiv interventions policymakers and donors remove legal barriers to access to comprehensive sexual and reproductive health services in existing laws policies and guidelines allocate adequate resources to improve linkages between targeted stihiv interventions and sexual and reproductive health services including family planning safe abortion fertility and conception counseling and pmtct services program managers and healthcare providers build the capacity of key population communities and networks to advocate for and raise awareness among peers of their right to and need for sexual and reproductive health services leverage the strong hiv infrastructure in the region to deliver or improve access to comprehensive sexual and reproductive services consider strategies to use postabortion care as an entry point for family planning screening counseling provision or referral address biases and related stigma by sensitizing and training providers on the comprehensive reproductive rights and options for all women including key populations promote dual method use track monitor and report on the impact of integrated services including on completed referrals method preferences and uptake and reductions in unintended pregnancies and abortions among key populations researchers conduct operations research to identify the most effective ways of designing services to meet the contraceptive needs of key populations paying particular attention to effective dual method promotion and referral strategies communicate the contraceptive needs of key populations to decision makers including preferences for location and delivery of services service delivery design and contraceptive method options we have a growing understanding of the unmet contraceptive needs of populations affected by hiv in the asia region yet a dearth of evidence about how to effectively address those needs investments in targeted stihiv interventions for key asian populations provide an important and promising platform for reaching these groups with family planning information and services efforts are warranted to strengthen the linkages between family planning services and targeted stihiv interventions for key populations in asia and to evaluate their impact on improving reproductive health and hiv outcomes conflict of interests the authors have no conflicts to disclose

like all women women living with and at risk of acquiring hiv have the right to determine the number and timing of their pregnancies and to safely achieve their reproductive intentions yet many women in asia affected by hiv lack access to family planning services and experience disproportionately high rates of unintended pregnancy and abortion programs that have succeeded in promoting condom use and providing hiv prevention and treatment services in this region have largely missed the opportunity to address the contraceptive needs of the key populations they serve the importance of better linkages between family planning and hiv policies and programs is now widely recognized by global health policymakers and donors however to date most of the efforts to improve these linkages have been conducted in africa greater attention is needed to the developing implementing and evaluating of integrated family planninghiv approaches that are tailored to the political cultural and public health context in asia in this paper we describe the use of and need for family planning among key populations affected by hiv in asia discuss the challenges to effectively addressing of these needs and offer recommendations for strengthening the linkages between family planning and hiv policies and programs in the region

introduction in 2015 the difference in the maternal mortality rate between developing countries and developed countries was enormous 1 these data reflect the existing inequalities in quality of care and in access to health services certain characteristics such as poverty or living in open access correspondence 1 health sciences department private technical university of loja san cayetano alto sn 1101608 loja ecuador full list of author information is available at the end of the article rural areas are the main causes of inequality in developing countries 2 another key element is ethnicity where indigenous peoples are a vulnerable group as they gather all these characteristics in a single context 1 the improving maternal health goals report states that a 37 reduction in maternal mortality has been recorded since 2000 and that the percentage of women who have undergone prenatal care has increased despite these data only half of the women receive the recommended share of medical care in developing countries with mortality still being 14 times greater in these countries than in developed regions 34 traditional midwives promote maternalchild health in rural communities and especially in places with indigenous populations they offer care during pregnancy and 40 days after delivery with the objective of ensuring the mothers and the childs wellbeing in countries where the maternal mortality rates are still high projects are designed that focus on saving lives and increasing care coverage within their health plans some latin american countries include integration of interculturality which in the last 2 decades has allowed for the reemergence of traditional medicine in the health system however ensuring accessibility and availability regarding good quality maternalchild care in rural areas is still a challenge 56 in order to improve quality of care and to ensure accessibility to the health system the ideal situation is to work in collaborative teams including biomedical health staff and traditional health staff the traditional midwives role is providing community care and getting people closer to the biomedical health system to reach this goal it is important to offer both parties biomedical and traditional health staff the necessary tools to attain their objectives 78 one of the tools is education based on community needs where midwives are able to make decisions and improve care coverage the creation and implementation of culturallyadapted algorithms in obstetric emergencies for example supporting medical and referral making comply with all of the aforementioned proposals as such they can become a strategy that can assist in reducing maternal mortality and improving the quality of the care provided to the mothers and children 9 in developing countries the obstetric emergencies with the highest maternal mortality rates are preeclampsia postpartum hemorrhage and childbirth complications 1 a number of strategies have been implemented to reduce the risk of maternal death due these three complications clear examples are the observational studies conducted by lutgendorf et al 10 and dillon et al 11 which evaluated clinical performance and the results associated with postpartum hemorrhage after the implementation of a multidisciplinary simulation program concluding that training was associated with a better clinical response 1011 this study focused on the training of traditional midwives from southern ecuador in obstetric emergencies by means of culturally adapted flowcharts next to training in the form of simulation sessions in this way we intend to improve the care provided to pregnant women and women postpartum in indigenous communities and additionally link all the actors involved in the community context methodological design participantaction research was set up for this purpose in this study we sought to create reflection dialog action and learning bonds between the traditional midwives and the biomedical personnel par seeks to enable participatory communities to understand and reflect about the problems they experience and promote actions to improve their living conditions 1213 the study was conducted in rural areas from southern ecuador where traditional midwives from the quechua nationalities live and which are important places for community meetings and traditional ceremonies this study was developed in four stages exploration planning action and evaluation in this study par was used to develop learning and communication bridges through flowcharts on the management of obstetric emergencies and patients referral to the biomedical health system in rural areas the project lasted approximately 35 years from september 2016 to january 2021 ethical approval the ethical requirements set forth by the research committee of the san francisco de quito university were fulfilled and the ministry of public health approved the study written consent was obtained from the indigenous community and from the participants who were free to decline or withdraw their participation at any time sampling convenience sampling was used to recruit the participants during the initial research phase a workshop was held where the project was presented and it was indicated that in the final phase each participant would receive instruments according to the projects objective and the needs of each healer the traditional midwives who agreed to participate in the research did so voluntarily the inclusion criteria were as follows working as a traditional midwife and speaking spanish however the participants mother tongue is not spanish which explains the grammatical errors found in the quotes phases of participant action research phase 1 exploration in this exploration phase we used two data collection instruments focus groups were used at a first moment which allowed for an initial reflection and interaction with the participants about the theme proposed 14 subsequently semistructured interviews were conducted which allowed us to go deeper into data that had not been discussed in the focus groups and to introduce emerging categories 1516 the guide used to develop the focus groups and the interviews consisted of three clinical cases which clearly presented the theme of obstetric emergencies the topics were selected according to the main causes of maternal deaths or complications during pregnancy delivery and postpartum at the local and national levels the topics which appear most frequently in statistics are preeclampsia postpartum hemorrhage and shoulder dystocia these were chosen for the present study next to specific information on dealing with emergencies some general themes on pregnancy counseling were brought up by our participants during the focus groups a total of 9 focus groups were conducted with 94 participants aged between 20 and 70 years old the focus groups lasted between 65 and 140 minutes plus 30 minutes for initial introduction after that 12 interviews lasting from 60 to 90 minutes were conducted informed consent and authorization table 1 obstetric emergencies clinical cases clinical case 1 preeclampsia a 35yearold patient who gave birth through a normal delivery 4 years ago she is currently pregnant with 38 weeks of gestational age she asks for your service because she had deliveryrelated pain yesterday which has become very frequent now she then evolved to normal delivery she had a male child that looks big and heavy half an hour ago while lying in her bed it is noticed that she presents abundant bleeding that she wets the bed feels weak looks sweaty and pale and says that her heart is beating faster clinical case 2 postpartum hemorrhage primigravida patient with 9 months of gestational age she has been having contractions for some days but they have gained strength and become more painful now she also says that her water broke approximately 2 hours ago you ask her to lie down to examine her and notice that the child is coming out you ask her to push the childs head comes out but something goes wrong and the rest of the body is stalled inside how long would you wait for the child to come out how do you realize that the child is not going to come out what would you do in this situation if the child doesnt come out whatever your efforts what would you do do you ask for help clinical case 3 shoulder dystocia pregnant patient you have been monitoring her she comes to you today because she says that she feels unwell tired with a headache and that she has seen little white lights in the morning she also says that her hands and feet are too swollen these last days she doesnt have deliveryrelated pain to audiorecord the discussions were requested the participants were guaranteed confidentiality of their contributions a thematic analysis with a phenomenological approach was used in this part of the study this method allowed us to identify the essence of the phenomenon as well as to obtain the participants options and ideas in a reflective manner 17 the data recorded from the focus groups the interviews and the observation notes were transcribed verbatim and analyzed with the nvivo software the researchers reviewed the data and assigned codes the code book was shared analyzed and interpreted by the researchers in addition categories and subcategories that describe the essence of the problem and the context were identified phase 2 planning creation of flowcharts by means of reflective sessions the results obtained in the exploration phase were presented to the traditional midwives and flowcharts about obstetric emergencies were developed in this way flowcharts on the following topics were created a preeclampsia b postpartum hemorrhage and c shoulder dystocia reflexivity in data collection analysis and interpretation allowed addressing some problems and establishing tools that enable better care for women before during and after delivery recognize warning signs and refer the patient to the biomedical health system in case of any obstetric emergency 18 the midwives involvement contributed to improving the tools flowcharts through effective feedback and empowering the research participants finally these culturally adapted flowcharts were designed and presented again to the traditional midwives last changes were implemented following several suggestions after which the culturally adapted flowcharts were accepted by all participants phase 3 action plan workshops based on the culturally adapted flowcharts developed in phase 2 were planned for the healersmidwives from the saraguro and cuenca communities the objectives were as follows to develop skills and competencies in the management of obstetric emergencies to recognize warning signs and to refer the patient to the biomedical health system in a timely manner in case there was any sign of emergency in addition it was sought to build communication bridges between the midwives and the biomedical system to improve the work performed at the community level workshops the workshops were initiated with presentation of the same clinical cases used in the focus groups subsequently the culturally adapted flowcharts were presented and skills were practiced with models and manikins finally the second part of the practice was performed in culturallyadapted delivery rooms where knowledge was shared between the midwives and the researchers a total of 94 traditional midwives attended the training workshops in addition as required by the ecuadorian ministry of public health 60 midwives from other communities in southern ecuador were trained phase 4 evaluation in the fourth phase traditional midwives use of culturallyadapted flowcharts in obstetric emergencies were assessed on year after training the assessment instrument was a survey to examine the process of knowledge construction in the participants the parameters evaluated were the following 1 skill learning and performance of the midwives for the management of obstetric emergencies 2 recognition of warning signs in obstetric emergencies and 3 referral to the hospital or to the biomedical health system reflexivity research team was multidisciplinary and consisted of mebv meeg nm kh and vv nm kh and vv are gps and senior researchers at the department of family medicine and population health of the university of antwerp belgium the project was developed in the context of a partnership between utpl and ua all members of the research team have a background in the biomedical health system results the total sample consisted of 94 participants 78 of them belong to the indigenous ethnic group 100 speak spanish and 48 speak both languages finally 84 stated having acquired their knowledge as midwives as a legacy from their parents or grandparents the themes that emerged in the focus groups were broader than the policies on emergencies and were classified into 5 categories 1 pregnancy control obstetric emergencies incorrect descent of the baby preeclampsia postpartum hemorrhage and postpartum control pregnancy control the traditional midwives from southern ecuador monitor the pregnant women throughout their pregnancies they provide care at the patients home or in their own houses during the control phase questions are asked about warning signs or symptoms that help them identify complications their main focus points are vaginal bleeding absence of movements in the baby and lower limb edemas during the physical examination gestational age and the babys position and size are checked through techniques that involve touching the pregnant womans abdomen if the baby is not in the cephalic position they perform the technique called manteada to correct its position this technique involves placing a bed sheet under the mother and making rocking movements while the midwives position the baby if it does not do so itself the midwives can also position it by applying massages to the abdominal region surveillance during the last month is important to know if the midwives can assist the delivery or if they must refer the pregnant women to the hospital or other health center they also monitor the family as a source of support for the mother q1i2 when the child is crossed then the guagua is all straightened up when its sitting for it to get into position i do the manteada and it positions itself alone or i help q2i1 yes on the belly i always have the measure with the hands i know where the head is i already see where the head is then i have the measure they taught me that this is the measure of the little head inside the belly then its just that the patient can give birth and if the little head is bigger she cant give birth either they need to be taken to the doctor during pregnancy the midwives recommend a good diet to the mothers rich in products that they grow themselves in addition some of them recommend that the postpartum control mothers see a physician for an extra control and exams such as pregnancy ultrasound q3i2 when for example they come like this the first months i tell them i recommend that they see a doctor that they undergo the echo whatever how a person feels then to go to the doctor obstetric emergencies incorrect descent of the baby during delivery the traditional midwives state that one of the complications presented by their patients has been incorrect descent of the guagua and they attribute it to problems such as nuchal cord they manage this complication by sliding the umbilical cord over the babys head subsequently they stimulate it by cleaning it and they cut the umbilical cord q4i3 i mean the moment theyre born you have to remove the cord remove it because the little baby is all black all black…then i remove it untwist it remove through the head like that and clean the little baby because you have to clean all that from the little face through here and there you already cut the cord and we hand it in to the relatives for them to put some clothes on it another complication mentioned by the midwives was that of guagua chupado a baby that cannot descend even if its head can already be seen in the vaginal canal in these cases the midwives state that the vertical position in a squatting position with the mothers legs wide open favors descent of the baby if the baby does not descend despite this position they move the mother to a crawling position once the baby descends they welcome and care for the newborn q5i3 when the guagua is retracted you have to tell the mum to keep pushing and as the delivery is in a squatting position the little baby slides off… some other times it wont come out and i tell the mother to get into a crawling position like children… and the baby comes out smoothly when the mother presents complications regarding the babys presentation such as breech some of the traditional midwives prefer to accompany the patient to the hospital and ask for help q6i2 it happened to me here in the hospital the child was seated then the doctors helped me and assisted her so the baby could come out preeclampsia during pregnancy control the midwives look for signs or symptoms that allow them to identify warning situations such as preeclampsia signs and symptoms identified are lower limb edema intense headache dizziness and abdominal pain traditional midwives do not measure blood pressure because they are not aware of the technique or because they lack the necessary materials given the above it is important that they continuously monitor and investigate signs and symptoms that guide them to a diagnosis of preeclampsia when facing a suspected case of preeclampsia they treat the patient with medicinal herbs and perform daily controls until the symptoms disappear in addition some midwives refer the patients to the health care center sometimes they even accompany the patients to the health care center although this is often marred overshadowed by the lack of relationship between them and the biomedical health staff in situations where the symptoms do not resolve all of them state the importance of immediately referring the patient to the health care center q7i3 i ask the mother if she has a headache if shes dizzy then i do say that pressure is high q8i2 we cant i mean with the headache and dizziness… and she turns red really red then you to have to try to lower the pressure as soon as possible if she doesnt give birth yet and is still with pressure you have to put some cabbage with ice immediately on the forehead or aloe vera thats refreshing and here also on the crown with the lemon that lowers it somehow and passion fruit waters q9i3… if i havent been able to lower from there i transfer her immediately i say come on the pressure is high not low jesus this needs a doctor some of the medicinal herbs used for the treatment of preeclampsia are passion fruit parsley pimpernel white carnations granadilla etc postpartum hemorrhage one of the complications that traditional midwives frequently must assist after delivery is postpartum hemorrhage some of the signs and symptoms they categorize as warnings are paleness palpitations sweating low energy and somnolence in addition they explore the abdomen and check uterine height they also check the garments for blood stains to approximately know how much blood the patient has lost the management performed by the midwives to prevent postpartum hemorrhage is immediately after baby and placenta come out they apply a massage around the entire abdomen with vegetable or animal oil until reducing uterine height below the navel and remain with the patient watching until bleeding stops if bleeding does not stop the midwives continue with the massage and offer herb infusions some midwives tie a band around the mothers abdomen over the navel thus preventing the abdomen from getting filled up with blood q10fg2 for the bleeding you have to massage… upwards from the pelvis until around the navel in this direction and see where it is and watch over here or over there the matrix has to be here in the navel in the full center way below the navel q11i5 we grab a band or a piece of cloth… only at this level here we tie it and apply very fast massages at the belly level putting little fats we give her plenty of massages very few of the traditional midwives had an experience where postpartum hemorrhage has not stopped despite the treatment they applied in those cases they refer the patient to the health care center or hospital when this is needed the midwives revealed that they did not feel confident enough or even felt certain inferiority towards the health staff this is due to the fact that their performance with the patient was questioned on several occasions q13i6 yes and if the bleeding doesnt stop with that then immediately look for a car and take her to the hospital so that the doctors help q14i6 no… i go to the hospital i accompany the patient to the door… the nurses look at us… theres no trust the herbs for the infusions used by the traditional midwives as part of the treatment for postpartum hemorrhage are the following parsley orange spinach alfalfa tree tomato mulle figs verbena oregano and carrot the objective of these herbs especially parsley is to stop bleeding q15fg1 parsley water is good and also fig water purple or white carrot water thats also good for all the blood to come out and the matrix to go strong postpartum control during postpartum control the patients remain 40 days resting and the midwives visit them at their homes almost daily with the objective of caring for the mother and the newborn throughout this period the midwives are in charge of maintaining good nutrition with special warm food options for fast recovery and which promote breast milk production until the fifth day postpartum taking a bath with chamomile water is another important aspect of the postnatal care for the genital area the objective of this bath is the healing process at the level of the genital area the rest of the body is not exposed to the water and thus not to temperature changes as the midwives mention that if the mother gets cold she runs the risk of breastfeeding interruption due to lack of breast milk however on days 12 20 30 and 40 of the quarantine the mother receives a full bath with chamomile water not only cleaning the genital area from the fifth until the fortieth day postpartum the woman is initially bandaged with a woolen fabric and later with a cottonlike fabric so that the uterus does not descend and to avoid urinary incontinence problems q16ig5 the mums have to take care of themselves for 40 days so that they dont get sick later and can work in the fields q17fg2 down here cleaning is with chamomile water with this you clean before day five q18fg2 if we apply the bandage after delivery but only with a shawl only with the shawl and the knot remains here or there towards the front so that it doesnt bother so that the hip gradually normalizes and do anything or apply force any other thing for the matrix to gradually settle later so that theres no urine descent nothing q19ig4 i clean her well then we always did everything on her in the house and until day 12 we havent made her walk or anything put her to eat on the little bed on the side like this they are seated 5 days from day 5 to day 12 shes bathed on day 12 q20fg1 ive always provided care like this then at day 12 she can already get up and then fully clean herself but the midwife no nobody but the midwife from day 12 to 40 i have cleaned her as usual 12 20 30 and 40 with the medicine they do the bath a fundamental component in the postpartum care is the use of medicinal herbs for postpartum hemorrhage parsley verbena alfalfa and fig are used for stimulating breast milk production they provide fennel with brown sugarloaf carrot and chamomile pain is managed with chamomile kapok bush lemon balm mauve maidenhair fern male gañel or herb of grace the latter with topical application at the abdomen or hip level in addition herbs such as andean blueberry chamomile mauves and guatos are used while bathing or cleaning the patient finally they treat problems inherent to their culture such as pasada de frío or mal de los nervios with matico chamomile valerian herb of grace andean blueberry rosemary white carnations and others the diet is mainly based on the consumption of cereals vegetables fruits and meats like chicken they totally omit pork at least during the quarantine it is important to mention that the mothers should not eat reheated food q21fg2 for the bleeding well there then immediately youll see i take out the alfalfa and lemon balm juice and give her the drink with egg whites with the juice really warm i boil her chamomile water i put a little bee honey and give her to drink and massage her a little q22fg4 lemon balm is very good for pain and nervousness we have a plant called male gañel they call so a plant thats big a big flower then it male gañel its very good too q23i1 to remove pain you give the lemon balm juice with a little bee honey then you give her to drink and also for example i warm the common rue or mugwort on the little heater and put it in the boiler q24i1 the pregnant woman gets nervous she gets a colic she catches a cold i can put some common rue water with chamomile a matico or anything that it catches there as the babys already been born it can choke but to have in a lejito planning and action based on the information obtained from the focus groups and the interviews the research team met with the traditional midwives in several work sessions and developed culturally adapted flowcharts on obstetric emergencies on the following topics shoulder dystocia preeclampsia and postpartum hemorrhage the midwives shared not only their expertise in each of the aforementioned fields but also their experience with the health staff and their ability to work in the biomedical health care system fig 1 incorrect descent of the baby the midwives who participated in the project received electronic tensiometers pulse oximeters 2 4 and 6in elastic and cotton bandages thermometers stainless steel scissors and tweezers sterile glove boxes and surgical pads the materials were chosen according to the needs of midwives for the training and care of women during childbirth and obstetric emergencies also the midwives were trained on using the culturally adapted flowcharts and techniques for managing obstetric emergencies for the training they all received material for the management of obstetric emergencies in addition traditional midwives from other communities were trained thanks to the joint work with the ministry of public health evaluation statistics on emergency obstetric care by midwives are not recorded because despite the ecuadorian ministry of public health where registration of care by doctors and healers is mandatory not all healers working in rural areas report their care to this entity an estimated number of ers our participants refer to per year is 25 but the current study did not focus on the number of births or patient outcomes we focused on selfreported knowledge construction rather than patient outcomes in the evaluation firstly 94 midwives who collaborated in the research were trained and secondly training was offered to 60 traditional midwives from other communities one year after training an evaluation of the first group was organized 90 of the participants reported having used the culturally adapted flowcharts 68 of the participants used the preeclampsias flowchart in their practice they also used the shoulder dystocia flowchart especially to review the technique required when nuchal cord is present ten midwives reported experiencing at least one of the obstetric emergencies the obstetric emergencies most frequently presented by the patients were postpartum hemorrhage and nuchal cord finally 3 midwives reported that they had to refer their patients to the biomedical health system discussion the implementation of culturally adapted flowcharts for the management of obstetric emergencies with the traditional midwives from southern ecuador was initiated as a strategy to improve maternalneonatal health and to reduce maternalneonatal mortality this has been pursued by strengthening quality of care before during and after delivery and by addressing obstetric emergencies in a timely manner our study was focused on developing culturally adapted flowcharts along with a customized training module to go with each flowchart according to data from the pan american health organization there was an estimated of 303000 deaths of women during pregnancy delivery and postpartum in 2015 in lowincome countries 19 most deaths occur in lowincome countries with the clear example of ecuador which recorded 180 maternal deaths 40 more than the number for 2019 the main causes were hypertensive disorders obstetric hemorrhages and indirect causes 20 one of the population groups affected is the indigenous populations where sociodemographic and economic factors make them more vulnerable to these health problems training is an important measure for tackling mortality rates and especially training in multidisciplinary teams this should certainly be put into practice in rural areas where traditional midwives play an important role as they are the first contact of a large number of pregnant women in their communities currently main barriers are miscommunication and the lack of clarity of roles during patient care 21 according to number 30 of the joint commission on the prevention of mortality and injury in childbirth it is mentioned that some of the strategies that reduce the risk of adverse events are the following review of the guidance and training process education and counseling review and reinforcing the protocols in a chain of communication 22 our study shows that par as a bottomup approach can be a useful tool to improve local policies in obstetric emergencies a current problem at the community level is lack of training and continuing education for traditional midwives it is necessary to qualify them for giving care taking into account their knowledge and culture in a study conducted in 1999 by the medical care committee it was estimated that medical errors are responsible for up to 98000 deaths in the united states and that one of the strategies to reduce these errors is individual and team training 23 among hypertensive disorders preeclampsia is a main cause of maternal death and its management in rural areas is complex due to the absence of a multidisciplinary team and to limited accessibility to the health care system in rural environments it is necessary to implement community interventions such as the one presented in this paper which is focused on the midwives recognizing the warning signs of obstetric emergencies making adequate decisions and referring their patients to the health care system when needed this study is consistent with two clinical trials whose objective was to reduce through communitybased interventions pregnancy adverse outcomes associated with delays in severity assessment transportation and treatment 2024 in our study the midwives acknowledge that preeclampsia is an emergency that can compromise the mothers and the childs lives therefore they look for warning signs and symptoms such as headache lower limb edema and abdominal pain these signs are in line with those indicated in the preeclampsia care guides from gestational hypertension and preeclampsia american college of obstetricians and gynecologists 25 although they have similar warning signs not measuring blood pressure is a shortcoming it causes a delay in diagnosis and thus if resolved could improve the care provided by midwives preand perinatal care means monitoring the patients for warning signs and symptoms and timely recognition of an obstetric emergency which prevents potentially fatal complications 26 the midwives interviewed as part of this study mentioned that they apply perinatal massages at the level of the uterine fundus until it descends below the navel subsequently they apply a bandage to the patient so that the uterus remains contracted in addition they pay attention to the number of stainedbloody garments during delivery and postpartum and watch for signs such as pallor low energy somnolence and palpitations which may be associated with postpartum hemorrhage also a number of deliveryand postpartum guides recommend watching the bleeding the mentioned warning signs symptoms and the massage at the level of the uterine fundus in contrast to the work of midwives oxytocin is used in the third stage of childbirth in biomedical health care system to reduce the risk of bleeding midwives use herbs or oils 2728 during delivery one of the complications mentioned by the traditional midwives is incorrect descent of the baby which can be due to a nuchal umbilical cord or to shoulder dystocia one of the warning signs here is bebé chupado known in the medical literature as the turtle sign the midwives indicate that these complications are uncommon and that vertical delivery care facilitates assistance in case they occur on the other hand the care provided in the biomedical health care system in this type of emergency requires training of the health personnel such as the use of obstetric maneuvers as mcroberts 23 29 30 31 limitations of our study include the fact that the perspective of the nationalities was not investigated from other cosmoviews furthermore in the evaluation we focused on selfreported knowledge construction rather than on patient outcomes our sample did not allow us to study actual health improvement the use of par methodology was one of the strengths as it takes into account cultural behavioural and contextual factors which hinder the application of research findings and guidelines 32 rather than doing research on a target group in this case traditional midwives it means to work together with them 33 developing a partnership in which different views on health and illness are recognized is crucial for a successful collaboration 34 it contributes to mutual trust and respect which has shown to be an important condition to build continuity between traditional healers and the formal health system as we observed in previous research in this population 35 also it promoted program buyin by the midwives which was likely to contribute to the overall success of this project without attaining buyin willingness to participate in the program would be reduced and even minor issues with the program could have resulted in midwives rejecting it whereas with buyin midwives are more likely to address and work through any unforeseen problems the researchers representing the biomedical health system and traditional midwives jointly decided to adapt the flowchart to the culture so that the method would be realistic and effective conclusion maternal mortality is still a severe problem especially in indigenous and rural populations in multiethnic countries where the health systems must be anchored with the different types of medicine alternatives must be sought to reach the entire population eliminating barriers such as miscommunication hierarchization or intimidation across the different health care providers inadequate followup of patients and geographical barriers early recognition of the warning signs and symptoms in pregnant women is a priority training offers the necessary tools to improve care quality and reduce the number of complications during pregnancy delivery and postpartum therefore culturally adapted flowcharts were developed for the midwives to have a tool that allows them to provide more relevant care and to classify obstetric emergencies early thus improving the clinical response abbreviations par participantaction research kic kichwa m mixed race sh shuar acog american college of obstetricians and gynecologists msp ministry of public health competing interests the authors declare that they have no financial or personal relationship that may have inappropriately influenced them in conducting the research or writing this article • 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 biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from

introduction maternal mortality is a health problem in developing countries and is the result of several factors such as sociodemographic and economic inequalities and difficulties in accessing the health services in addition training strategies in obstetric emergencies targeting the nonmedical personnel such as traditional midwives are scarce the focus of this study is to develop learning and communication bridges on the management of obstetric emergencies and on policies of patients referral to the biomedical health system in rural areas methodology a participant action research par study with a mixed methods approach was set up to elaborate culturally adapted flowcharts the project lasted approximately 35 years from september 2016 to january 2021the study was conducted with 94 traditional midwives from southern ecuador and is divided into 4 phases namely 1 exploration focus groups and interviews were conducted to document the management of obstetric emergencies through the presentation of clinical case scenarios in three important topics namely preeclampsia shoulder dystocia and postpartum hemorrhage 2 planning a number of reflective sessions were conducted between the researchers and the healersmidwives to elaborate flowcharts 3 action the training was conducted in rooms dedicated to proficiency in the aforementioned topics and using the flowcharts 4 evaluation 90 of the participants reported having used the flowcharts during the first year after the training the most frequently used flowchart was that of preeclampsia for the recognition of warning signs during pregnancy controlthis study documents common practices of pregnancy and delivery management by traditional midwives furthermore cultural flowcharts were developed for and together with midwives to improve the clinical response to obstetric emergencies the preliminary evaluation was favorable the most frequently used flowchart concerned preeclampsia in this process establishing a partnership was crucial for successful intercultural collaboration

introduction the malays live in several areas of malaysia the east coast of sumatra around the coast of kalimantan southern thailand and the small islands that stretch along the malacca and karimata straits in indonesia the number of ethnic malays is around 15 of the total population most of whom live in the provinces of north sumatra riau riau islands jambi south sumatra bangka belitung and west kalimantan malay culture existed before the colonial invaded the archipelago this culture grew in coastal areas which were strategic waterways and important international trade routes at that time this makes malay society an open society both physically and culturally the values of malay culture which are full of islamic religious values are able to provide encouragement or motivation to become a society that is quwwah which can also be interpreted as a society that can fulfill the need for glorious achievements and accomplishments in addition it is also expected to form a icopsy malay community that has a form of ukhuwah namely a society that always strengthens kinship ties which is also known as a need to be affiliated or joined in social groups one of the media that is now often used by people to establish relationships and interact is through social media social media is the most popular choice of internet service that is in demand by young people with an attractive visual appearance and the convenience of connecting someone with friends or strangers who have a wider range as well as the ease of accessing various information social media supports users to freely share content regarding various information about life or moments they experience the freedom to send and receive photos or videos from peers family celebrities even strangers photos of models or artists can actually affect the body image of its users one of the intermediaries that is often used to build relationships and interactions is through social media social media is the choice of the most popular internet service that is of interest to young people with an attractive visual appearance and the ease of connecting a person with a wider range of friends or strangers as well as the ease of accessing various information social media supports users to freely share content regarding various information about their life or moments they experience the freedom to send and receive photos or videos from peers family celebrities even strangers pictures of models or artists can actually affect the body image of its users according to the results of research by looking beautiful and attractive is also important when entering early adulthood appearance is considered important and primary for a woman this opinion is also justified that women consider appearance important so they often compare their physical appearance especially body shape with the bodies of other women who are considered more attractive this phenomenon is closely related to body image body image itself is the attitude that a person has towards his body which can be in the form of positive or negative assessments body image is a strong predictor of selfesteem where the higher the evaluation of appearance the more it will affect the increase in ones selfesteem selfesteem is an assessment and assessment of oneself how individuals see and evaluate and assess themselves as a whole selfesteem comes from successes and failures that form a selfimage with both positive and negative things between the two namely body image and selfesteem there is a relationship where in this modern era most people including students try to present a good image through their social media as a way to increase selfesteem in this case you are more likely to associate success in presenting a good selfimage with popularity on social media in this case the doi 1018502kssv8i1914386 icopsy researcher tries to prove this assumption by exploring the views of students especially those with malay ethnic backgrounds on body image selfesteem and the popularity of social media literature review body image body image is an evaluation and ones affective experience of physical attributes so that it can be said that investment in appearance is a major part of individual selfevaluation body image is a construct that has various dimensions that represent how a person can think feel and behave based on psychological experience and then influence the perception of his physical appearance the perception of the body can be in the form of a positive or negative assessment of oneself depending on how the individual reacts to it body image is a combination of perceptions of the body where individuals can have accurate perceptions of body size shape and weight and satisfaction with the body so that these individuals have their own satisfaction with body size shape and weight body image consists of an evaluation attitude component and a belief component where both components are related to feelings of satisfaction and dissatisfaction with the state of the body shape one has in addition eysenck also argues that body image is generally a container of thoughts about a persons body which is dynamic constantly changing according to information received from the environment around the individual it can be concluded that body image is a picture thoughts perceptions and attitudes of a person towards his body that lead to physical appearance accompanied by positive or negative beliefs and judgments about his appearance in front of other people and according to other people selfesteem selfesteem is a positive or negative attitude or assessment of an individual selfesteem is an affective cognitive and behavioral component which also involves problems of social interaction and not only comes from psychological and personal problems selfesteem is an attitude that comes from perceptions related to individual selfworth selfesteem is an assessment of oneself which includes selfconfidence that oneself is successful important capable and valuable in general selfesteem is doi 1018502kssv8i1914386 icopsy a construct that is an evaluation of selfconcept which includes an attitude of agreeing or disagreeing and the level of feeling valuable important and capable is a representation of oneself as a whole including cognitive and behavioral it is also defined as a result of an individuals assessment of himself which is expressed in positive and negative attitudes meanwhile according to maslow selfesteem is a human need that must be met in order to proceed to the next level of needs in maslows hierarchy of needs theory the need for self is divided into two namely respect for oneself and respect from others selfesteem is one of the factors that determines how individuals see themselves and behave individuals with high selfesteem will judge themselves as positive and think that they are someone who is useful and useful to others conversely individuals who have low selfesteem tend to judge themselves negatively and feel worthless so they dont have good selfconfidence individuals with high selfesteem are always positive and will look like a winner based on some of the definitions above it can be concluded that selfesteem is an individuals subjective assessment of himself as an interpretation of selfassessment also from other people about himself which can be seen in positive and negative attitudes popularity the word popularity or popularity is taken from the latin popularis which means common or much liked several sources state that popularity means being liked by many people cared for and valued but there is no definite definition of popularity itself popularity doesnt always happen to humans many other things can gain popularity such as food place and clothing and so on the term popularity is well known to many people although from this statement it can be seen that the meaning of popularity is not certain but the meaning that is very attached to the word popularity is that many people like or like it in the human context popularity is often used as a benchmark to prove how an individuals ability to build social relationships method this study uses a qualitative research method with a phenomenological research design phenomenological study is a qualitative approach that aims to describe the general meaning of the participants life experience for a concept or phenomenon in the view of the researcher this approach is considered appropriate for expressing matters doi 1018502kssv8i1914386 icopsy related to the views or perceptions of the participants on the concepts promoted by the researcher namely body image selfesteem and popularity in the context of social media in this study the researcher acted as the main instrument for data collection because the researcher was directly involved in conducting semistructured interviews in the interest of extracting data from the participants the interview process was conducted informally using a voice recorder and field notes the semistructured interviews in this study referred to openended questions prepared by researchers based on aspects of body image selfesteem and popularity semistructured questions allow the emergence of new questions according to the answers from participants during the interview session result and discussion result with regard to body image there is an appearance evaluation component or evaluation of appearance in which how individuals assess the whole body and appearance whether attractive satisfying or unsatisfactory comfortable or uncomfortable with appearance in view of beauty is when she can be confident able to accept the shortcomings that exist in herself and also women have their own beauty meanwhile according to beautiful is when a person can represent himself confidently who live by societys standards of beauty feel that their physical appearance does not match even so she still feels beautiful as a woman then related to satisfaction with his body he felt that there were several things that did not meet the beauty standards of people whereas had felt insecure because she felt that she did not match the standards of beauty on social media one of the bad effects of beauty standards that apply in society is that it can cause a person to become insecure about himself insecure is a feeling of insecurity or fear caused by dissatisfaction and lack of confidence in ones own capacity nevertheless still feel satisfied and also not too insecure and focuses more on how to be confident with oneself while now believes in the existence of beauty diversity so that even though they feel that they do not conform to beauty standards they still feel that they are beautiful and try to be more selfaccepting and selfconfident this is in accordance with abdillah and masykurs research which shows that there is a positive relationship between body image and selfconfidence doi 1018502kssv8i1914386 icopsy in addition feels that there is a discrepancy between what he posts on social media and his daily appearance because posts more on social media when there are moments such as eid or holidays wearing nice clothes whereas in daily life not so much like that this is in accordance with the opinion that the ideal body image displayed via the internet even though it is not the same as the individuals real self can make individuals dare to express themselves social media makes it easy for someone to display the selfimage or physical image they want to display individuals can select sort and edit in advance what kind of physical image and selfappearance will be shown on social media individuals can display whatever selfpresentation he wants body image is also related to appearance orientation appearance orientation is an individuals attention to his own appearance and efforts made to improve and improve his appearance according to the criteria used in posting himself on social media are good aesthetic and interesting posts this was applied by the two participants by using filters and paying attention to angles to display interesting results one of the posting trends on social media today is a woman who is fashionable photogenic a photo style that includes selfies close ups candid and ootd however doesnt feel confident enough to post selfies or ootds and only occasionally posts them to close friends in this regard also doesnt think too much about outfits the important thing is that they are in accordance with the situation they are in and like to wear clothes that are not complicated and dont have to be fashionable the two participants also felt insecure they needed an assessment from other people as validation that the photos to be uploaded were appropriate so there was a lot of consideration before posting their photos the two participants did it all as a process to become more confident and presenting themselves attractively was one of the ways this is in accordance with the opinion that looking beautiful and attractive is also important when entering early adulthood appearance is considered important and important for a woman then feels the importance of having to show the best self so that it can be seen positively assessed well and appreciated by others this shows two behaviors in selfpresentation ingratiation and selfpromotion ingratiation is behavior when an individual tries to display an impression that will make him or her liked by others for example being perceived as a humorous warm and friendly person meanwhile selfpromotion is when individuals try to show the impression that they are capable and competent the two participants also indicated dissatisfaction with some of the physical parts or aspects of themselves feeling dissatisfied with their disproportionate height and doi 1018502kssv8i1914386 icopsy weight apart from that also on the teeth which according to him are uneven meanwhile felt dissatisfied with their skin color weight and height however as a whole both of them feel satisfied with their physique while still feeling beautiful in their own way this is related to body area satisfaction or satisfaction with body parts which is individual satisfaction with specific body parts and the body as a whole overall it can be concluded that both participants had a fairly positive body image where both of them were satisfied with their physical shape and appearance even though there are some things that they think are not suitable they still respect their body shape and understand that no ones physical appearance is perfect in social media they try to show their best and attractive selves because this is a process of increasing their selfconfidence which also affects body image the views of the two participants regarding body image which is quite positive is one of the predictors of their level of selfesteem but selfesteem itself is how a person evaluates and views himself as a whole and does not focus on physical appearance only in addition to physical appearance the two participants expressed their feelings of satisfaction regarding character and competence or expertise participant felt quite satisfied with his character which he thought was quite good meanwhile participant felt quite satisfied with his competence and how well he presented his selfimage aspects of selfacceptance in both subjects are also indicated by the emergence of indicators of feelings of having advantages both participants can mention well the strengths they have participant can mention that his strengths are being someone who has leadership skills problemsolving skills and makes good decisions and has responsible characteristics whereas participant mentioned that his strengths were having good public speaking skills being able to do makeup and easily blending in or adapting to the environment also added that occasionally he would share his experiences in this regard such as when he was an mc or moderator on his social media this is one of the actions that shows his efforts to use social media as a tool for selfbranding the assessment of the two participants was certainly not only on the positive side they realized that they also had deficiencies that they were trying to improve this awareness is a form of selfacceptance both are able to accept both their strengths and weaknesses and try to be better the two participants and used to think that a deficiency was an obstacle but now this perception can be changed that a deficiency is a challenge for oneself to try to be better in addition to a positive view of oneself selfesteem can also be measured through indicators of feeling respected by others the two participants did not explain too much doi 1018502kssv8i1914386 icopsy about their feelings of being respected by others but in the context of social media the response from other people towards them was quite positive and this had an impact on their selfconfidence participant explained that there is an effort to be respected by others by showing the best selfimage but also what it is so that other people can see themselves as who they really are participant also showed the same effort by trying to achieve the ideal self where the ideal self that he wanted to show was a self that was useful for others however participant added that he was still quite far from that participant also admits that he rarely represents efforts to achieve his version of the ideal self on social media because social media also has negative impacts such as making him compare himself to other people so participant still limits his own freedom to share things about himself in the media social this is in accordance that women often compare their physical appearance with other people who are considered more attractive furthermore according to the two participants the things they do to respect themselves are by doing positive and fun things such as taking walks and eating delicious favorite foods discussion from the explanation above it can be concluded that the two participants showed quite good selfesteem overall they saw themselves from a positive side and were satisfied with it even so there are some shortcomings and feelings of insecurity sometimes arise but are balanced with efforts to improve themselves even though these efforts are not always represented through social media regarding popularity on social media it is known that s instagram social media has a number of followers of 1474 followers it was found that felt satisfied with the responses received felt the good responses obtained were sometimes true but sometimes only a form of formality felt satisfied with activities on social media so far and this behavior shows aspects of popularity namely physical attractiveness and personal characteristics perceptions of popularity and physical attractiveness are a reciprocal effect of one another then someone who is popular usually has traits that are liked by people which shows characters such as being friendly not arrogant and intelligent of the three concepts discussed in this study the participants who is a malay ethnic student who has views regarding good body image and makes it one of the supports for the emergence of a good level of selfesteem as well in the context of social media they try to display a good selfimage to create positive branding and because appearance is very important to beautify themselves and increase selfconfidence a good and attractive selfimage can make the interlocutor feel comfortable and as a form of spreading positivity this can be understood as an effort to build quality relationships with other people who are also nurtured in the values of malay culture

this study examined how the malays perceived their body image selfesteem and popularity in the realm of social media this study used a qualitative method by conducting indepth interviews with two ethnic malays the result discovered that both participants had a fairly positive body image and were satisfied with their physical appearance even though there were some things they thought were not ideal they still appreciated their body shape and understood that no ones physical appearance is perfect the views of the two participants regarding body image were quite positive and were one of the predictors of their level of selfesteem but selfesteem itself is how a person evaluates and views themselves as a whole and does not focus on physical appearance only

obstacles facing survivors and recommended needed reforms to new york states family law system 4 specifically the conference focused on widespread inequities in custody visitation and family offense cases which proceed in both the family and supreme courts and the devastating impact they have on survivors 5 throughout the two days panelists confronted the ways in which these courts fail to provide an effective and equitable system for domestic violence survivors seeking safety and protection for themselves and their families and identified the most significant challenges they face in family law proceedings the stakes could not be higher for survivors and their children as this inadequate and inequitable system of justice has led to tragic consequences including death or injury at the hands of abusers loss of child custody andor visitation rights and further trauma inflicted by the litigation itself panelists also addressed the egregious underfunding and poor functioning of the family courts and the endemic bias woven into these institutions the conference included ten keynote and panel presentations addressing significant systemic challenges and potential solutions for survivors of intimate partner violence in the family law system 6 the conference featured firsthand accounts by survivors and practitioners original research presented by renowned experts and insights provided by prominent sitting and retired judges conference panelists drew from materials regarding the intersection of racism misogyny and other forms of oppression and its impact on systems 7 including groundbreaking reports on gender and racial bias in the court system in addition each panel provided relevant materials including scholarly research reports studies articles statutes and proposed legislation all of which remain available on the conference website at 4 there is a family court in each county across new york state the family court possesses original jurisdiction over disputes involving minors as well as over family offense proceedings issues related to custody and visitation are also heard in the new york state supreme court in connection with divorce proceedings this report uses the term family law system to encompass matters adjudicated by both courts in which survivors of domestic violence proceed in disputes over child custody visitation and orders of protection 5 the proceedings are available for viewing at 6 a complete list of the conference panelists follows as appendix a to this report 7 columbia law school and ucla school of law professor kimberlé crenshaw developed the conceptual framework for and coined the term intersectionality which addresses how intersectional parts of identities such as race gender sexual orientation class immigration status and others combine to produce specific experiences of discrimination and oppression rich russo professor kimberlé crenshaw defines intersectionality youtube a require ongoing and immersive training on bias cultural sensitivity substantive family law and domestic violence including trauma vicarious trauma lethality factors coercive control and litigation abuse and 2 require the same level of training for all judges hearing family law cases regardless of duration of assignment increase the number of qualified family law judges and the diversity of the bench 3 end rotation of judges through the family court on temporary assignments 4 enhance accountability of family law judges a develop effective case management strategies and procedures for family law judges mandate training and implement oversight process to ensure compliance b enhance administrative oversight of judges c establish uniform procedural rules for family court including for virtual proceedings handling of evidenceexhibits and other court procedures d improve complaint process for reporting and tracking incidents of bias and other misconduct in the courts make widely available to court users and ensure transparency and accountability for violations and e implement transparent fatality review process for both child and adult fatalities b reform family law 1 reform custody law to protect children and families a require judges to conduct a preliminary safety assessment that prioritizes the safety of children and considers lethality factors before issuing temporary custody and visitation orders b implement an interim appellate process for temporary custody and visitation orders in family court c prohibit the courts from considering allegations of parental alienation or unfriendly parent in domestic violence cases d introduce best interest factors that discourage disrupting primary caretaking relationship and prioritize protecting the safety of the child and e ban use of reunification therapy and reunification camps 2 recognize coercive control in new york state law a amend the social services law definition of domestic violence to include coercive control and b include coercive control in the family offenses enumerated in the family court act c implement court reforms 1 institute court unification and simplification and 2 increase resources for and modernize the court system a increase funding for adequate staffing of court attorneys clerks and other necessary staff b modernize the office of court administration website c repair and upgrade dilapidated courthouse facilities d improve accessibility of virtual proceedings e institute new york state courts electronic filing system in the family court and expand access to the unified case management system f ensure all courthouses provide childcare services g improve availability of interpreters and h allocate resources to increasing compensation for court appointed attorneys d institute collaboration among stakeholders 1 institute coordinated community response task force to meaningfully engage stakeholders including law enforcement judges domestic violence advocates and others conference findings obstacles to protection and justice in the family law system the objective of this report is to highlight the primary issues raised by conference participants that continue to perpetuate an inequitable and underresourced family law system for survivors and the recommendations and advocacy plans proposed by the panels in order to promote justice and safety i bias against survivors and counsel on the basis of intersecting identities including race gender ethnicity religion sexual orientation immigration status gender identity and poverty survivors and the practitioners who represent them experience negative case outcomes and denigrating experiences due to biased treatment in new york states family law system rather than impartial decisions that reflect the facts of a case and the applicable law counsel and litigants face bias due to their intersectional identities including race class gender ethnicity religion sexual orientation immigration status and gender identity in a court system that serves diverse communities and primarily those in poverty bias remains a foundational problem and subverts equal protection under the law and the proper administration of justice for the most vulnerable in order to confront systemic intersectional bias conference keynote panelists discussed how litigants and practitioners experience bias how bias influences evaluations and decisionmaking by judges and key court personnel and the role bias plays in perpetuating an underresourced court system a race and gender bias in the courts yesterday and today first during a keynote panel entitled addressing inequity and injustice in the family law system the hon betty weinberg ellerin hon judy harris kluger and hon troy k webber discussed the extent to which gender and race biases have been found to exist in the new york court system both justice ellerin and justice webber elucidated the history of bias in the court system and ongoing bias within the courts by explaining the findings from four groundbreaking reports 1 the 1986 report of the new york task force on women in the courts 1986 one of the most disturbing takeaways of their discussion was that many of the recent report findings and current survivor and practitioner experiences repeats much of the gender and race bias that was identified in the earlier reports close to forty years ago in fact justice webber memorably exclaimed the findings of secretary johnson were a mirror image of what franklin williams found in his report in 1991 to an extent that you could have just taken the page from the franklin williams report and put it on the johnson report and say hey or heres the report in the context of gender bias the 2020 gender survey found that female lawyers litigants and witnesses continue to experience higher levels of inappropriate and inequitable behaviors stemming from gender bias than their male counterparts despite any advancements that may have been made 10 in addition in the 1986 report and as panelists indicated remains true today p erhaps the most insidious manifestation of gender bias against women one that pervades every issue respecting the status of women litigants is the tendency of some judges and attorneys to accord less credibility to the claims and testimony of women because they are women 11 another disturbing finding of the 1986 report that has remained a constant is that judges often perceive the testimony and allegations of women to be unpersuasive in cases involving allegations of abuse as explained by justice ellerin at the conference the lack of credibility afforded to women in domestic violence cases often requires these litigants to in effect double prove their case because their testimony and evidence are given less weight than their male counterparts ultimately the 2020 gender survey concluded that there is all too often an atmosphere of inappropriate behavior experienced by female 9 jeh johnson report from the special adviser on equal justice in the new york state courts the johnson report found that the new york state court system faces a lack of resources an overabundance of cases and many instances of implicit and explicit racial bias from people working in the court system to confront these concerns and create a more equitable justice system the report proposed changes to the courts existing policies and the introduction of new programs the report was based on 96 interviews during which 289 individuals shared their opinions these interviewees consisted of those who work within and outside of the official court system 10 gender survey supra note 8 at 10 with regard to racial bias the johnson report chronicled the extent to which litigants counsel and court personnel reported personal experiences and observations of racial bias within the new york state court system including instances of dehumanizing language being directed at litigants of color by court personnel 13 appallingly the johnson report noted what had been found by the minorities commission in 1991 and remains true today there are two justice systems at work in the courts of new york state one for whites and a very different one for minorities and the poor 14 justice webber further expounded on the secondclass status of the family courts by detailing facts such as the unacceptable deterioration of the bronx family courts physical building which leaks during heavy rain it is even the conventional sentiment among judges that they are punished for infractions by being assigned to that court and it is known that judges cannot be promoted to the appellate divisions directly from serving in the family court moreover because judges are human too and not above the reach of the implicit racial biases that pervade our society efforts to expose and confront bias and to undo its systemic and implicit roots have proved difficult in new yorks underresourced court system 15 importantly while each of these groundbreaking reports addressed race and gender bias separately judge kluger pointed out that the survivors accessing family court in new york city are predominantly lowincome women of color and many are immigrants and that an intersectional analysis must be applied to fully understand the compounded experiences of bias that they experience b manifestations of bias the second keynote panel entitled how bias manifests in new york states family law system as well as the keynote address delivered by stephanie mcgraw provided vivid examples of the systemic bias that has led to tragic outcomes including the death of women and children ms mcgraw a survivor of child abuse and intimate partner violence and founder and ceo of the nonprofit organization warm holds vigils for victims of intimate partner homicides provides support services for those left behind in these tragedies and assists survivors and their children who need to flee for their safety she critiqued the lack of services made available to lowincome black and brown communities noting that warm sheds light on implicit bias in systems because what happens to women and children and black and brown women when it comes to family court when it is just us it is not justice for all the psychological origins of implicit bias were described by conference panelist dr carolyn springer an applied social psychologist and associate professor in the gordon f derner school of psychology at adelphi university she explained that humans develop associations of characteristics with certain social groups in order to build mental mapsor schemasthat are needed to help process information through this process presumptions are made about certain groups or populations prereflexively inadvertently leading to prejudices and stereotypes that are linked to particular demographics 16 unfortunately refusing to acknowledge the presence of these biases can cause people to unknowingly constrict and distort information they receive and consider which leads to impaired thinking and decision making dr springer noted that implicit bias is universal it exists within nearly everyone including attorneys litigants and court personnel in the context of family law proceedings bias implicit or otherwise is particularly detrimental because judges are afforded wide discretion and determinations of survivor credibility are crucial in addition the lack of safeguards in the family law system including a thorough understanding of bias domestic violence and trauma uniform rules and protocols proper oversight and accountability ample resources and support services exacerbate the impact of bias on survivors thus to the extent that research supported by the evidence collected in the johnson report suggests that judges and court personnel tend to hold many of the same implicit associations on race gender sexual orientation and gender identity as most adults a judges position of influence means that their biases have reallife consequences for litigants conference panelists discussed specific examples of tragic consequences that have resulted from biased decision making one conference panelist jacqueline franchetti spoke of the devastating failure of the nassau family 16 bias can either be explicit or implicit explicit bias is a conscious preference whether positive or negative for a particular social category implicit bias is a preference that operates outside of social awareness a host of factors contribute to our implicit biases including societal and media influences and portrayals of different groups and stereotypes dr springer explained the natural reluctance to recognize or admit to implicit bias especially when such biases go against what we believe to be our values or ethics court judge forensic evaluator and attorney for the child to believe or accept her presentation of evidence establishing the danger posed by her childs father tragically he went on to murder their twoyearold daughter during a courtordered visit that was ordered over ms franchettis vehement objection17 indeed in 2020 then governor cuomo convened a commission of experts charged with providing recommendations to the governor regarding if andor how forensic custody evaluations should be used by new york courts…after hearing from parents attorneys and other court actors who reported negative experiences with forensic custody evaluators 18 the commission was adopted by governor hochul and ultimately the governors blue ribbon commission on forensic custody evaluations independently reviewed the use of such evaluations throughout the state and concluded in a vote of 911 that forensic evaluations are so rife with bias that they should be eliminated entirely these commission members argue these reports are biased and harmful to children and lack scientific or legal value at worst evaluations can be dangerous particularly in situations of domestic violence or child abuse there have been several cases of children in new york who were murdered by a parent who received custody following an evaluation these members reached the conclusion that the practice is beyond reform and that no amount of training for courts forensic evaluators andor other court personnel will successfully fix the bias inequity and conflict of interest issues that exist within the system another example of implicit bias in the new york court system is the consideration and reliance on stereotypes in judicial decision making specifically cultural stereotypes of womens roles in marriage and parenting unduly influence custody determinations for instance womens behavior and life choices are frequently held to a higher andor different standard than that of men conference panelist linda lopez sanctuary for familys deputy legal director echoed justice ellerins observation on credibility and lamented that her clients often experience a double standard regarding parenting while judges expect mothers behavior and decisions to be perfect they accept far less from fathers moreover in her experience women are seen as hysterical mentally unstable mastermanipulators and frauds and are treated as such by the court system immigrant clients are also too often accused of committing immigration fraud by raising allegations of domestic violence in order to obtain immigration relief even where there are documented instances of abuse moreover parenting is most often assessed in accordance with dominant predominantly white middleclass norms leaving lowincome andor women of color at risk of losing custody when their personal circumstances fall outside that inherently biased standard 19 panelist shain flicher executive director lgbt bar association foundation of new york explained that the family court system was not designed for lgbtq families and that courts question the credibility and experiences of parents who are outside the heterosexual norm the impact of bias can be compounded when judges are guided by other participants in the family court system such as forensic evaluators case workers and visitation supervisors who fall prey to the same biases 20 such bias can cause litigants to abandon their cases with decidedly unjust results ms lopez shared that one of her clients in a custody case was forced to testify on the first day of trial in detail about the severe physical abuse perpetrated by her childrens father even as the client shared testimony about her abuser repeatedly banging her head against a wall the judge admonished her repeatedly even yelling at her for answering a question before the judge could rule on an objection the client was so distraught after this experience that she relinquished custody instead of enduring further berating by the judge nothing ms lopez said could change her mind unfortunately female attorneys have also been subjected to bias and gender stereotypes by judges court personnel and male attorneys ms lopez recounted an incident when she advocated strenuously for appropriate legal remedies when her clients abuser violated an order and the judge responded that she was personalizing the case the reports of the task force on women in the courts have also noted instances in which male attorneys speak disparagingly to female attorneys and jurists often do not correct or reprimand this appalling behavior at the conference new york state court deputy chief administrative judge edwina mendelson highlighted the office for court administrations recognition of systemic bias and efforts to address it judge mendelson noted that chief judge janet difiore commissioned secretary johnson to take an unflinching look at the court system after the murder of george floyd coincided with public exposure of overtly racist social media posts made by court officers oca has embraced the findings and recommendations of the johnson report and the 2020 gender survey and tasked judge mendelson with implementing them in her capacity as deputy chief administrative judge for justice initiatives and leader of ocas equal justice in courts initiative 21 it is incumbent upon advocates to demand accountability from oca in implementing reforms within its purview while continuing to push for changes that require support from external actors such as the need to increase funds allocated to the court system to remediate dilapidated buildings c training and accountability conference panelists agreed that training of judges and all court personnel is necessary to combat bias robust antibias training that is immersive as opposed to simply lecturestyle would be interactive enable participants to broaden their perspective and assist in curtailing implicit biases this form of training would support judges as they work to comply with the revisions to the new york state administrative rules on judicial conduct which now explicitly direct that a judge shall perform judicial duties without bias or prejudice including but not limited to bias or prejudice based upon age race creed color sex sexual orientation gender identity gender expression religion national origin disability marital status or socioeconomic status 22 as noted by the hon tamra walker the ultimate goal of these training efforts is to ensure that when the parties the families the people that we serve walk into the courthouse…everyone that they come across has to know how to treat others with dignity and respect and avoid any bias because thats not the court system that we want to promote 22 the rules stipulate that a judge shall perform judicial duties without bias or prejudice against or in favor of any person a judge in the performance of judicial duties shall not by words or conduct manifest bias or prejudice including but not limited to bias or prejudice based upon age race creed color sex sexual orientation gender identity gender expression religion national origin disability marital status or socioeconomic status and shall require staff court officials and others subject to the judges direction and control to refrain from such words or conduct 22 nycrr § 1003 increased accountability was also raised as an important remediation of bias as linda lopez strongly stated oppression discrimination racism and sexism in the family courts lead to women and especially women of color being viewed unfavorably merely because of who they area dynamic which can only be changed with a cultureshift within the system that is spurred by accountability d culture change in the family law system in order to eliminate the secondclass system of justice there must be recognition that the family law system serves an important role in order for this to be accomplished attitudes towards survivors and their intersectional identities must change in order to mitigate this harm judges must reduce the role of stereotypes in their decision making this requires less reliance on intuition gutchecks and hurried rulings wherever possible judges should instead use checklists and objective criteria to promote more structured legal analysis additionally judges should seek feedback where possible and be amenable to motions for reconsideration this will allow them to reexamine whether bias may have played a role in their decision making judges should also promote diversity in chambers and within the court as a whole being exposed to different groups helps eliminate stereotypical thinking and in exposing judges to the unique lived experiences of their colleagues clerks and assistants they can also gain a deeper understanding of the litigants they serve in the last several decades the domestic violence field has evolved to include a deeper and more nuanced understanding of the trauma experienced by survivors the dynamics of coercive control and how to better assess the level of danger a survivor may be in the ability of the court system to adequately protect and serve the families that come before it for relief is hindered by the failure of the family law system to keep pace with these advancements the fact that courts often do not engage with cases in a traumainformed manner examine instances of coercive control or use lethality assessment tools has led to tragic consequences including the murder of children conference panelists raised numerous examples of ignored warnings that led to instances of femicide or continued abuse for individuals who were involved in family law proceedings at the time conference panelists shared their own experiences and those of their clients with these shocking and tragic outcomes in order to expose the gaps in the law and in the training of judges and evaluators that could prevent the reoccurrence of such tragedies e key recommendations to address bias in the family a trauma and traumainformed practices courts frequently fail to understand that survivors often experience trauma23 as a result of domestic violence and that repetitive or severe trauma is likely to have detrimental and chronic effects on the survivor 24 posttraumatic stress disorder is a frequent reaction to experiencing domestic violence and is characterized by intrusion avoidance and arousal 25 additional responses to traumatic stress may include a sense of helplessness becoming aggressive nervousness withdrawal and substance abuse or addiction 26 domestic violence can be even more traumatic to survivors than for example natural disasters because it shatters their fundamental sense of trust and attachment 27 any one or combination of these responses may impact a litigants demeanor andor presentation and can be negatively misconstrued by judges and other court personnel who lack understanding of or disregard the manifestations of trauma moreover engaging with an abuser through the litigation process itself can be traumatic for survivors there have been significant advancements in the study and understanding of trauma in the context of domestic violence including the physiology of the traumatic response how it impacts brain functioning and how survivors are often retraumatized or triggered 28 like coercive control and lethality factors the courts have failed to keep pace with this research and their lack of understanding is evident in their interactions with litigants for example courts frequently fail to assess and understand the extent to which experiences of trauma may impact a litigants demeanor andor presentation or how being forced to engage with an abuser through the litigation itself can be triggering unfortunately several of the most common traumarelated reactions are those that may otherwise be viewed negatively in a courtroom setting for example a survivor may engage in minimization or disassociation 29 as a result judges can misconstrue a survivors actions or statements that stem from symptoms of trauma and instead make negative credibility assessments chastise the survivor for how they react and behave or deny reasonable requests such as protective measures during visitation exchanges this misinterpretation and the contentious nature of the court process itself can both trigger underlying trauma and expose survivors to further trauma 30 victims then become more reluctant to trust that the family courts will protect them or that judges understand the trauma they have suffered to avoid such misinterpretation family court can and should adopt a traumainformed approach to the interactions it has with litigants during a proceeding and place the realities of an individuals trauma at the forefront of how its systems are designed and interactions measured such an approach must include a required training component for judges and other court personnel in order to assist courts in understanding the manifestations of trauma guide courts in viewing certain reactions from a litigant as a product of trauma and inform the courts interactions with that person this type of training can also help the court system identify actions and practices that appropriately avoid retriggering such as speaking respectfully and calmly to litigants attention to positioning of the litigant in relationship to exits explaining note taking and explaining the roles and responsibilities of the various personnel in a courtroom 31 in addition to training a comprehensive inventory of practices within the family court system to assess the effects of trauma on the people being served and practical modifications to acknowledge how trauma manifests in contentious litigation would benefit all of those who serve and appear in family court b coercive control moreover the new york state family law system fails to recognize that many abusers use coercive control defined as an ongoing implementation of abuse tactics designed to limit a survivors decisionmaking ability by denying her liberty autonomy and equality in a context of chronic power imbalance that is created andor exploited by an intimate partner32 this type of abusive behavior described by evan stark in his groundbreaking book coercive control the entrapment of women in personal life33 can sometimes seem subtle but instills overwhelming fear and harm to the survivor and is i ncreasingly argued to constitute the core of an abusive relationship34 conference panelist chitra raghavan phd a clinical psychologist in new york city and a tenured professor at john jay college of criminal justice outlined a range of coercive tactics that are used to continuously exploit a power imbalance including surveillance to an extent that a survivor feels constantly watched isolation of the survivor microregulation and demanding compliance with trivial unpredictable demands and degradation 35 dr raghavan compared the power imbalance associated with coercive control to a constant electric current causing steady pain where every now and then the voltage goes up as dr raghavan stated at the conference courts and practitioners often misclassify incidents of coercive control as minor but if we actually understood the context we would know that the cold look the silence the breaking of the teacup was not minor but extremely severe in the context whereas in a healthy relationship one would expect negotiation and compromise in a relationship permeated by coercive control resistance is met with increased coercion and increased retaliation the end result is constant fear which ultimately leads the survivor to submit to the abusers power a key feature of coercive control is that the control is so pervasive within the relationship that survivors may have trouble identifying what is happening to them especially at first indeed many insidious forms of technologyfacilitated abuse constitute coercive control including monitoring using gps and stalker ware technology cyber sexual abuse imagebased abuse36 hacking into a survivors devices and accounts and using other evolving technologies to harass intimidate and threaten survivors for survivors engaged in family law cases litigation abuse or legal abuse is another overlooked yet extremely detrimental aspect of coercive control delay tactics that adjourn cases repeatedly filing unnecessary or additional cases or petitions that are timeconsuming and often expensive to defend and extensive negotiations over simple issues related to visitation orders are common examples of this form of abuse this abuse further triggers survivors who are still recovering from the trauma inflicted by the abuser 37 panelist tanya selvaratnam herself a survivor of coercive control discussed the abuse perpetrated by her exboyfriend thennew york state attorney general eric schneiderman ms selvaratnam read an excerpt from her book assume nothing 38 which chronicled the relationship and how she extracted herself from it and detailed the destructive effect of threats of surveillance isolation and controlling behavior inflicted by schneiderman ms selvaratnam discussed how this intense controlling behavior included glaring at her when she spoke on the telephone preventing her from eating foods she enjoyed and critiquing her body his threats that he could have her followed were especially credible and frightening given that he was the top law enforcement official in the state of new york 39 ms selvaratnam was broken down by these dynamics in addition to schneidermans 40 slapping spitting on and choking her during sex without her consent 41 she was subjected to a year of this conduct before extricating herself from the relationship when ms selvaratnam learned there were other women abused by schneiderman she bravely chose to share her experience with the new yorker schneiderman resigned only a few hours after the publication of an article detailing an eerily similar pattern of abuse of ms selvaratnam and three other women 42 as raghavan and mitchell noted in their 2019 study the impact of coercive control on use of specific sexual coercion tactics conventional questions posed by a court as to a history of domestic violence may not fully capture the traumatic environment which the survivor has endured where compliance behaviors were repeatedly enforced 43 for a domestic violence survivor to obtain an order of protection in family court she must first file a petition alleging that at least one of the family offenses enumerated in the family court act was committed 44 these family offenses are defined in new york state penal law and include offenses such as harassment assault menacing stalking sexual offenses strangulation unlawful dissemination or publication of an intimate image among others 45 then the 39 schneidermans abuse of ms selvaratnam and three other women was first revealed in an article by jane mayer and ronan farrow published in the new yorker on may 7 2018 see jane mayer ronan farrow four women accuse new yorks attorney general of physical abuse new yorker three hours after the publication of this story schneiderman resigned from his position id 40 id 41 this experience aligns with the research of professors mitchell and raghavan who identified a direct relationship between instances of coercive control and sexual coercion including an increased likelihood of coercive tactics to obtain unwanted sex jenny e mitchell chitra raghavan the impact of coercive control on use of specific sexual coercion tactics 27 violence against women 187 187206 42 mayer farrow supra note 39 43 raghavan mitchell supra note 41 at 187 44 ny fam ct act § 812 45 the full list of family offenses is disorderly conduct unlawful dissemination or publication of an intimate image harassment aggravated harassment sexual misconduct forcible touching sexual abuse menacing reckless endangerment criminal obstruction of breathing or blood case will either go to trial at which the survivor must prove by a preponderance of the evidence that every element of at least one family offense occurred or will settle with the respondent consenting to the issuance of an order of protection usually with no admission of wrongdoing such an order can direct that an abusive party stay away from a survivor her home her job her children end any contact with the survivor including electronic communication or refrain from engaging in further similar acts in order to protect both survivors and their children 46 notably coercive control is not among the enumerated family offenses in article 8 of the family court act and therefore cannot be alleged in a petition for an order of protection certainly a petitioner can allege behaviors that might constitute coercive control and at the same time might also constitute another enumerated family offense for example threatening suicide withholding food or monitoring of a partners emails or phone could potentially be found by a court to constitute the family offenses of harassment disorderly conduct or stalking in addition whereas coercive control is an ongoing and pervasive pattern of behavior new york states legal architecture requires an incidentbased analysis asking the court to look specifically at each individual allegation because the family offenses derive from the penal code the family court essentially adopts the criminal laws hierarchy of crimes in which an offense is deemed more serious or more deserving of the courts concern depending on the severity of violence or the presence of aggravating circumstances 47 elements such as whether a weapon was used or whether physical injury resulted from the incident the courts analysis of the domestic violence circulation strangulation assault or attempted assault stalking criminal mischief identity theft grand larceny coercion id 46 new york family court act § 841 provides that upon a finding that one or more family offenses was committed a court may inter alia place a respondent on probation for a period of up to one year and require the respondent to participate in a batterers education program which may include referral to drug and alcohol counseling direct payment of restitution andor make an order of protection in accordance with § 842 of the family court act in turn § 842 provides that an order of protection shall set forth reasonable conditions of behavior to be observed for a period not in excess of two years by the petitioner or respondent or for a period not in excess of five years upon a finding by the court on the record of the existence of aggravating circumstances such an order may inter alia direct a respondent to stay away from the home school business or place of employment of any other party the other parent or the child or other specific location or to refrain from committing a family offense moreover a court may enter an order directing the respondent to abstain from communicating by any means including but not limited to email or other electronic means with the person against whom the family offense was committed ny comp codes r regs tit 22 §20574 therefore often overlooks the subtle ways in which an aggressor can utilize the tactics of coercive control against a survivor indeed research indicates that coercive control may more accurately signal danger to survivors than the presence of physical abuse 48 many domestic violence advocates believe the damage and danger of isolating degrading and manipulative behavior should stand as independent grounds for seeking an order of protection otherwise such conduct may go unreported or unacknowledged for years 49 as panelist anna maria diamanti noted advocates in new york are seeking to address the legal gap in defining coercive control as a form of intimate partner violence one advance would be enabling survivors to obtain orders of protection as a result of coercive control by amending article 8 of the family court act to include it as a family offense another would be to introduce coercive control as a factor that is considered in custody divorce andor child support matters 50 these reforms would align with those achieved in the united kingdom and several other states including california which enacted the type of coercive control legislation that has provided a nonlimiting list of behaviors that may comprise acts of coercive control and protects those whose lives are upended by such behavior 50 in new york a bill also has been introduced to establish the crime of coercive control as a class e felony state assembly bill a3147senate bill s5650 provides that a person is guilty of coercive control when he or she engages in a course of conduct against a member of his or her same family or household…without the victims consent which results in limiting or restricting in full or in part the victims behavior movement associations or access to or use of his or her own finances or financial information a 3157 202122 reg sess the bill provides that lack of consent results from forcible compulsion or from fear that refusal to consent will result in further actions limiting or restricting the victims behavior movement associations or access to or use of his or her own finances or financial information however there is consensus among the family law roundtable participants that the family offense provisions of article 8 in the family court act should be decoupled from the penal law such that coercive control would be included as a means of obtaining an order of protection and other relief in the family court without criminalizing the underlying conduct 51 in california senate bill 1141 was signed into law on september 29 2020 the law amends section 6320 of the california family code so that disturbing the peace of the other party which is grounds for a domestic violence restraining order includes coercive control the law defines the term as a pattern of behavior that in purpose or effect unreasonably interferes with a persons free will and personal liberty and the legislature recognized while making this law that such nonphysical actions destroy the mental or emotional calm of victims s1141 201920 reg sess coercive control is also recognized in the uk as well as in hawaii in hawaii hb 2425 was signed into law on september 15 2020 the law revised statutes to conference panelist paula cohen senior attorney at the survivor and family justice workgroup of the legal aid foundation of los angeles touted the benefits to her clients of californias coercive control law she described one client in california whose husband had monitored every aspect of her life by camera and other forms of surveillance keeping her a prisoner in her own house the court in california was able to use the coercive control statute to identify the extreme harm caused by this isolation and control and issue her a restraining order and other relief ms cohen also described a california case in which the court found that an orthodox jewish husband who refused to agree to a religious divorce had committed coercive control and issued the survivor an order of protection 52 c lethality factors and danger assessment tools lives are threatened or in some cases tragically ended when judges who are responsible for making determinations in child custody and visitation cases are not trained in or do not have knowledge of lethality factors in fact despite their wide use by domestic violence advocates and law enforcement partners to help determine the risk of danger of death or near fatal assault in a domestic violence situation new york states family law systems generally do not understand or utilize evidencebased lethality indicators also known as danger assessment tools first developed by researcher dr jacquelyn campbell 53 these lethality factors as defined by dr campbell are a set of factors that can help determine the increased likelihood that an abuser will murder a survivor of include coercive control as a form of domestic abuse defining it as a pattern of threatening humiliating or intimidating actions which may include assaults or other abuse that is used to harm punish or frighten an individual…a pattern of behavior that seeks to take away the individuals liberty or freedom and strip away the individuals sense of self including bodily integrity and human rights whereby the coercive control is designed to make an individual dependent by isolating them from support exploiting them depriving them of independence… hb 2425 30th leg while these factors are now used frequently by law enforcement legal advocates and case workers there is no legal requirement nor common practice that a court consider or apply them in assessing risk in a family offense or custodyvisitation proceeding as a result courts often focus more on the presumption in the law that a parent should be permitted as extensive contact with a child as possible than on the consideration of the risk to the other parent or child where visits or custody transfers are ordered as discussed above jacqueline franchetti shared the heartbreaking story of her own such experience in a new york state family court in the case related to custody of ms franchettis twoyearold daughter kyra a nassau county family court judge permitted unsupervised overnight visits between kyra and her father over ms franchettis vehement objection only a few days after the court granted the father overnight visits with kyra he shot and killed the child while she slept and then set his house on fire and killed himself in a murdersuicide kyra is now among the 23 children murdered by their own parent during a custody case separation or divorce in new york state in the past 6 years alone 57 in kyras case ms franchetti repeatedly warned the court and the forensic evaluator of prior conduct by kyras father that under a lethality factor analysis would have indicated that the father posed a grave risk to the child this included ms franchettis testimony and that of third parties that the father had stalked harassed and threatened her had expressed suicidal ideation and engaged in fits of rage and that he had access to firearms however tragically during those court proceedings the judge presiding over the case viewed ms franchettis opposition to kyras father having visits as a sign of ms franchettis vindictiveness rather than reflecting her real and credible fear because of his stalking and threats against her the court admonished ms franchetti that just because he abused you doesnt mean he will abuse the child when she continued to express her fear for her daughters safety she was told that she needed to grow up similarly the attorney for the child who was assigned to represent kyra in the family court and the forensic evaluator appointed in kyras case 58 both dismissed the documented evidence of the fathers dangerous behavior and his recent purchase of firearms 58 shortly after the conference new york state enacted legislation that specifies that when a court appoints a forensic evaluator to evaluate and investigate the parties and child in a custody or visitation proceeding the evaluator must be a licensed psychologist social worker or psychiatrist who has received training on the dynamics of domestic violence and child abuse within the last two years the office for the prevention of domestic violence is directed to contract with the new york state coalition against domestic violence to develop this training this law takes effect on june 21 2023 and amends domestic relations law § 240 with a new paragraph the new paragraph requires a child custody forensic evaluator to notify the court in which such individual requests to be considered for such court ordered evaluations requires such individuals to notify the court should they fall out of compliance and includes training documentation requirements the legislation also amended executive law § 575 to add a new paragraph that requires the office for the prevention of domestic violence to contract with the new york state coalition against domestic violence to develop a training program for psychiatrists psychologists and social workers so that such individuals may conduct court ordered forensic evaluations involving child custody and visitation the new paragraph lists the topics that shall comprise such training including but not limited to relevant statutes case law and psychological definitions of domestic violence coercive control and child abuse the dynamics and effects of domestic violence and child abuse trauma particularly as it relates to sexual abuse and the risks posed to children and in the years since kyras murder ms franchetti has become an outspoken advocate and leader in efforts to reform the law to better address evidence of safety risks as a result kyras law has been introduced in the new york assembly and senate59 kyras law would among other things require judges in custody and visitation disputes to make the health and safety of the child the top priority and to conduct an early safety assessment that would include lethality factors and coercive control update the best interest factors judges use in determining custody to prioritize the safe receiving custody of the child prohibit the court from considering claims of parental alienation in domestic violence cases and require training for judges and hearing officers on domestic violence including lethality factors 60 kyras law remains pending in the new york state legislature d femicide femicide which is defined as the killing of women and girls on account of their gender is tragically occurring every day and is a devastating form of gender violence while the international feminist community has begun to name and confront femicide this scourge is not directly being addressed or prioritized as a crisis in the united states conference panelists noted that murders of women are reported in local new york city newspapers with alarming frequency but are described as individual crimes not linked to a larger pattern of violence against women and girls indeed each time a murder is reported agencies like sanctuary for families check their client databases to confirm whether the victim was a client tragically on many occasions they have been the vicarious trauma impacting staff from these femicides is also a serious concern for nonprofit agencies and must be addressed stephanie mcgraw poignantly elucidated the profound impact of these devastating losses of life on families and communities by holding vigils honoring femicide victims she raises awareness that these murders are not simply isolated cases ms mcgraw called upon conference attendees to raise your conscious level get a little uncomfortable and stay woke to these the longterm dangers and impacts imposed by the presence of adverse childhood experiences and the danger of basing child custody decisions on claims that a childs deficient or negative relationship with a parent is caused by the other parent atrocities in fact the incidence of femicide in the united states is steadily rising one study estimates that american female intimate gendered killings are happening at a rate of almost three women every day 61 the new york city domestic violence fatality review committee annual report for 2020 found that communities of color are disproportionately affected with black females being particularly adversely impacted and that communities of color in lowincome neighborhoods account for just over 20 of the citys population but 40 of nycs intimate partner homicides 62 moreover using national center for health statistics researchers in a 2021 report in the journal of obstetrics gynecology found the homicide rate was 16 higher for pregnant women than their peers of reproductive age and noted that homicide during pregnancy or within 42 days of the end of pregnancy exceeded all the leading causes of maternal mortality by more than twofold 63 conference panelists called upon and senior advisor for the femicide watch platform a joint project of the united nations studies association global network and the unsa vienna femicide team points to repeated lockdowns and a lack of access to services and shelter as well as violent home environments for the steady increase in sexand genderrelated killings of women and girls as the pandemic persists so do these obstacles to safety for survivors especially those marginalized by gender race ethnicity and gender identity 62 nyc domestic violence fatality review comm annual report 2 according to the cdc black and indigenous women are at greatest risk followed by latinx and asian women 2021 was the deadliest year for transgender individuals with 9 out of 10 victims trans women or transfeminine women in the sex trade have the highest homicide victimization rate of any set of women ever studied devon d brewer et al extent trends and perpetrators of prostitution related homicide in the united states 51 j forensic sci 1101 11011108 femicide profoundly negatively impacts marginalized communities especially communities of color leaving children motherless families without the members who do the lionesss share of nurturing and caregiving and communities without the members who frequently are the most serviceoriented survivorofcolorled communitybased antidomestic violence organizations have prioritized this issue autodidact 17 harlem mothers save hosts antiviolence forum amsterdam news domestic violence advocates in new york to join the international feminist community in exposing the crisis of femicide and promoting policies to address it the burden should not be on the survivor to establish the risk of harm to a litigant or children the burden should be on the court and evaluators to assess the risk the court and evaluators within the system must understand both when and how to perform a risk assessment in any case where domestic violence is a factor therefore a require training for judicial personnel and all actors within the system on lethality assessment and factors e key recommendations on b temporaryinterim orders when judges issue temporary visitation and custody orders in a child custodyvisitation case i they should be reduced to writing and include the judges basis for the determination and factors that the judge took into consideration ii there should be a mechanism for appeal or intermediate review so that immediate relief can be accessed if an order poses a risk to a child enact legislative changes a pass legislation prioritizing the health and safety of the child i require judges in custody and visitation disputes to make the health and safety of the child the top priority and to conduct an early safety assessment that would include lethality factors ii train judges and court personnel on traumainformed practices and conduct an inventory of the ways in which retraumatizing practices and interactions within the family court system can be minimized iii failure to prioritize the safety of survivors and children and their allegations of domestic violence and child safety risks over the other 64 kyras law 65 conference panelists agreed that while coercive control should be actionable in civil actions in the family and supreme courts it should not be added to the penal code and should therefore not be actionable in criminal actions partys demands for custody and visitation and claims of parental alienation conference participants agreed that court decisions that preceded the tragic murder of twoyearold kyra and the experience of her mother in family court were not outliers but examples of a systemic pattern in which domestic violence survivors are punished or have negative case outcomes as a result of raising allegations of domestic violence or child abuse during custodyvisitation cases these unjust consequences for survivors are closely tied to another dynamic in family law abusers invoking the concept of parental alienation when protective parents raise legitimate safety concerns parental alienation is a debunked junk science theory first introduced by psychologist richard gardner in his 1998 book the parental alienation syndrome a guide for mental health and legal professionals 66 gardners theory posits a scenario in which one parent through emotional manipulation turns a child against the other parent as a form of retaliation often by making false allegations of sexual abuse parental alienation syndrome has never been scientifically substantiated or recognized by the american psychiatric association or any other medical or professional association and it is not admissible in child custody hearings because of its lack of scientific basis 67 however the term parental alienation often gets considerable traction in family court where allegations that one parent is alienating children from the other parent are commonplace and regularly used by attorneys representing abusive parents to undermine the credibility of domestic violence or abuse allegations indeed one parent may be reframed as a parent severely emotionally abusing their children by falsely teaching them to hate and fear their other parent 68 66 richard a gardner the parental alienation syndrome a guide for mental health and legal professionals 67 see alyssa g rao rejecting unjustified rejection why family courts should exclude parental alienation experts 62 bc l rev 1759 1760 and world health organization and that the drafters of the most recent versions of the diagnostic and statistical manual of mental diseases and the international classification of diseases declined to include parental alienation syndrome in either of these highlyrespected and highlyutilized diagnostic tools notwithstanding proposals by the syndromes advocates in many cases parental alienation claims lead to legitimate warnings 69 about child safety made by survivors of intimate partner violence being ignored or rejected by judges who instead accept abusers unverified claims that survivors are unfriendly parents these outcomes are often rooted in the fact that new york and other states have case law that specifically adopts the friendly parent principle which holds that if one parent is more likely to support the childs relationship with the other parent andor if one parent is more likely to comply with the concept of shared parenting then that more supportive parent should be awarded custody 70 although consideration of the friendly parent factor is just one of several best interests factors to be assessed in a custody proceeding others of which include a demonstrated history of domestic violence 71 this legal principle is frequently leveraged by abusers and their counsel when concerns about violence and ongoing threats to a child are raised thus credible claims of prior history of domestic violence andor child abuse have led to changes in custody to the abuser due to a perception that raising such claims constituted alienating behavior by the parent seeking to protect a child from violence 72 or as an attempt to block a child from the other parent jennifer friedman senior program director family law project and policy at sanctuary for families identified this dynamic as a backlash against survivors that has taken hold in family law since the early 2000s she described one case in which a judge scolded her client for engaging in alienating behavior and warned she could transfer custody of the children after ms friedmans client shared legitimate fears that her ex was attempting to track her location by giving the parties child a cell phone during a supervised visit this followed a history of abuse perpetrated by the father including the presence of lethality factors such as stalking and a suicide attempt in the home while the children were present 69 certainly in cases where allegations of abuse are not present a judges focus on encouraging coparenting is reasonable 70 for a detailed analysis of the friendly parent principle and its application see the friendly parent principle does it get conflated with parental alienation sanctuary for families 71 see ny dom rel law § 240 this example and other conference participants observations on the extent to which claims of alienation can be weaponized in custody proceedings aligns with empirical data presented by panelist joan meier the national family violence law center professor of clinical law at the george washington university school of law professor meiers work examines the outcomes of reflected bias in reported custody and visitation cases from around the united states 73 and reveals the extent to which judges undervalue survivors allegations of domestic violence and safety threats and overvalue noncustodial parent custody rights where parental alienation is asserted specifically the data reveal that mothers losses in custody cases skyrocketed if an allegation of abuse was met by a crossallegation of alienation by the father 74 professor meiers research also highlighted gender bias within the realm of parental alienation claims as her studies demonstrated that there was no effect on frequency of fathers custody loss when mothers crossclaim alienation to a fathers initial accusation of abuse 75 moreover the cases reviewed by professor meier uncovered that when fathers assert alienation crossclaims courts are far less inclined to accept a mothers abuse claims including claims of partner abuse child abuse or child sexual abuse 76 incredibly a review of published cases reflects that courts are half as likely to believe a mothers claim of abuse when a father presents an alienation crossclaim 77 thus survivors of domestic violence are constantly faced with a predicament reporting abuse to the court during a custody dispute to seek protection for their children can pose the risk of being perceived as hostile 73 a 2020 study conducted by professor joan s meier describes how the impact of parental alienation on mothers and fathers varies in situations of abuse her findings relied on analyzing and codifying judicial opinions posted online across the united states over a tenyear period the research found that in situations where fathers alleged abuse against the mother of the child they gained custody at higher frequencies than when the mother alleged abuse against the father meier supra note 68 74 samantha schmidt a gendered trap when mothers allege child abuse by fathers the mothers often lose custody study shows wash post 75 meier supra note 68 at 100 of the time but this is not a statistically significant result due to the relatively low numbers 76 id at 98 unfriendly or alienating with adverse implications for the outcome of a litigation as has been noted courts typically immediately demand coparenting and take risks before they have time to consider the evidence of abuse or the critical context many court professionals immediately start promoting and pressuring for shared parenting victims are routinely punished if they object to cooperating with their abusers victims lawyers often tell clients not to raise abuse issues and not to object to dangerous arrangements this results in courts making harmful decisions without ever learning about the history of abuse this approach also serves to silence children who are exposed to the abuser 78 that environment frequently drives litigants to accept custody and visitation terms that threaten their safety and the safety of their children or terms that require a level of communication with an abusive party that enables ongoing coercive control including extreme and dangerous programs such as reunification therapy and reunification camps have also emerged from this overall trend of prioritizing claims of alienation over credible allegations of abuse by a parent one conference panelist ally cable founder of the youth initiative at the center for judicial excellence offered her horrifying personal experience as a 16yearold subject child in a contentious custody litigation the court in her case accepted the fathers narrative that her mothers claims of abuse were simply alienation and issued an order removing ally and her sister from kansas and forcibly bringing them to a reunification camp in a remote part of montana where they were made to endure a therapy program with their father who sexually abused them in her case the guardian ad litem rejected the statements that ally and her sister made describing their fathers abuse and accused them of lying about the abuse allys case exemplifies the courts retraumatizing adult and child survivors by prioritizing parental relationships with abusers over the emotional and physical safety of children and survivors in fact new york state is home to linda gottlieb a social worker whose socalled therapeutic visitation programs involve sequestration and prohibitions on contact with family members other than the parent claiming alienation 79 in many cases children are removed from their primary caretaker a safe parent and custody is awarded to an abusive parent who had claimed alienation moreover allys story illustrates the extent to which participants other than judges in custody proceedings including evaluators and guardians ad litem 80 can also improperly prioritize parental relationships over legitimate concerns for child safety 81 indeed as discussed above regarding bias in the family law 79 see hannah dreyfus barricaded siblings turn to tiktok while defying court order to return to father they say abused them propublica the reunification camps and other programs where children are held or forced to participate against their will or made to interact with a parent who has credibly been alleged to pose a threat or risk to their emotional or physical health differs greatly from the form of supervised therapeutic visitation that has long been accepted in new york state family courts where children may engage in individual therapy sessions with a parent facilitated by a mental health professional for limited periods such as one hour per week see stephanie b v joshua m 183 nys3d 309 the distinction in approaches can also be traced to whether an order is made as part of an effort to protect a childs best interests including their emotional wellbeing or whether the order is being made to prioritize the parents interests 80 allys case was heard outside of new york in new york state family courts children are represented by attorneys for children as their independent counsel rather than by guardians ad litem conference panelist michael sherz esq director of the domestic violence project at lawyers for children noted the importance of providing children with this form of direct and independent representation in order to ensure that their experiences and position can be put before the court and considered along with that of the parties 81 see udesky supra note 57 professor meier also has documented how in cases with a guardian ad litem or an evaluator system in new york state a majority of the governors blue ribbon commission on forensic custody evaluations members believed that the states custody evaluation system is so deeply biased that their use should be eliminated entirely if these and other reports are to continue to influence the outcomes of contested custody cases we must require training on domestic violence for all such actors and adopt assessments and factors that promote the best interests and wellbeing of litigants and children a key recommendations to prioritize the safety of survivors and their children early safety assessment when ordering visitation and temporary custody in a child custodyvisitation case judges should be required to make and prioritize an early determination of safety risks to the child or children when there is a credible allegation of child abuse or domestic violence provide clear direction in the law as to when in the course of a proceeding the court is mandated to perform such an assessment such as at the first appearance parental alienationfriendly parent when presented with credible evidence of domestic violence or child abuse judges should not be permitted to consider arguments regarding the friendly parent principle or parental alienation at any point in a custodyvisitation case redefine best interest factors to prioritize safety safety of the child should be a primary best interest factor and accorded more weight than other factors in custody cases other factors to be considered should include the negative consequences mothers alleging abuse are more likely to lose custody joan s meier ending the denial of family violence an empirical analysis and path forward for family law gw law faculty publications other works 28 when alleging physical child abuse this difference increases to 34 and when alleging mixed physical and sexual child abuse to 53 professor meier observed that these data indicate that these neutral court professionals are putting a heavy thumb on the scale against mothers associated with separating the child from their primary attachment figure and whether either parent is better able and more likely to attend to the daily physical emotional developmental educational and special needs of the child ban use of family reunification therapy no court should be permitted to authorize family reunification therapy or reunification camps where allegations of abuse are present iv underresourced and poorlyfunctioning family courts including insufficient numbers of judges to handle overwhelming case dockets which undermine the equitable and timely administration of justice for victims and families new york states antiquated court system itself is a profound barrier to justice for survivors of domestic violence indeed insufficient resources for the family courts have negatively impacted the safety and security of our most vulnerable populations including primarily black and brown lowincome women children and families moreover the covid19 pandemic laid bare longstanding inequities impacting the families accessing the new york city family court during the pandemic the family court shut down for a substantial number of socalled nonessential matters over an extended period of time these matters however were anything but nonessential leaving many new yorkers including survivors of domestic violence without access to justice on issues impacting the safety and security of their families and children with a substantial backlog resulting in unreasonable delays the impact of covid will be felt for years to come and accordingly the need for reform has never been greater finally the family law system encompassing the family and supreme courts does not have programs protocols or effective training in place that acknowledge and address the vicarious trauma experienced by counsel jurists and other service providers who handle difficult cases on a daily basis a new york states outdated court structure at the heart of this crisis lies new yorks antiquated court structure combined with a lack of judges resources and adequate technology as panelist denise kronstadt interim executive directordirector of advocacy and policy at the fund for modern courts described in detail new york state has the unwanted distinction of possessing the most complex court structure in the nation with eleven separate trial courts with varying and sometimes overlapping jurisdiction 82 the system is not only confusing but also leads to wasteful parallel proceedings with the possibility of inconsistent results those most negatively impacted are people of limited means vulnerable populations and unrepresented litigants of note survivors of domestic violence often have to make repeated appearances in multiple courts represented by different lawyers on each case if represented at all while subject to inconsistent court orders and rules furthermore if litigants are seeking a divorce they cannot do so in family court but must bring an action in the supreme court where they would have to pay filing fees and are not entitled to an appointed lawyer also of concern this byzantine court structure locks in resource disparities negatively impacting courtslike the family courtwhich disproportionately serve the poor and people of color the lack of sufficient funding compounding over decades means that there are not sufficient judges staff or technology to effectively manage the volume and seriousness of the cases before the court this is especially detrimental given that 80 of litigants in family court are unrepresented b shortage of family court judges the severely inadequate number of judges and insufficient staffing has for decades caused significant delay in new york city family court proceedings to make up for this critical shortage the office of court administration transfers judges from other courts and assigns them to the family court on a temporary basis usually for two years83 however these temporary transfers create significant problems for litigants who are survivors of intimate partner violence and the attorneys who represent them first while the rules of the chief judge section 174 require that judges in a court that exercises criminal jurisdiction family court judges and each justice of the supreme court who regularly handles matrimonial matters shall attend every two years an approved program addressing issues relating to domestic violence judges from other courts are often temporarily assigned to the family court without receiving the required training 84 as a result it is not uncommon for judges serving in family court to be unfamiliar with the issues and needs of survivors of intimate partner violence 85 to illustrate this problem a panel participant described a case where a temporarily assigned family court judge did not know the meaning of a therapeutic visitationa common term that refers to visitation between a child and the noncustodial parent with supportive servicesand was poorly prepared to consider services that would protect the custodial parent and subject child in that case family court litigants also often appear before judges who have not made family law a professional priority and others who seek to minimize their time serving in that court as justice webber explained judges cannot be promoted to the departments of the appellate division directly from family court meaning that any judge with ambitions to promotion would seek transfer from the family court as soon as possible 86 according to a new york city bar association report the constant flow of judges in and out of the family court presents serious challenges specifically the court found e very time an acting judge departs from the family court that judges cases must be reassigned causing delay and confusion among litigants and when judges are assigned without experience or expertise in family law as they take over cases lacking familiarity with prior proceedings they understandably do not perform at the same level of efficiency as fulltime family court judges87 vacancies often are not filled immediately and cases in front of a departing judge will be adjourned until a new judge is reassigned from another court or is appointed to the family court thereby causing unacceptable delay and potentially putting lives at risk in cases involving domestic violence 88 as explained by the bar association report the current system leaves the family court in a state of constant flux referred to by some in court leadership as a transient bench that compromises the administration of justice often at critical points for the safety and security of families and children 89 thus in january 2022 when many judges were reassigned attorneys at sanctuary for families reported to justice webber that several judges sitting in the manhattan and brooklyn family courts declared mistrials in cases that were open before them requiring survivors to be forced to either retestify to their traumatic experiences at a new trial or accept unfavorable settlements to avoid this scenario although justice webber in her capacity as cochair of the franklin h williams commission contacted the office for court administration supervising judge of the family courts and confirmed that this practice was contrary to official court policy several sanctuary attorneys handled cases that were in fact ultimately mistried indeed the swapping of judges is especially prejudicial and traumatizing to survivors of domestic violence who have no choice but to bring the court up to speed and recount their experience over and over again every time a new judge is reassigned one sanctuary attorney is currently representing a survivor of sexual abuse and domestic violence who filed for an order of protection and custody in june of 2019 her matters have proceeded before seven separate judges a full order of protection trial took place before one judge who sat in family court for less than a year and made findings of multiple family offenses committed the case was then transferred to a new judge who is unfamiliar with the case history and is conducting a full custody trial this outrageous situation is requiring the client to retestify to the abuse in order to educate the new judge about the history which is imperative to best understand the custody issues this case is not an outlier practitioners report that many of their cases currently before the family courts have been handled by multiple judges over the course of years the shortage of judges also was addressed in a compelling report recently issued by the franklin h williams judicial commission of the new york state courts the commission which is charged with addressing racial bias in new yorks courts noted further increasing the number of family court judges will address unconscionable delays in resolving cases avoiding longer periods of stay in foster care for children longer periods of uncertainty in custody cases 89 id the report raises a number of concerns including 1 family court parts go without a complete complement of judges for extended periods of time due to the lags in the appointment process and delays in the replacement of judges from other courts whose temporary assignments to family court have ended and 2 shortterm appointments result in cases being handled by several different judges over the life of the case longer time for resolution of juvenile delinquency cases longer periods of anxiety for domestic violence victims and protracted periods of the stress instability and trauma implicit in the cases heard in family court 90 the staffing issue also pertains to the inadequate number of appointed counsels including attorneys for children who ensure that their clients positions experiences and views can be properly assessed by the court to protect their safety and wellbeing moreover the onlyrecently addressed insufficient pay rate for courtappointed attorneys which had been set at 75hour severely exacerbated these inequities as a flood of departures left the remaining members of the panel with overwhelming caseloads resulting in an inability in many cases to spend adequate preparation time on each clients case 91 the rate in new york city was recently raised to 158 per hour as the result of a judges order in a class action lawsuit brought to increase counsel rates and the 2023 new york state budget finally includes funds to pay 18b attorneys at this rate 92 thus with a lack of judges and counsel to adequately serve those who seek to appear and pursue their claims the pressures on the family court system have never been greater many efforts have been made over the years to reform new yorks court structure in order to not only simplify the system that works against equality and dignity for everyone who enters the courtroom but to streamline the system to have the authority to better distribute resources and to provide them where they are needed the most reduce court appearances and give all litigants a better and more equal justice system 93 simplifying the outdated and highly inefficient court structure has proven difficult however because it requires a constitutional amendment which in turn requires passage from two successive legislative sessions followed by a public referendum 94 there are however other reforms that can be implemented through legislation and by the court itself to address the revolving door of family court judges that as explained above causes disruption and delay the new york city bar association has identified several recommendations in their comprehensive report which include increasing the number of family court judges providing them with better and more uniform training and improving communication between oca and the mayors advisory committee on the judiciary in order to avoid delay in the appointment process and to provide adequate notice of vacancies to the public 95 the report also recommends that oca collect compile and analyze data in each county as to the length and frequency of delay caused by vacancies which would help track caseload and staffing needs and would also help identify the causes of delay 96 while this conference strongly endorses these recommendations it also contributes the perspective that the outrageous condition of the family courts also places domestic violence survivors and their children at greater risk of harm and of retraumatization by the court system itself c family courts lack of childcare services and other supports for lowincome parents access to the family courts and court resources is another way in which implicit bias manifests against domestic violence survivors who are predominantly women of color from lowincome communities for example at the conference justice ellerin discussed how litigants who do not have reliable childcare are often forced to miss court hearings or are turned away at the court for attempting to bring their children with them for a period of time this issue was remedied through the operation of childrens centers inside the courts where litigants could leave their children with appropriate care while they attended their court proceedings unfortunately in recent years budget reductions have eliminated this service in many courts this courts 3 there would be greater opportunities in the appellate division which would draw from a bigger pool of supreme court justices 4 a fiveyear implementation period would allow an orderly process for change and 5 court administration could be standardized and streamlined 94 ny const art xix § 1 95 family court report supra note 83 at 25 96 id one issue has significant ramifications for all participants in an overburdened system and should remain an issue of central importance to advocates for judicial reform the conference also cited the economic disadvantages faced by women litigants who often hold jobs with inflexible hours and who may recently have reentered the workforce to achieve financial independence especially in the domestic violence arena where economic control and restrictionsmonitoring of outside employment are commonplace in such circumstances the inability to miss work or to not be paid for taking off an hourly shift poses too great a burden on litigants who otherwise would actively participate in their cases the conference also discussed the need for accessible high quality interpretation services in court the absence of which has a disproportionate impact on lowincome immigrant litigants and impedes their ability to successfully litigate d impact of covid19 on court administration in early 2020 the family court operated much as it had for many decades with no electronic filing system in place petitions had to be filed in person if litigants needed a court document or help in filing papers they had to show up in person at the clerks office to make a request court staff did not even have the ability to work from home accordingly it should come as no surprise that when the pandemic struck a court with an insufficient number of judges and inadequate staffing levels and burdened with limited resources and technology would face difficulty functioning and challenges transitioning to a virtual model this is especially true given the high volume of cases in 2019 there were a total of 192000 new family court filings across the citys five counties 97 without the benefit of any increased funding or resources during the pandemic the family court had to make difficult decisions which as described below severely impacted vulnerable populations essential v nonessential matters during covid19 the court distinguished between matters it deemed essential including orders of protection and certain child protective and delinquency proceedings and those it deemed nonessential including visitation custody adoption guardianship and support matters while essential matters proceeded nonessential matters stagnated for months many for almost a year without being calendared the court heard certain nonessential matters to the extent they qualified as an emergency but that term was never defined nor broadly applied furthermore the best way to attempt to have a case heard as an emergency is to file an order to show cause something only an attorney would have the legal knowledge to do as a result the vast majority of the litigantsespecially unrepresented litigants who make up 80 or more of the court populationhad virtually no access to the family court as the pandemic progressed and especially as other new york courts were transitioning to virtual proceedings the distinction between essential and nonessential matters in family court became more and more arbitrary thus it is impossible to explain to a mother trying to provide food for her children or the survivor of domestic violence without the means to leave an abusive household that their child support cases were somehow nonessential and that their lack of access to the court was somehow justifiable panelist karla george deputy director of the family law project at the bronx family justice center for sanctuary for families shared a compelling experience from her practice an abusive father who had a finding of neglect against him took the children away from ms georges client a survivor of domestic violence when ms george called the administration for childrens services they refused to remove the children from the father as the situation was not considered an emergency despite the fact that the daughter constantly texted the mother about feeling unsafe and having suicidal ideations acs refused to take action and when ms george filed an order to show cause with the family court it was denied as the court categorized the situation as nonessential the effects of covid were often felt even when emergency matters were taken up by the family court christine perumal then the director of the safe horizon domestic violence project provided an example where she filed an order to show cause in a pending custody case where there was concern for the safety of her clients daughter ms perumal explained that it took the court about four weeks to schedule the order to show cause on what could have been a lifeordeath situation for the child when ms perumal followed up she was told that there was limited capacity that the judge did not have a court attorney and that she should check back in with the petition room ms perumal recounted the stories of other survivors who contacted safe horizon and stated that the inability to obtain child support orders and payments during the pandemic forced them to remain in a household with an abuser so as to not be left without resources while seeking safety virtual proceedings and access to justice as highlighted by the pandemic nowhere is the disparity among new yorks various trial courts more profound than in the use of technology many new york courts transitioned relatively smoothly to remote proceedings including the supreme court which in divorce proceedings even addressed many of the same family law issues as the family court while the supreme court had embraced electronic filing and had the capacity for remote proceedings leading up to the pandemic the same was not true for the family court in addition family court personnel were not even equipped with the technology to enable them to work from home 98 as discussed above this epitomizes what former us secretary of homeland security jeh johnson observed in his groundbreaking report on racial justice in the new york courts system as a secondclass system of justice for people of color in new york state 99 while covid19 exposed weaknesses and inequities in the court system it also underscored the importance of technology in furthering access to justice panelist joan gerhardt nyscadvs director of public policy and advocacy explained some of the advantages of remote proceedings for survivors of domestic violence avoiding a trip to the courthouse means not having to take a day off from work and makes child care concerns more manageable it also provides physical separation from abusers who otherwise would be in close proximity both in the courtroom and the waiting area reducing both the anticipatory anxiety of court dates and trauma experienced by survivors from inperson experiences however special considerations must be taken into account as remote proceedings become a permanent fixture in family court some litigants do not have access to technology a reliable internet connection or a safe place to access court proceedings remotely there is also a lack of technical support from the court making it difficult for some to navigate remote proceedings cases have been compromised and even dismissed as a result of these issues this is especially of concern when english is not the litigants first language also of concern is that the expansion of remote proceedings has occurred without any uniform rules about when and how these proceedings should be conducted and without sufficient training for judges and staff e vicarious trauma 98 covid report supra note 97 at 4 99 id at 25 n37 the report further notes the following making matters worse the family court struggled to develop an effective system to disseminate updates and guidance to the public people were turned away from courthouses with limited information even now the family courts website provides limited and often unclear information on the status of the courts operations and offers only limited guidance for unrepresented litigants id at 5 trauma in the court system also extends beyond survivors and affects social workers lawyers and other professionals who routinely engage with survivors about their trauma and work closely with them throughout their cases as discussed in the panel selfcare as selfpreservation understanding vicarious trauma enhancing support for providers the issue of vicarious trauma is particularly acute for attorneys and as one conference panelist observed has become a workplace hazard for those who work and appear in family court in an empirical study on secondary traumatic stress lawyerscompared to mental health professionals and social workersranked highest in levels of secondary traumatic stress burnout and caseloads with traumatized clients 100 family court attorneys and court personnel who face traumatic client experiences in their work on a daily basis 101 frequently report symptoms associated with vicarious trauma including irritability emotional detachment or exhaustion secretive selfmedication and overvigilance 102 typically the effects of this secondhand or vicarious trauma manifest over a period of years reflecting the cumulative transformative effects of working with survivors in a cycle of trauma this trauma may be particularly acute for women and people of color who often share intersecting experiences of trauma with their clients based upon experiences of race andor gender bias accordingly courts must be trained in identifying the manifestations of trauma and secondary trauma among litigants attorneys and court personnel themselves indeed at the conference professor joan meier posited that judges themselves may be responding to vicarious trauma from handling voluminous dockets involving abuse when they minimize survivors experiences when courts come to understand the manifestations of trauma in the courtroom case outcomes will more closely align with the needs of litigants and subject children f key recommendations for increasing resources and modernizing the court system 1 end rotation of judges through family court rotating judges through the family court for temporary assignments causes massive turnover of judges entire case dockets litigants whose lives have been laid bare to one jurist suddenly have a new jurist with no knowledge of the family history the new judge might not be adequately trained expand mandated domestic violence training to members of the judiciary throughout the court system expanding domestic violence training to all judges acknowledges the reality that domestic violence impacts litigants throughout the legal system attract quality talent committed to serving in the family court family court should not be a mere stepping stone toward more prestigious court appointments the mayoral committee must find judges who are deeply committed to the family court want to remain there and will undergo the necessary training to succeed increase resources modernize the family courts the family courts must be allocated more resources to address the profound operational problems and institutional inequities that lead to unjust outcomes and appalling litigant experiences court simplification and unification would ameliorate the gross imbalance of resources faced by the family courts as compared to other courts by reducing costs centralizing administration and providing greater access to qualified judges however conference participants were aware that the process necessary to fully reform and unify the court system would be long complex and challenging in the interim and to immediately f modernize the office for court administration website to be more transparent userfriendly and informative providing information including advance notice regarding appointments and reassignment of judges posting easily understandable basic court information in multiple languages such as filings court appearances schedulingdeadlines and related court requirements 5 institute a system for tracking and investigating litigant complaints of bias and unfair treatment by judges court personnel and the court system and providing notice of outcomes of investigations 6 fund and develop programs to address vicarious trauma to recognize its impacts as a workplace hazardissue among advocates attorneys and court personnel 7 institute coordinated community response for stakeholders including law enforcement courts and domestic violence advocates v lack of administrative oversight of judges uniform court rules transparent mechanisms to report misconduct by judges and court staff and a viable appellate mechanism for improper interim decisions the new york state family court system suffers from a lack of transparency and methods of oversight there are few official protocols that are consistent across courts and judges are afforded wide discretion in how they manage their courtrooms for example there is a lack of uniform procedural rules that specify the methods by which litigants introduce various forms of evidence in virtual and inperson proceedings nor are there rules that clarify when virtual proceedings are available including proceedings by phone this lack of accountability and consistency allows bias and other judicial mistreatment to go unchecked moreover whether due to shortcomings in training unfamiliarity with the family court system error or a failure to abide by a rule of judicial conduct 103 including but not limited to a misapprehension of the role of the judge as a neutral arbiter or making inappropriate or 103 see part 100 judicial conduct rules of the chief administrative judge new york state unified courts 22 nycrr § 100 the new york state commission on judicial conduct is the independent state agency established under new york state law that will review a complaint and if a complaint proceeds to a final determination the commissions actions can include dismissal of charges issuance of a letter of caution admonition censure or removal from office see ny state commn on jud conduct notably many of the individuals who preside in family court matters in new york state are not judges who are subject to the commissions disciplinary system including support magistrates and referees however these individuals are employees of the unified court system and can be subject to disciplinary action through the supervising or administrative judge of the court in which they serve and through the inspector general of the unified court system humiliating statements towards a litigant 104 panelists described the barriers that prevent litigants and attorneys from obtaining full relief through the court system as conference panelist robert tembeckjian administrator counsel nys commission on judicial conduct explained when judges behave improperly litigants or counsel can file a formal complaint with the new york state commission on judicial conduct if proven the result can be a decision to admonish censure or remove the judge this solution has multiple drawbacks often attorneys are reluctant to report or invoke available disciplinary procedures for fear of delaying or undermining claims within a particular case or of retributioneither within the court system overall or by a particular judge also this process does not apply to a judicial ruling within a case itself such as where a judges application of the law threatens the health or safety of litigants or subject children in those instances even if such interim or final order was the result of an improper departure from application of the law that constituted misconduct or of bias or conflict of interest that ruling still must be addressed by reargument or appeal moreover with regard to judicial decisions the current appellate process is insufficient for temporary orders which are put in place by judges early on and can stay in place for years during the pendency of a case until a final result is reached the challenge is that temporary orders are often issued with very little background information or in some instances by coerced agreement of the parties as discussed above long delays in cases result in temporary orders remaining in place for years thus becoming the status quo the temporary order then becomes exceedingly difficult to undo even at times in the face of evidence that it was inappropriate in the first place moreover since a temporary order granting or denying custody is not a final order it is not appealable as of right the only recourse for litigants in this predicament is to obtain permission for an interim appeal the process of which is strict confusing and not easily obtainable a key recommendations for selection training and accountability of judges and court personnel 104 for example a decision of the new york state commission on judicial conduct removed a judge from office after finding that he or she violated the rules governing judicial conduct by failing to comply with the law when he did not inform several family court litigants of their right to an attorney and also by making inappropriate comments of a sexual nature while presiding over a proceeding in a treatment court matter of abramson 2010 wl 4485946 judges presiding over family law cases in the family and supreme courts should be knowledgeable in family law and family procedure and have an understanding of domestic violence child abuse and related trauma this should be the case both for judges assigned to family court on an interim basis and those taking the bench longerterm the application process should require that applicants demonstrate an awareness of bias and facility with cultural sensitivity require annual enhanced training on legal updates and related family law issues for judges presiding in family court this training would address judges misapplication of the law when presiding over custodyvisitation cases the process would also require annual training requirements on substantive law family court procedure understanding of domestic violence child abuse and related trauma as well as robust antibias training such training must include segments addressing i parental alienation as a commonlyraised defense when a litigant raises safety concerns and the gendered aspects of how alienation allegations are considered ii coercive control and lethality factors to move away from incidentbased view of domestic violence iii the opportunities provided for under the law for a subject childs views and safety concerns to be heard directly by the court through an attorney for the child or directly to the court through testimony or interviews in camera iv vicarious trauma and how it may impact counsel court staff and the judiciary itself v all judges should be trained in domestic violence not only those in the family court establish uniform procedural rules columbia journal of gender law 50 there should be uniform procedural rules across parts including for evidenceexhibits virtual proceedings and all other aspects of court procedure commission a study examine longterm impact of family court experiencedecisions on a diverse range of subject children for presentation to judges and court personnel temporaryinterim determinations there should be transparency regarding the factors that a judge considers in making temporaryinterim determinations and a process for interim appeal of such decisions broaden access to information about available disciplinary tools for judicial misconduct the court system should provide litigants and counsel with easily accessible information about when and how complaints can be made vi insufficient training of judges and court personnel in family law domestic violence and trauma conference panelists agree that enhanced training of judges and court personnel in family law domestic violence and trauma is crucial to transforming the current family law systems in topics ranging from bias to coercive control to custody law panelists described experiences in which judges court personnel forensic evaluators courtappointed attorneys and others have displayed a need for training in these areas therefore training has been integrated in the key recommendations in every section of this report conclusion the new york family law system will continue to marginalize domestic violence survivors and their families unless a multifaceted reform strategy is implemented to address the numerous barriers to justice it is our hope that the broader domestic violence community will be successful in its efforts to advocate for meaningful reforms that will not only achieve equitable treatment of survivors but also ensure the safety and protection for survivors and their children available at appendix a family law roundtable and conference jennifer friedman senior program director family law project policy at sanctuary for families launched this initiative and led the conference alongside jennifer barry legal volunteer sanctuary for families legal center the work of the conference flowed from a previously convened family law roundtable led by friedman and barry consisting of lawyers from the following organizations which provide legal services to domestic violence survivors and their families in new york city sanctuary for families new york legal assistance group her justice safe horizon and proskauer rose llp a law firm which provided pro bono support to the roundtable the vast majority of clients served by these organizations are lowincome or indigent women of color residing in new york city and a significant proportion are immigrants maya grosz an independent consultant facilitator and former family law practitioner and legal educator facilitated the roundtable meetings

domestic violence survivors seeking justice and safety in new york states family and supreme courts often encounter a deeply flawed poorly functioning system that exposes them and their children to further harm 1 on october 13 and 14 2022 a coalition of leading nonprofit agencies that serve and advocate for survivors 2 convened a conference in new york city to address these systemic inequities and identify meaningful solutions 3 during the conference justice for survivors of intimate partner violence transforming an inequitable family law system attorneys scholars survivor leaders members of the judiciary social service professionals psychologists and advocates identified key 1 this report was prepared by members of the family law roundtable see infra note 3

introduction family is the basic agency of socialization that forms the personality of youth in every society family satisfies the basic needs of a child and polishes the inner abilities of the child khatal m n family is the first agency which moulds the behaviour of youth according to the values and norms of its society macionis j j the word family is derived from the latin famulus which literally means domestic slaves it is a team of producers and slaves and other servants and members connected by marriage or descent alam a there are various types of families but joint and nuclear family systems are the most common types of family systems and exist in almost every society in the world alam a the study by jayachandran s found that the youth who live in the joint family system are more adjusted than youth who belong to the nuclear family system family arrangements play an important role in empowering improving or weakening the youths performance in every aspect of life a smooth and peaceful environment within the homes has a great impact on youth psychological health family is the primary source of socialization which prepares the child for social life elliott s revealed that residential patterns tie a deep relationship that affects the lifestyle of their members further the network of these relationships is primary and secondary in nature the family has an impressive influence on the academic achievement of the children family is the source of the kinship system which energize and support its member to achieve any goal in life unesco unesco classified the pattern into five segments of which joint and nuclear is the most common setup in pakistani society in pakistani society the family which is composed of two generations is considered a nuclear family and a joint family is composed of three or more than three generations living together in a single home lopata h z argued that she is acquainted with charles horton cooley who is a sociologist and argued that family has many important functions it avails the chances of emotional support encouragement and strong intimation therefore both nuclear and joint family patterns have some rules and regulations about their childrens social life and achievement according to gilford the family is always the basic atmosphere for a child it focused on family surrounding playing a role in escalating and abating the intellectual achievement of the child akubue f define the family terms as a kinship group with the process of the fundamental function of natural socialization of newborn babies objective ▪ to know the youths perspective on nuclear and joint family systems in quetta city ▪ to examine the social experiences of youth regarding the nuclear and joint family system in quetta city research questions ▪ how are familial relations affected in nuclear and joint family systems ▪ which system of family is financially strong ▪ what is the impact of residential patterns on personality development ▪ how have residential patterns affected the academic achievement of youth statement of the problem the family system is considered essential for individuals social emotional and financial needs of survival pakistani society is divided into two main categories on the basis of family arrangement joint family and nuclear family system in early times a joint family system was preferred to a nuclear one however the changing trends of society affect the culture of pakistan and the nuclear family is dominating the joint family every individual is a part of either a joint family or a nuclear family previous studies conducted both negative and positive consequences of nuclear and joint family structure on individuals lives one study by ghani s portrayed that quarrels and jealousy are general features in the joint family system mostly its members confront accommodation issues because of aggressive competition according to kauts a study the children of joint families showed sensible conduct compared to nuclear families moreover the research of khatoon a showed that in joint families childrens selfdecision is discouraged due to the dominance of the family head in all their choices even the parents of children cannot be involved in their future decisions due to the authority of other elders at home similarly in quetta both kinds of families exist and there was little scholarly work on their consequences so the researcher covered this gap through her qualitative research work moreover the present study analyzed the social familial and financial experiences of students regarding joint and nuclear family structures rationale of the study this research was conducted to analyze the experiences of bs students of the university of baluchistan quetta regarding the joint and nuclear family system previous literature revealed that there have been many studies on the impact of the residential pattern of the family on childrens lives according to the findings of rao c n in a joint family setup the parents of children are disheartened to take an interest in the matter of their children parents are prevented from encouraging their childrens talents and choices parents will find the current study useful in helping them plan for their childrens future choices and opportunities limitations of the study this study mainly focuses on undergraduate students enrolled at the university of baluchistan in quetta city restricting its scope to the exploration of viewpoints and experiences among the young regarding the joint and nuclear family structures prevalent in quetta city the goal is to obtain a thorough grasp of how young people in this academic setting interpret and negotiate the dynamics of various family relationships the purpose of the study is to shed light on the perspectives and experiences that quettas university students have about the joint and nuclear family systems in the city by delving into their distinct views and experiences review of literature a research article written by virginia cooperative extension argued that family plays an essential role in making the personality of the child and developing various skills in a child the emerging skills in children including learning skills and educational development are influenced by the process of nurture and family support moreover family patterns and surroundings will provide the child with the confidence to be responsible for social and cultural norms in pakistani society the advancement of science and technology persuaded the new generation of pakistani society to transform the joint family system into a nuclear family system especially in urban areas of pakistan another study by suleman q a also observed the effect of family structure on childrens educational performance however they studied the family structure on the basis of family size and number of family numbers and concluded that a small family size pattern has a great effect on childrens academic performance and involves a great participation of parents with children regarding academic activities another study conducted by muola j m all the condition and situations in the family which affect the child intellectually physically and emotionally is called family background muola j m a family can be classified into two main categories joint and nuclear family joints are those in which a large number of people and kinship groups are involved including more than one nuclear family the family in which only a married couple with their children is called a nuclear family and this trend is more familiar in western countries according to andersen and taylor maduewisi his environmental experience in a family peer group has more impact in explaining a childs intellectual ability durosaro f a argued in their study that family size always influences the academic achievement of the child according to lisa a gennetian academic achievement is higher in nuclear families than in joint or singleparent families khatoon asia conducted research to find out the effect of the joint and nuclear family systems on the educational performance of secondary school students in karachi they found that the family structure has a significant effect on the decisionmaking and interpersonal skills of youth but there is no impact on confidence personality leadership and creativity moreover in the joint family system children have more chances to communicate with any member of the family and gain more experiences while less intimacy is found in the nuclear family due to the small family size and usually mothers were found to be working ladies one study by ghani s portrayed that quarrels and jealousy are general features in the joint family system mostly its members confront accommodation issues because of aggressive competition another study by haider k described that a joint family is a centre of conflicts as the women of joint families belong to various cultures and family setups thats why they are incapable of accommodating easily with the new social environment individuals of joint family have clashes in every matter of life resultantly that provokes an insecure milieu according to khatoon a in a joint family the childrens selfdecision is discouraged due to the dominancy of the family head in all their choices the childrens needs are subordinated in the fronts of family decisions even the parents of children cannot be involved in their future decisions due to the authority of other elders at home similarly the findings of rao c n conducted that in a joint family setup the parents of children are disheartened to take an interest in the matter of their children parents are prevented from encouraging their childrens talents and choices there is a low level of satisfaction among joint family individuals regarding autonomous decisions in their personal lives they face higher constraints in every part of life their own determinations are killed by the judgement of the family holder mentioned by saqib lodhi f a kn according to bilal h ts study the effect of nuclear and joint family system on academic achievement of students represented that the children belonging to joint family system confronted intense hardship in academic life they have to face more challenges to strive as a part of a crowded environment they are deprived of their parents affection and attention to educational problems contrary to the above outcomes one study by kumar a stated resilient social accommodation among joint family individuals rather than nuclear family members members of joint families are much more cooperative as they are socialized jointly by all family members moreover according to kauts a study children of joint families have shown sensible conduct compared to nuclear families children from joint families are much more experienced with the guidance of older members and their grandparents research by giri d collected that individuals living in joint family setups always compromise on their wishes and aspirations for the sake of family concern further the findings of ali m m research work mentioned that individuals living in joint families were ethically better as compared to nuclear families thus exploring the locationwise effects of joint and nuclear families it was stated that individuals from rural areas were morally better than their counterparts of nuclear family individuals methodology in order to obtain comprehensive information about the family system in quetta the current study is qualitative in nature according to dr khalifa elmusharaf qualitative research is utilized to comprehend the studys subjective reality the universe is thought to be a place where all people live and from which primary data is obtained for research purposes however the study focuses on quetta citys nuclear and joint family systems from the viewpoint of young people the university of baluchistan was the location for data collection to further accomplish the goal of the current study the target population consisted of bs single students between the ages of 19 and 25 sampling method convenience sampling is the process of selecting a group of individuals who are believed to be representative of the population from which they are drawn as opposed to selecting them at random this strategy which is the least rigorous selects the themes that are the most easily understood in terms of money time and effort it is the least expensive for the researcher nonetheless convenience sampling was used to choose the target population for this inquiry sampling size ritchie and lewis discovered that one of the features of qualitative sampling is that the sample size is usually small this is because as was previously mentioned a phenomenon needs to occur only once to be valuable scale is not necessary just as estimates of statistical significance are not needed to give an indication of the size of the qualitative inquiry one can expect to conduct 20 to 50 interviews for a oneonone study in the current study 33 interviews were done based on data saturation with 17 respondents from joint family systems and 16 from nuclear family systems moreover one fdg was conducted with 12 respondents including boys and girls was conducted tool for data collection dr khalifa elmusharaf asserts that with appropriate sampling and equally cautious datagathering techniques a very small number of interviews narratives or focus groups can yield the data required to address your research issue the interview guide was employed by the researchers to obtain data for this study report tool for data analysis boyatzis contended that thematic analysis is a subset of qualitative analysis categories are examined and themes or patterns that relate to the information are displayed it covers a wide range of subjects by delving deeply into the data and offering opinions the primary data was analyzed using thematic analysis results privacy many of the respondents who are associated with joint family experiences primarily relate to unpleasant experiences with privacy being the main focus these people said there were very few possibilities to keep personal information private in the joint family arrangement their stories indicate that when each family member actively engaged in and meddled in other peoples personal affairs the loss of privacy became more and more obvious the respondents expressed a great deal of anger with this ongoing interference which jeopardized their personal space and boundaries the collective narratives brought to light the complex balance needed to manage familial closeness while honouring individual autonomy and freedom highlighting the inherent difficulties connected with maintaining these qualities within the complex dynamics of a joint family structure as respondent said if we lock the door for few minutes it will turn into agony and knock the door on every second on the other hand the respondents who belong to nuclear families were more stable in their privacy matters as compared to the joint family system as respondent said i had been in a joint family system which was the worst experience regarding personal matters because every member of the family tried to interfere in our intimate affairs which was very irritating for us however i prefer the nuclear family system to live in a relaxed environment and less chances to disclose privacy financial stability the researcher collected data from the university of baluchistan which is the only public university in balochistan the students of uob belong to various rural areas which are considered highly backward and quetta is the only urban area of balochistan the students belonging to a joint family in rural rural areas are negatively affected due to financial instability henceforth in rural areas a joint family system has deep roots in their culture in addition to these more than seventy or eighty family members live in a single home at the same time few male members of the family contribute to the family income at the same time the rest depended on them which highly burdened the earner of the family this situation leads to poverty and poor financial condition in the family besides this the students who belong to a joint family in quetta have positive experiences of financial stability because every family head is responsible for feeding his own children and wife furthermore a larger workforce in urban areas is an indirect cause of financial stability as respondent said i am living in a joint family system where a single kitchen by all family members every earning member of the family contributes to the grocery of the kitchen which does not burden the earning members of the family moreover earning member of the family has good savings and are financially stable students from nuclear families the majority of whom live in quetta have expressed satisfaction with their financial stability and have demonstrated excellent saving practices for these students a more stable economic environment is facilitated by the advantageous financial circumstances found in nuclear family arrangements especially in an urban area like quetta their pleasant interactions not only demonstrate the benefits of the nuclear family structure but also emphasize how the metropolitan setting may affect students financial security security concerns the students who belong to a joint family feel more secure than students who belong to a nuclear family a strong sense of belonging and emotional wellbeing are enhanced by the presence of extended family members such as grandparents aunts uncles and cousins who create a loving environment a network of people who share duties offer support and provide companionship is common in mixed families creating a nurturing environment for the pupils students from nuclear families where there are only parents and their kids living together may have a different dynamic and a lower level of emotional stability and social security than those from other types of households the communal aspect of joint families can have a favourable effect on kids perceptions of general safety and stability affecting their academic performance and wellbeing as respondent said joint family system has pros and cons but the social and emotional security system is very strong in the joint family system and society cannot threaten this system in baluchistan the family structure has a crucial role in determining ones sense of security especially in homes with nuclear families students from these households are more conscious of security issues which can be largely related to the small number of males living in the home students may become more watchful if there is a lack of male presence in nuclear households due to the social backdrop of baluchistan where conventional gender norms frequently give male family members a protective role this awareness is a result of the widespread cultural correlation between safety and the ability of male family members to defend themselves students in baluchistan from nuclear families may therefore approach daily life with an increased awareness of security dynamics reflecting expected responsibilities and familial roles as respondent said whenever my father leaves for another city we go to my uncles home due to security issues because my brothers are too young and we feel fear of staying home in the absence of my father familial support strong familial support is generally more common in joint family systems than in nuclear family systems according to research that has been conducted on the subject people who live in joint families gain from having a larger family network which promotes a sense of shared accountability and interdependence grandparents uncles aunts and cousins living close by frequently create a strong support network where family members are willing to lend practical financial and emotional help conversely students from nuclear families can receive less familial assistance because these households are usually made up of parents and their children nuclear families may have a less diverse support system due to their smaller family sizes which could have an impact on the breadth and depth of services offered to kids this dichotomy draws attention to the differences in dynamics between nuclear and joint family systems and emphasizes how crucial familial structures are in determining the kinds of support networks that people have access to as the respondent belonging to a joint family said my parents uncles aunts and first cousins are part of my extended family and they are always there for us financially and emotionally supporting us through good times and bad as such i think that this constant support is one of the main characteristics of the joint family structure the respondent belongs to a joint family and said my father had financial difficulties at a crucial time when my younger sister was diagnosed with hydrocephalus a disease that required emergency brain surgery my paternal uncle intervened in this dangerous scenario and made all the necessary surgical arrangements he promised to be by our side for the rest of his life and gave us his undying support my uncles generosity is still a source of great gratitude and i am eternally grateful for his support and generosity as the respondent who belongs to the nuclear family said my interactions with my paternal uncle and cousins have become strained as a result of living in a nuclear family a sense of remoteness may have been created by the restricted family structure which may have led to irregular interaction and a lack of shared experiences academic achievement the residence pattern has a significant impact on how well young people do academically there was a clear pattern among respondents from joint family systems where there was a general unhappiness with academic accomplishment these people mentioned that it was hard for them to stay focused and dedicate enough time to their academics they mostly attributed these problems to the busy and crowded environment due to living in joint families on the other hand respondents with nuclear family histories demonstrated more effective academic success the main distinction was the smaller family size which enabled parents to give their kids academic endeavours more focused attention this discrepancy qlantic journal of social sciences volume 4 no 4 203 highlights how residential patterns affect young peoples academic paths with family structure having a significant influence on their educational experiences and accomplishments as the respondent belonging to a joint family said my parents were unable to give us their undivided attention or focus on our schooling due to their hectic schedules and my mothers overwhelming workload of household chores ive always wanted to do well academically but ive never been able to fulfil this ambition due to a busy atmosphere and conflicts that interfered with my performance but i have to work for this degree of education on my own discussion the results of this study reveal the deeply ingrained foundations of the joint family system in quettas cultural context but they also reveal a noticeable tendency in favour of the nuclear family paradigm the respondents participated in a thoughtful dialogue exchanging perspectives on the advantages and disadvantages of the two family structures that are common in quetta society one big concern that surfaced was privacy which was also noted as a key downside in the context of a joint family underscoring the fine balance needed for peaceful cohabitation in contrast respondents highlighted the strong familial support and cooperative environment that the joint family structure generates which was one of its significant features this is consistent with findings from kumars study which emphasized the longlasting ties and support among family members in joint family systems because they navigated a variety of situations in the same setting the children raised in joint families were said to be more mature and insightful these observations were supported by kautss study which highlighted the greater experience growth and maturity of children raised in joint families as opposed to their nuclear counterparts the previous literature also draws attention to the negative aspects of joint family dynamics supporting ghanis findings that prevailing problems in joint family environments include disputes jealousy hostile competition and privacy invasions its interesting to note that quetta citys youngsters mirrored the same ideas giving a glimpse of the difficulties this conventional family system presents therefore the study provides a thorough investigation of young peoples perspectives on both family systems illuminating a complex understanding of the advantages and disadvantages of each even while the joint family system continues to be popular young people personally prefer the nuclear family because they want more personal freedom and a quieter home life the preference for nuclear households is further supported by bilals research especially when it comes to academic achievement the supportive and concentrated environment described in nuclear families stands in stark contrast to the difficulties faced by children in joint families which include a congested atmosphere and a lack of parental attention this comprehensive investigation of family dynamics reveals the complex interplay between household arrangements and the experiences and perspectives of young people in quetta culture conclusion the research examined young peoples perceptions in quetta city with regard to nuclear and joint families historically the joint family structure has been prevalent in quetta a city that is a cultural melting pot of pashtun baloch punjabi hazara and other communities the purpose of this qualitative investigation which was carried out among university of balochistan students in quetta was to record the diverse experiences and opinions of respondents from various family configurations surprisingly the primary data revealed respondents from joint and nuclear family systems had different experiences and opinions young people in joint households reported feeling more pressure because of the strong rivalry and internal disputes in the family on the other hand individuals from nuclear households reported more financial stability even though they acknowledged receiving less support from paternal relations as a result each respondent personally preferred the nuclear family structure due to its ability to create a calm and stressfree atmosphere qlantic journal of social sciences volume 4 no 4 this choice is consistent with the studys finding that young peoples academic success is greatly influenced by their residential arrangements when compared to their peers from joint family systems students from nuclear families demonstrated more efficacy in their academics as well as a greater sense of responsibility in completing academic assignments as a result family structures effect on academic achievement becomes a significant factor to take into account illustrating the complex connection between living situations and young educational achievements in quetta city

every human being is a part of either a joint family or a nuclear family both types of families have multiple positive and negative consequences on individuals lives as previous literature represented various advantages and disadvantages of joint and nuclear families according to khatoon a 2008 in a joint family the childrens selfdecision is discouraged due to the dominancy of the family head in all their choices the aim of the present study was to analyze the actual experiences and perceptions of youth regarding joint and nuclear families in quetta city even though the existence of joint and nuclear families has a strong influence on individuals lives there is still no scholarly work on them henceforth the study selected a qualitative approach to analyze the experiences of youth bs students from the university of balochistan one focus group discussion fgds and nine interviews were conducted on the basis of data saturation through convenient sampling data collection tools included interview guide schedules in order to obtain rich pieces of information for targeted phenomena further data was analyzed through a thematic analysis tool however the findings of the present study portrayed the experiences and perceptions of respondents belonging to both family systems

introduction lesbian gay bisexual transgender and queer individuals experience challenges in accessing care and achieving positive health outcomes 12 compared to their heterosexual and cisgender peers lgbtq people are more likely to be uninsured to delay or avoid medical care due to stigma and to report poor overall health 23 lgbtq patients cite discrimination in healthcare and providers lack of awareness of relevant health issues as reasons to delay or avoid care 4 the largest survey of transgender individuals in the united states found that 28 of transgender respondents postponed medical care due to discrimination and 19 had been refused healthcare due to their transgender or gender nonconforming identity 5 transgender and gender nonconforming individuals are less likely to have health insurance or regular primary care providers than their cisgender peers 6 these disparities are at least in part due to bias and lack of training among healthcare providers including physicians dentists and nurses some recent studies suggest that access to high quality inclusive healthcare is increasing 7 but further improvements in the training of all health professionals will be necessary to improve health outcomes among lgbtq populations recognizing these disparities the us department of health and human services healthy people 2020 program set goals to improve the health safety and wellbeing of lgbtq individuals 7 in 2011 the national institute of health also commissioned the national academy of medicine to conduct a comprehensive review of the health needs of lgbtq populations 2 the report highlighted the paucity of and necessity for research focused on lgbtq patients and communities more recently the national institute on minority health and health disparities announced the inclusion of sexual and gender minorities as a health disparity population for health research 8 several studies have evaluated lgbtq health training and education in medical schools both the american medical association 9 and association of american medical colleges 10 specifically recommend the inclusion of lgbtqfocused topics in medical education to adequately prepare clinicians the aamc has also developed a curriculum for implementing curricular and institutional climate changes to improve healthcare for individuals who are lgbt gender nonconforming or born with dsd which outlines the health needs of lgbtq individuals and strategies for medical schools in designing curricula around lgbtq health 10 however a 2011 survey of 176 us medical school deans reported a median of two hours of lgbtqrelated content with 441 of deans reporting poor or very poor coverage of lgbtqspecific topics 11 in an online survey of 4262 medical students in the us and canada most respondents evaluated their lgbtqrelated curriculum as fair or worse after receiving specific education on lgbtq health 626 of these students felt more prepared and 463 felt more comfortable caring for lgbtq patients 12 some limited evidence suggests that inclusion of lgbtq content can effectively improve patient care for example a survey of one urban us medical school found that students who had more clinical encounters with lgbtq patients were significantly more likely to take comprehensive health histories hold positive attitudes toward lgbtq patients and possess knowledge of lgbtq health than students with little or no clinical exposure 13 recent studies have also revealed underlying bias and discrimination against lgbtq populations in medical educational settings one 2017 study found that 417 of medical students had witnessed discriminatory behaviors toward lgbtq students by their peers and superiors 14 in another large study of medical students 458 of heterosexual firstyear students exhibited explicit bias and 815 demonstrated implicit bias toward lgbtq individuals 15 a third study tested relationships between medical students implicit sexual orientation bias and various aspects of their medical school environment they concluded that medical schools may reduce bias among students by reducing negative role modeling among faculty improving the overall climate of diversity and improving formal student preparedness in lgbtq healthrelated topics 16 fewer studies have evaluated lgbtqrelated content in us dental schools or attitudes among dental students however the existing evidence suggests that dental medical training may include significantly less lgbtqrelated content to provide high quality oral healthcare dental professionals must be prepared to address issues of access to care and inclusion usage of inclusive language including the preferred name and pronouns of transgender patients and recognizing the family structures of lgbtq individuals additionally dental professionals must elicit appropriate information and make clinical decisions related to pharmacologic agents that lgbtq clients may use this includes awareness of the side effect profile associated with such agents including possible oral effects such as increased inflammatory reactions risk for autoimmune reactions in the oral cavity and medicationrelated xerostomia 17 despite the need for lgbtq competency in dental medicine in a 2004 survey of 47 us dental schools 49 of administrators reported that their curriculum contained between zero and two hours of lgbtqrelated content 18 a 2009 survey of student leaders from 30 dental schools in the us and canada found that only 133 agreed that their education prepared them well to treat lgbtq patients 19 among us and canadian dental school administrators 629 reported that their school had a written policy to protect lgbtq students and 833 reported a general antidiscrimination policy however 722 disagreed or strongly disagreed that it was important to provide specialized academic support for lgbtq students 20 research on lgbtqrelated curriculum in nursing schools is also limited in one study scores on a 15item lgbt health questionnaire improved from 1348 to 1467 after a brief learning module 21 another study surveyed 1231 nursing school faculty members about lgbtq curricular content and their preparedness to teach it 22 while 70 of faculty respondents indicated they were moderately or fully ready to teach lgbtq topics only 29 reported they had full or adequate knowledge of lgbtq health issues to our knowledge there have been no published studies comparing lgbtq curriculum and attitudes across medical dental and nursing schools however increasing attention on interdisciplinary education highlights the value of comparing how these three disciplines address preparedness to care for lgbtq patients by comparing three individual schools at one large institution we can gain perspective on the strengths and weaknesses of each and identify the ways health professional schools may work together to improve efficiently comparing the attitudes and experiences of students at different health profession schools may also suggest some underlying differences in the current attitudes of providers in each field the purpose of this study was to assess medical dental and nursing students perceptions of their preparedness to care for lgbtq patients by measuring their comfort levels with attitudes toward and formal training in lgbtq health we hypothesized that responses in all three domains would vary by both discipline and demographic groups specifically we hypothesized that students identifying as lgbtq would be more comfortable treating lgbtq patients and have more positive attitudes towards lgbtq populations but would be less likely to agree that their formal training in lgbtq health was adequate methods we conducted a crosssectional survey of students in the schools of medicine dental medicine and nursing at the university of pennsylvania between august and november 2014 students enrolled in any degree program at these schools were eligible for the study recruitment and procedures respondents were recruited through emails from the study team and school administrators and through distribution of surveys during large course meetings students had multiple opportunities to complete the survey either on paper or online but were instructed to do so only once the studys aims and a statement about voluntary participation were shared verbally in all emails and in writing on the survey tool survey tool we developed a 12item survey to assess students perspectives on how both the formal and informal curricula at their respective schools prepared them to care for lgbtq patients the formal curriculum refers to planned programs and learning experiences and the knowledge and skills that students are explicitly expected to learn the informal curriculum refers to ideas and lessons conveyed through policies rolemodeling and institutional culture 24 our 12item survey tool evaluated selfperception of preparedness across three domains that frame our broad understanding of preparedness to care for lgbtq populations 1 comfort with providing care to lgbtq populations 2 attitudes towards lgbtq populations and health and 3 formal training in lgbtq healthcare these domains reflect the recommendations of aamc leaders in a recent publication that institutions make active changes to both the formal and informal aspects of healthcare training curricula in order to effectively enhance provider competency and improve patient care 25 a recent review of educational interventions in lgbtq health also supports that both knowledge and attitudes towards lgbtq populations and health are important indicators of provider preparedness 26 this review and other observational studies confirm that comfort attitudes and formal knowledge are all likely to play important roles in improving patient care 26 27 28 table 1 displays the survey items in their respective domains we developed individual survey items de novo and reviewed them for face and construct validity with an interprofessional group of lgbtq and allied students questions were explicitly formulated to be applicable across healthcare disciplines based on the input of our interprofessional group we also distinguished between sexual and gender minorities in all survey items since all three domains are likely to vary based on the distinction of sexual orientation and gender identity respondents indicated their level of agreement with each survey item on a 5point scale from strongly agree to strongly disagree we also collected the healthcare discipline age gender identity sexual orientation and raceethnicity data data management and statistical analysis we first conducted descriptive analyses of survey data since the meaningful distinctions between response options strongly agree and agree were unclear we combined responses into three groups agreestrongly agree undecided and disagreestrongly disagree all statistical analyses are based on these combined response groups since the survey tool had not been formally validated we analyze each survey item individually throughout the analysis several demographic variables were grouped for analysis we divided age data into four categories 22 years old 2325 years old 2629 years old and 30 years old respondents could indicate multiple responses for raceethnicity sexual orientation and gender identity but we created mutually exclusive categories for analysis respondents were categorized as an underrepresented minority if they indicated black latinohispanic or native americanalaskan nativepacific islander to reflect common definitions of underrepresentation in healthcare fields all respondents with any nonheterosexual sexual orientation were grouped as lgbq for analysis to achieve enough statistical power for meaningful findings we distinguish lgbq respondents from gender minority respondents because gender identity is distinct from sexual orientation and transgender individuals also have a distinct sexual orientation four respondents marked other as their gender identity two of these individuals also marked male or female gender and were grouped accordingly while the two respondents who chose only other were grouped in an other gender category we then compared responses to each question across schools using both the nonparametric kruskalwallis test with α set to 005 and an ordered logistic regression model the model estimates the effects of demographic variables including school on the likelihood that respondents agreed or strongly agreed with each survey item regression coefficients are reported as odds ratios statistical analysis was performed using stata and r analysis software results a total of 1010 students completed the survey table 2 describes characteristics of the sample the overall survey response rate was 43 with a response rate of 76 in the school of medicine 24 in the school of dental medicine and 33 in the school of nursing the variation in response rates is likely a product of the convenience sampling method used for data collection and may reflect students in each school were given opportunities to complete the survey medical students for example were most commonly recruited fewer respondents agreed with survey items focused on formal training in lgbtq health fortyeight percent of respondents agreed that their training had prepared them to care for lgbtq patients and 45 of respondents agreed that they knew where to look for information regarding lgbtq health overall 79 of respondents agreed that they were interested in receiving more education about lgbtq health students perceptions of instructor competency in lgbtq health was low with only 48 of students reporting that their instructors had demonstrated lgbtq health competency similarly 52 of respondents reported that their school had integrated lgbtq content in to the formal curriculum however most students were interested in further education on lgbtq health topics in their professional program variation across participant disciplines we performed kruskalwallis tests to measure differences in the distribution of responses between schools and found significantly different response distributions for all survey items except items 8 9 and 12 most of these differences reflect differences between dental students and other respondents for example significantly fewer dental students agreed that they felt comfortable discussing sexual health than medical students and nursing students significantly fewer dental students agreed that their instructors demonstrated competence compared to medical and nursing students additionally only 13 of dental students agreed that their curriculum had incorporated lgbtq related content compared to 58 and 55 of medical and nursing students respectively while only 3 of medical and nursing students agreed that they could visually identify whether a patient was lgbq 6 of dental students agreed similarly while only 4 of medical and 5 of nursing students agreed that they could tell whether a patient was transgender or gender nonconforming by sight 12 of dental students agreed conversely more dental students agreed that they were comfortable treating lgbq and trans patients than medical and nursing students table 3 shows the results of the ordered logistic regression model which was used to estimate the effects of demographic variables and specific discipline on the likelihood of agreeing with each survey item individually this model confirms our findings from kruskalwallis tests that dental students were less likely to be comfortable discussing sexual health than medical students but more likely to be comfortable treating lgbq and transgender patients both dental and nursing student respondents were more likely than medical students to indicate that discussing sexual health with lgbtq patients was more difficult than with heterosexual patients dental students were also again less likely to agree that lgbtq content was integrated into their program and that their instructors demonstrated competency in this area nursing students were more likely to agree that their instructors demonstrated competency in lgbtq health than medical students dental students were less likely to report interest in further training than medical students variation across demographic characteristics results from the logistic regression model also suggest that demographic factors such as participant gender sexual orientation and raceethnicity may be associated with the likelihood of agreeing with the survey items the two respondents remaining in an other gender identity group were excluded from the regression analysis therefore comparisons by participant gender include only male and female respondents compared to male respondents female respondents were more likely to agree that all healthcare providers have a responsibility to care for lgbtq patients female respondents were also more likely to disagree that one can identify a sexual or gender minority individual by sight alone finally female respondents were also twice as likely as male respondents to express interest in further education on lgbtq health topics the odds of agreeing with several survey items were also impacted by participant sexual orientation respondents with any lgbq identity were overall more likely to endorse comfort with and positive attitudes towards lgbtq populations lgbq respondents were more than twice as likely to agree that they were comfortable caring for lgbq and transgender patients than were heterosexual respondents lgbq respondents were also more likely to agree that all healthcare providers have a responsibility to care for lgbtq patients similarly lgbq respondents were less likely to agree that they could recognize sexual and gender minorities by sight alone lgbq respondents were less likely to agree that discussing sexual health with lgbtq patients is more difficult however lgbq respondents generally had more negative perceptions of their formal training in lgbtq health lgbq respondents were less likely to agree that their programs had prepared them to care for respondents who indicated gender identifications other than female or male were excluded from this analysis though their presence at the studied institution should be noted comfort level attitudes formal training variable 1 discussing sexual health treating lgbq patients 3 treating trans patients 4 responsibility to treat lgbtq patients can tell if a patient is lgbq 6 can tell if a patient is transgender 7 lgbtq patients more challenging lgbtq patients that lgbtq content was integrated into their programs and that their instructors demonstrated competency in lgbtq health lgbq respondents were over 5 times as likely to report interest in receiving additional lgbtqspecific education in addition participant raceethnicity was found to be associated with the odds of agreeing with some survey items respondents in the asian raceethnicity group were less likely to agree with all three survey items reflecting comfort levels compared to white respondents this group of respondents were more likely to agree that they could identify gender and sexual minority patients by sight alone and that discussing sexual health with lgbtq patients was more difficult we found no statistically significant differences in odds of agreeing with survey items between white and urm respondents discussion to our knowledge this was the first study to examine and compare medical dental and nursing students perceptions of their preparedness for caring for lgbtq populations our results demonstrate that health professional students generally hold positive attitudes towards caring for lgbtq populations and have interest in receiving more lgbtqfocused training however respondents reported mixed evaluations of the formal preparation they had received variation across disciplines dental students specifically displayed slightly less positive and more stereotypical attitudes towards lgbtq populations and had less positive perceptions of their formal training in lgbtq health there are several possible explanations for these findings there may in fact be a more significant gap in lgbtq health content and instructor competency in this school of dental medicine compared to the school of medicine and school of nursing there was also less interest in lgbtqspecific training among dental students however dental student respondents had the highest odds of agreeing that they were comfortable treating lgbq and transgender patients alternatively the high reported levels of comfort treating lgbtq patients in this survey may be attributable to selection bias in which dental students who already felt more comfortable with lgbtq populations and therefore perceived less need for additional training in lgbtq health were more likely to complete the survey the significantly lower response rate in the school of dental medicine also suggests that selection bias may disproportionately affect findings about dental student respondents these seemingly contradictory findings may also reflect the misconception that lgbtqspecific training is not relevant to or required for highquality dental practice in fact the inclusion of lgbtq healthcare topics in dental curricula is important for various clinical skills first dental practitioners like all healthcare professionals need to be aware of and be able to address barriers to healthcare that are commonly experienced by marginalized populations dental practitioners must also understand the effects of relevant medical history or medication use on dental care and effectively screen for oral infections and diseases for which parts of the lgbtq population may be at higher risk these include oral lesions that result from sexually transmitted infections as well as oral complications of other health disparities faced by the lgbtq population such as decreased healthcare usage increased substance abuse and others it is important that a dentist can effectively elicit relevant information from all patients by asking appropriate questions and speaking knowledgeably about sexual health with all patients the commission on dental accreditations accreditation standards include standards for cultural competence 29 the american dental education associations diversity and inclusion advisory committee also recommends that dental education programs include cultural competency education and a broader diversity agenda that goes beyond raceethnicity 30 while these standards and recommendations can be interpreted to include gender and sexuality topics they do not specifically mention or require coverage of lgbtq populations national dental education organizations should identify and name relevant lgbtq health topics and schools of dental medicine should outline specific curricular goals related to lgbtq health these actions by national organizations can help lead to more effective and complete care of lgbtq patients in dental care settings differences in trainees perceptions of their preparedness to care for lgbtq populations across disciplines in this study highlight the potential value of interprofessional learning and resourcesharing when addressing lgbtqfocused content the national academy of medicine has identified interprofessional learning as a key strategy for effective health professional education 31 improving lgbtq health outcomes and narrowing disparities will require interprofessional and healthcare teambased interventions using interprofessional approaches to improving lgbtq health education will allow individual schools to benefit from others resources and successes and increase opportunities for exposure to lgbtq populations during clinical training for example schools could develop crosslisted courses focused on lgbtq health topics that are available to students across health professions students could engage in interprofessional clinical and simulationbased training experiences focused on lgbtq health that teach both clinically relevant information but also communication and teamwork skills 32 interprofessional programs also have the potential to increase the visibility of lgbtq health initiatives within a university or health system further improving aspects of the training environment that may impact students comfort level with and attitudes towards lgbtq populations variation across demographic factors respondents gender and sexual orientation also impacted responses in this study for example holding other factors constant female trainees were more likely to agree that all healthcare providers have a responsibility to treat lgbtq patients and be interested in further lgbtqfocused education our data cannot explain what is driving such differences but it is possible that femaleidentified trainees have more personal experience with the impact of gender on health and therefore recognize the importance of lgbtqspecific health education further research on the impact of provider gender identity on patient care among lgbtq individuals is warranted lgbq respondents also reported poorer perceptions of their formal training in lgbtq health than those who identified as heterosexual this population may have higher expectations for such training or may be more attentive to the quality of lgbtq content in their training lgbq respondents also reported more comfort with treating lgbq and transgender patients possibly due to personal or extracurricular clinical experiences in settings with lgbtq patient populations health professional schools may be able to draw on the experience and expertise of lgbtq and allied students to develop formal content clinical immersion opportunities and a safe and welcoming climate ongoing collaboration with these student leaders can help identify deficiencies in the formal curriculum and foster innovative solutions and initiatives to include lgbtq health once identified however it is crucial that the work of students be fully institutionalized via course content special educational opportunities programmatic policies and elsewhere so that these improvements become effective longterm solutions changing institutional culture to fully include lgtbq health content requires that all students be consistently exposed to lgbtq content and that schools maximize opportunities for clinical encounters with lgbtq patients this requires the engagement and commitment of both faculty and school administrators and permanent integration of lgbtqrelated topics into health professional training some survey items were also significantly impacted by the raceethnicity of respondents holding other variables constant respondents in our study who identified their raceethnicity as asian were significantly less likely to be comfortable with lgbq and transgender patients agree that all healthcare providers were responsible for caring for lgbtq patients and had poorer perceptions of their formal training in lgbtq health compared to their white peers again our data cannot explain the cause of these differences but differences in comfort levels may reflect different social norms around sexuality and lgbtq populations poorer perceptions of their formal training in lgbtq health may represent a similar attentiveness to content related to marginalized populations among nonwhite trainees while no other raceethnicity identities were statistically significantly associated with the odds of agreeing with survey items all nonwhite groups had point estimates less than one for all survey items that evaluated formal training some research has suggested that a more diverse healthcare workforce may have the potential to mitigate some healthcare disparities especially those related to access 3334 study limitations our study was limited by several factors for instance we achieved a relatively low response rate from the school of dental medicine and conveniencesampling techniques limit the representativeness of the sample in addition we conducted this study at a single large private university in the northeastern us which may attract a nonrepresentative student body with particular preexisting attitudes towards lgbtq populations investigators should extend this research to include representative samples of medical dental and nursing trainees throughout the us additionally we did not formally validate our survey prior to data collection though items were reviewed by an interprofessional group of lgbtq and allied students larger studies would benefit from a validated instrument to measure aspects of curriculum including formal evaluation of unconscious and conscious bias against lgbtq populations among health professional students it is also likely that social desirability bias had some effect on our findings that is respondents may not have responded honestly about negative attitudes towards or discomfort with lgbtq individuals because they felt pressured to express acceptance of these populations due to social norms healthcare providers may be specifically subject to this bias students with positive attitudes toward lgbtq populations or more knowledge of lgbtqrelated healthcare topics may have been more likely to respond to the survey we made efforts to ensure anonymity of all respondents in order to mitigate the impact of this social desirability bias but we recognize that it may still be present by offering multiple opportunities to complete the survey to maximize response rate this survey also was susceptible to redundant sampling with deidentified response data we were not able to delete any duplicate respondents but all potential respondents were consistently instructed only to complete the survey once both verbally and in writing our study was also limited by relatively small sample sizes of lgbtq respondents this required us to combine all sexual minority identities into the lgbq group for analysis our sample did not include enough transgender respondents to provide a meaningful group for analysis it may be true that respondents identifying as lesbian gay bisexual queer or other identities may have significantly different perceptions of their training in lgbtq healthcare but we believe that a combined sexual minority group are likely to represent a meaningful analytic group and that these potential differences are more likely to be at the level of specific lgbtq content which our study did not aim to evaluate our survey did not collect certain data that may also be important in understanding healthcare trainees perceptions of preparation in lgbtq health for instance medical trainees with different intended areas of medical specialization may have different comfort levels with or attitudes towards lgbtq patients however these differences could be preexisting as opposed to a reflection of their preprofessional training regardless of the cause of these potential differences though efforts to improve clinical care will need a basic understanding of the preparation of clinicians practicing in specific specialties additionally we did not analyze our data by trainees level of education nursing students are typically at a different stage of postsecondary education than are medical and dental students the inherent differences between medical dental and nursing schools including required number of years of training different degree programs and undergraduate or graduatelevel training prevented this analysis from being meaningfully included in the current study our findings do however support further investigation of how informal and formal curriculum shape comfort attitudes and knowledge throughout the course of healthcare education recommendations the results of this survey further knowledge of lgbtq healthcare education by comparing preparedness across three health professional schools the results suggest a need for continued improvements in curriculum and development of validated evaluation tools for health professional curricula findings from this study show that medical dental and nursing students report similar issues in both the informal and formal curricula related to lgbtq populations our findings suggest that interprofessional efforts to improve lgbtq health training are warranted interprofessional approaches may be specifically valuable in their capacity to capitalize on limited resources and effect longterm change in trainees behaviors as mentioned above several previous studies have evaluated the shortterm impact of brief educational and integrated curricular interventions on lgbt health knowledge but to our knowledge no studies have included longterm follow up to track objective aspects of patient care among those exposed to these educational interventions as healthcare training institutions work to improve curricula they should also consider the prevalence of lgbtq patients and professionals in their own communities institutions should foster inclusive environments and respect the expertise of these individuals and communities interventions can also be made in individual programs to improve lgbtq healthcare training lgbtqrelated content in all healthcare training programs should appear as distinct topics such as hormonal and surgical gender affirmation the increased risk of mood disorders in certain lgbtq communities due to social isolation and discrimination health disparities affecting lgbtq populations including increased alcohol drug and tobacco use and appropriate use of language and gender pronouns this content should also emerge through increasing visibility of these populations within more general topics for example case studies introduced throughout the curriculum should include lgbtq people and families and courses that focus on patientprovider communication building rapport or professionalism should include specific issues faced by lgbtq populations this content should be evidencebased and should avoid further stigmatization of lgbtq people while addressing difficult and sensitive topics through contextualization all relevant data are within the paper and its supporting information files ethics statement the authors disclose no conflicts of interests the university of pennsylvania irb approved this investigation as an exempt study because the study did not require the collection of any identifiable data from any participants this designation waived the irb need for formal written consent respondents read a statement which informed them that the study was completely voluntary summarized the purpose of the study and how their data would be used respondents were informed that by completing the survey they were offering their consent to participate students were encouraged to contact the study team with questions or concerns we did not collect any identifying information in order to ensure anonymity and reduce refusal rates due to related concerns all survey data were stored in the redcap online data application 23 the irb approved this consent procedure as submitted in our irb protocol methodology madelyne z greene kevin d chen andy wu supporting information s1 table complete participant data this table includes responses project administration madelyne z greene supervision andy wu baligh r yehia writing original draft madelyne z greene katherine france edward f kreider emily wolferoubatis kevin d chen writing review editing madelyne z greene katherine france edward f kreider emily wolferoubatis andy wu baligh r yehia

lesbian gay bisexual transgender and queer lgbtq populations face multiple health disparities including barriers to healthcare few studies have examined healthcare trainees perceptions of their preparedness to care for lgbtq populations and none have compared perceptions of training across medicine dental medicine and nursing we aimed to understand variations across disciplines in lgbtq health by assessing medical dental and nursing students perceptions of preparedness across three domains comfort levels attitudes and formal trainingwe developed a 12item survey with an interprofessional panel of lgbtq students from the schools of medicine dental medicine and nursing at a toptier private university in the united states any student enrolled full time in any of the three schools were eligible to respond we performed descriptive statistical analyses and examined patterns in responses using kruskalwallis tests and an ordered logistic regression model1010 students from the schools of medicine dental medicine and nursing responded to the survey for an overall response rate of 43 while 7074 of all student respondents felt comfortable treating lgbtq patients fewer than 50 agreed that their formal training had prepared them to do so overall 7181 of students reported interest in receiving formal lgbtq health education though dental students were significantly less likely than medical students to report this interest or 053 p 001 respondents who identified as lgbq

with eds present descriptive data on symptomatology and psychopathology for a community sample of latinas with binge eating disorders discuss barriers that hinder treatment seeking make recommendations for future research and practice and consider challenges posed by cultural and sesrelated factors for the duration of this paper latinas will refer to latinas in the us eating disorders in us latinas what do they look like case illustration 1 kp is a 20yearold college student born in the united states to parents who emigrated from mexico she lives at home with her parents and describes having excellent social support from family and friends she is a highly motivated student who works several jobs in addition to attending school kp reports that her weight and shape are of little importance to her however she is very petite and has sought medical care for being underweight despite her size she consumes large amounts of food during a typical binge her work schedule often causes her to go the entire day without eating and at night she will then consume an entire days worth of food in one sitting for example one night from 900 to 1030 pm she consumed two hot pockets five bowls of cereal three cups of noodles a small salad a grilled chicken breast and a snacksize bag of doritos she explains that since she is so hungry at the end of the day once she begins eating she just cant stop she describes a loss of control as once i begin eating i feel i have to eat more and more cereal ice cream and chips are the trigger foods she most commonly associates with a binge and with feelings of being unable to stop eating to avoid binging kp will lock herself in her bedroom and avoid the first floor and kitchen area of her house after dinnertime kp reports that she has an average of nine binge episodes during a typical month she recognizes that her eating habits are unhealthy and could cause her longterm harm but feels she is unable to control them kp expresses that she is interested in making changes to her eating for her own health case illustration 2 ba is a 33yearold mexican woman she is a mother of four daughters from three fathers who no longer support her she describes her life and childhood as having been very difficult since moving to the united states ba and her daughters have resided with her brother and his family who help to support her she has an eighthgrade education and works parttime and only as needed money is a major concern and her eating patterns recently were affected by a stomach illness that went untreated for several weeks because of lack of health insurance ba is very overweight and hopes to gain control over her eating and her size she is highly concerned with her weight and her shape and has constant fear of weight gain and feelings of fatness she describes being easily triggered to binge when her daughters are eating unhealthy yet appealing foods she also frequently binges after her children go to sleep ba describes a typical binge as being an entire bag of groceries she rarely eats breakfast and eats late most nights ba reports that she binged on 20 of the 28 days prior to her interview and twice on most of those days for example one night from 1100 to 1130 pm she consumed two large portions of rice two large portions of beans four pieces of meat and 15 tortillas ba expresses a desire to change her eating patterns for both her appearance since she is a single woman and her health she is concerned that her health will interfere with her ability to care for her daughters as these case illustrations demonstrate eating disorders do exist among latinas although no true epidemiological studies have been conducted existing data indicate that rates of occurrence are similar to those reported for the general population of us females lifetime prevalence estimates for bulimia and binge eating disorder among latinas range from 19 to 20 and from 23 to 27 respectively symptomatology and associated psychopathology are similar to those of europeanamerican white women as with white women latinas with eds are more likely than healthy controls to report histories of abuse particularly sexual abuse and to report lifetime experiences of depression anxiety substance abuse and other comorbid disorders the available empirical evidence suggests that risk factors for development of an ed may be similar for the two groups despite these similarities group differences in presentation of dietary restriction or drive for thinness have been identified latinas with eds are less likely to report histories of dieting or current dietary restriction compared to white women and anorexia nervosa is rarely noted in studies with latinas among latinas binge eating is commonly reported and typically accompanied by obesity and its associated health problems to date there has been little research comparing diagnostic groups or criteria within the latina population for the most part it seems that available diagnostic categories are adequate for detecting clinically significant eating problems and can be used in research and practice with latinas using these diagnostic categories we present descriptive comparisons of ed symptomatology and psychological functioning between groups of latinas with bed recurrent binge eating and bn participants were recruited from latino communities in two large metropolitan areas in the united states a wellestablished diagnostic exam was administered as an interview in english or spanish to establish eating disorder criteria and commonlyemployed measures of psychopathology were used to assess psychological functioning the three diagnostic groups are similar in eatingrelated pathology age of onset and psychological functioning it is interesting to note that in this sample the average age of onset for women with bn is slightly later than those for bed and rbe which is the converse of what is generally reported for europeanamerican women latinas in the bn group report higher frequencies on average of binge eating and higher levels of psychiatric distress than those with rbe or bed the association of bn with higher levels of pathology is welldocumented for white europeanamerican women and may have affected our sample size for bn by serving as a barrier to participation average weight is somewhat lower for the bn group as compared to the other two diagnostic groups which is as expected given their regular use of compensatory behaviors overall mean scores on these measures for this latina sample are comparable to those reported for both white and latina samples of women with bed and bn in recent studies these data indicate that recurrent binge eating in latinas is associated with significant levels of distress and psychopathology therefore the most current criteria proposed in the recent diagnostic and statistical manual of mental disorders 5 th edition which formally recognizes bed as an ed with a threshold criterion of binge eating at one time per week for three months appears to be valid for accurately detecting eating disorders in us latina populations unfortunately these disorders are for the most part underdetected and undertreated why dont they seek treatment findings from communitybased research indicate that a very small percentage of latinas seek treatment for eds despite reporting clinically significant distress due to their disorder those few who do seek professional help typically turn to primary care physicians who may address the accompanying obesity but often miss the opportunity to recognize and treat the underlying ed the main barriers to treatment seeking are similar to those that hinder mental health care utilization in general feelings of shame fear of stigma a belief that one should be able to help oneself inadequate insurance coverage or financial resources lack of awareness that a formal disorder exists and that treatments are available and lack of confidence in healthcare providers as would be expected greater acculturation to us mainstream society may increase likelihood of treatment seeking among latinas although among communitybased samples the effect of acculturation on eds and help seeking is mixed ultimately factors related to ses or education may play a greater role in helpseeking behaviors among latinas what is clear is that binge eating disorders with the accompanying weight problems and obesity pose serious health risks at the same time while disparities in access to health care have diminished for all other minority groups they have increased among latino communities therefore the lack of evidencebased ed treatments that are accessible to this population is of particular concern implications for theory research and practice the empirical evidence suggests similarities in risk factors symptomatology and associated psychopathology between latinas and white europeanamerican women diagnostic dsm criteria seem to fit latinas particularly the new dsm5 criteria for bed despite these similarities some group differences in behavior symptoms and helpseeking behaviors are apparent future research is needed to investigate culturespecific factors that might help explain these differences furthermore research to date has focused on samples of mexican americans in the us or on hispanic groups of unspecified origin we are not aware of any data documenting differences in eds or risk for development of eds between latina groups given the potential importance of cultural factors in identification and treatment additional investigations that focus on specific groups or that compare groups of latinas would be valuable importantly it is unclear if such identified differences between latinas and europeanamerican women are the result of cultural beliefs and norms or the result of sesrelated factors food consumption and preparation are mechanisms used by ethnic minority groups in order to maintain a sense of identity and belonging among latinos women serve as the keepers of cultural values by selecting and preparing foods and organizing family activities although culture plays a role in food choice those choices are also determined by ses and other factors financial difficulties time constraints and the multiple demands typically placed on latinas from lowses backgrounds are associated with preference for easytoprepare and energydense foods future studies would benefit from including women from different latino groups and from diverse ses backgrounds to systematically assess and potentially disentangle the joint influence of these factors on symptoms and behaviors among women with eds with the aim of better addressing the needs of this population based on the available evidence efforts to meet the treatment needs of latinas in the us should aim to increase awareness and education about eds and to address cultural beliefs or norms that may act as barriers to treatment utilization further latinos in general often rely on primary care providers for their mental health needs as such educating and training healthcare professionals on how to identify eds can contribute to increased rates of detection and treatment finally it is important to develop accessible culturallyacceptable and costeffective evidencebased treatments for latina and lowincome women that can be disseminated through partnerships with primary healthcare clinics and community organizations

this paper provides a brief summary of the literature on eating disorders eds among latinas in the us and presents data that illustrate symptomatology and associated psychopathology in this group the current empirical evidence suggests similarities between latinas and white europeanamerican women in regards to risk factors symptomatology psychopathology and prevalence of eds despite these similarities latinas are less likely to report dieting dietary restriction and are more likely to be obese compared to white women although latinas report distress associated with eds only a small proportion ever seek treatment several factors appear to contribute to their underutilization of services including lack of knowledge stigma beliefs about seeking treatment lack of health insurance and lack of affordable and accessible treatment services it is unclear whether the identified differences between white and latina women are the result of cultural factors or are better explained by disparities in ses efforts to meet the treatment needs of latinas in the us should aim to increase awareness and education about eds in this population and to address cultural beliefs and norms that may act as barriers to treatment utilization further it is important to educate and train healthcare professionals to be aware that eds may develop in or affect latina patients and to develop accessible culturallyappropriate and costeffective evidencebased treatments that can be disseminated through partnerships with primary care providers and community organizations keywords barriers eating disorder latinas treatment this global postcard describes eating disorders eds in the latina community in the united states latinos are the fastest growing and largest minority group in the united states the latino population is highly heterogeneous and includes individuals from varied countries of origin generational status and socioeconomic status ses we begin by presenting two case illustrations of latina women with eating disorders from different backgrounds then we briefly describe symptoms and associated pathology among latinas

introduction domestic violence and abuse includes any controlling coercive or threatening behaviour violence or abuse between those aged 16 or over who are or have been intimate partners or family members it is a widespread phenomenon that impacts on victims health and exposure to dva in their home has adverse effects for childrens health and social development in many countries clinicians have a professional duty to identify children in need of special support from social services suggests gps take a lead professional role providing and coordinating support services from an early stage and gps are advised to provide advocacy and services tailored to … risk and specific needs which include specialist domestic violence and abuse services for children and young people while a body of research is emerging on the general practice response to adult victims of dva uncertainty remains about the best general practice response to children and young people family physicians are uniquely privileged in working with adult and child family members over sustained periods in the uk they are the first point of access to health care for both children and adults and potentially the first professionals to identify early signs of child maltreatment victims of dva see gps as a source of support but clinicians are uncertain about whether they have sufficient knowledge and competence to respond clinicians feel relatively competent in making a child protection referral when risks are high and apparent but are hesitant where levels of risk are less clear conflict of interests between protecting children and sustaining relationships with all family members arise research has shown consistent potential for the needs of children experiencing dva to be overlooked in favour of a focus on adults this article draws on 54 interviews with general practice clinicians in england to illuminate current practice and attitudes towards engaging with other family members when a parent discloses dva interesting contrasts emerged in clinicians perspectives on engagement with children and abusive fathers methods qualitative semistructured telephone interviews with 42 gps and 12 practice nurses and nurse practitioners were conducted by a multidisciplinary academic research team in 2013 a mix of metropolitan urban and semirural practices were recruited by email from across six clinical commissioning areas covering locations of both higher and lower levels of specialist dva service provision in the north south and midlands of england the majority of practices approached chose to not participate usually due to lack of time the total number of interviewees was not predetermined it was based on ensuring geographical spread and recruitment continued until no new themes were identified table 1 details the gender age and experience of the interviewees it shows a slightly higher proportion of female gps compared with the national figure only half of the clinicians had the experience or awareness of at least one dva case interviews lasted on average 30 minutes the interviews started with a vignette in which a patient disclosed physical violence from her partner to a gp or pn she also described his controlling behaviour towards their three children aged 7 5 and 2 years the vignette allowed for exploration of clinicians views on responding to dva and child safeguarding even where their own experience was limited additional questions eliciting clinicians responses in the event that dva was disclosed are detailed in table 2 interviews were audio recorded with consent transcribed verbatim loaded into qualitative data analysis software and analysed thematically a coding frame was developed by the multidisciplinary team from the literature and concepts that emerged during data collection and following recommendations developed through discussions with two panels of professional and service user experts the analysis reported here focused on perspectives of barriers and facilitators of engagement with child victims and adult perpetrators who were patients of the practice not the adult victims disclosing dva clinician and practice variables are reported where they correspond to visible differences in perspectives on engagement with other family members results in response to the vignette and questions about their own practice clinicians provided their perspectives on talking with other family members they talked about children and abusive partners in families experiencing dva their perspectives revealed considerable variation in their practice and attitudes towards the two groups children five of the 47 respondents who discussed engaging with children in families experiencing dva said they routinely would seek to talk to children directly these five female clinicians were based in relatively affluent areas with higher levels of specialist dva service provision seventeen respondents said they might seek to directly engage with children in some circumstances of these 17 5 gps noted this would be quite a way down the line after talking to other professionals 6 gps said this would depend on whether an opportunity arose twentyfive respondents would not seek to engage directly with children to assess them to elicit information from them or to directly support them if you ask children about domestic violence youre making this accusation about so and so … i think that talking to the mother is how you kind of assess the … impact on the kids probably wouldnt actually go and say engage with the children … probably wouldnt proactively … might put a code in their notes nine qualified their answers during the interview to say that if a parent brought a child to be examined or a child disclosed experience of dva they would naturally pick up on this over half of those who discussed the issue said they would never see children alone while 11 respondents said that they might ask parents to leave the room so they could talk to the child alone one gp outlined an approach to achieving this would you mind if i just had a word with them your child on my own for a few minutes just to explore whether there are any issues that they … wanted to talk about that they didnt feel comfortable to raise in front of mum or dad another gp described the importance of being led by a childs wishes in this regard there were concerns regarding competence related to both childrens competence as informants and clinicians competence as communicators five gps and two pns made clear distinctions between childrens competence at different ages there was no age above which clinicians consistently agreed it would be appropriate to talk to children about dva some were hesitant even about talking with teenagers although most interviewees had received child protection training seven clinicians had concerns about their ability to make themselves understood saying i dont have the skills talking about dva was seen as particularly difficult even for those who had skills in discussing sensitive issues i talk to children a lot about their parents dying and things and i find that a lot easier funnily enough than talking to them about violence fear of misunderstandings was evident with three clinicians concerned that children could twist things that adults say and that children could potentially divulge to perpetrators that dva had been discussed surprisingly three of six interviewees with safeguarding lead responsibilities and six of nine who had received specialist dva training said they would not talk to children either because they would not see it as their role to do so or for fear of asking leading questions four gps saw talking to children as something they would leave for social services or saw it as the role of the safeguarding team or the police four pns saw this as a gp rather than pn responsibility gps who would not proactively engage with children tended to have less experience of patients experiencing dva they were less likely to consult a health visitor social services or school nurse or make a child protection referral abusive fathers of the 46 respondents who discussed this issue 12 would not attempt to raise the issue unless abusive partners raised it themselves sixteen said they would attempt to broach related issues but that they would be aware of the need not to break confidentiality or increase risk eleven would proactively ask the victim for consent or direction about whether to raise the issue with a perpetrator seven gps said they would confront the perpetrator about dva these gps tended to be older proportionately more were male and three had received no training on dva for the 12 gps and nurses who would not attempt to raise the issue of dva unless perpetrators raised it safety for the victim and children was the key concern they perceived potential risks that engagement with perpetrators might pose to families whilst im understanding of the need to help support and get treatment for perpetrators where possible i would be very concerned about increasing the risk to these to the children and adults … it may escalate problems the seven who would confront the perpetrator indicated no awareness of the risk posed to families three of them assumed that if their practice received official written notification of dva from another agency the abusive partner would already know about allegations or might as well know from the gp as anyone else in contrast to their diffidence with respect to talking with children interviewees concern for their own competence regarding talking to perpetrators was markedly absent only one pn felt she was not competent to do this and seven gps appeared confident that they had the appropriate skills to work effectively with couples noting that they would seek to see both victim and perpetrator together if possible itd be nice to have them you know both in as a couple to talk about it listening to his … take on things this couplecentred approach tended to come from gps with little or no experience of dva cases and more years in practice key differences in clinicians relationships with children and perpetrators the extent of clinicians readiness to engage with other family members related to similar issues opportunity concerns about potential consequences and risks and responsibilities regarding consent and confidentiality however perceptions of other family members as competent informants as patients and as established relationships emerged as key differences in their attitudes towards engaging with children when compared to perpetrators abusive fathers were perceived as competent informants some gps would engage to see if there are ways that we can engage dad to find out dads perspective on this or noted that there are always two sides to any story perpetrators were also seen as active service users able to engage with advice behaviour change and support with dvarelated health problems recognition of children as competent patients in their own right appeared to be limited rather nonabusive parents or other professional adults were identified as informants about children when engagement was envisaged with children they tended to be conceptualized as passive informants who might not even know the reason for the consultation a gp may just look for … signs of physical abuse that the parent may not have noticed children were conceptualized as lacking any direct access to health services you couldnt phone a child and talk to them you know … you could maybe say to a parent do you mind if i speak with them on their own some gps reflected extensively on the needs of perpetrators as illustrated by this gp who reflects here on the needs of danny the father in the vignette you could have a situation where a man has been violent towards a woman and feels really bad about it and and doesnt know why he got that angry and needs some help in controlling his anger and … hes your patient … so maybe he needs some input although 11 clinicians said they would never or only in exceptional circumstances see children in relation to their experience of dva none suggested that perpetrators should never be seen at the surgery about dvarelated issues one gp had to correct himself to even concede that children are patients in principle in line with previous research existing relationships were consistently described as significant to working with perpetrators if youve got a relationship with the man already then it makes it more likely that theyll come in in contrast only one gp suggested that existing relationships could enable proactive and direct engagement with children lack of time was repeatedly cited as creating difficulties in establishing relationships with children in contrast lack of time to engage with perpetrators was not mentioned those few clinicians who were prepared to engage directly with children argued that offering opportunities to see the doctor could facilitate active patienthood and give children the sense that its okay to come and talk to you about anything that worries them two female gps described providing children with direct support rather than simply assessing and referring on to childrens social services they listened to children over time and would assist them to access specialist services discussion we found low levels of gp and nurse proactive engagement directly with children experiencing dva and our study suggests that a focus on adults extends to include a tendency towards working with the abusive partner when shehe is a known patient in the practice rather than with children this trend may have relevance for family physicians in other countries as the invisibility of children in general practice has been noted elsewhere and adult patients experiencing dva have suggested that family doctors should provide children with followup support if they too are patients of the practice strengths of our study include the relatively large number and wide spread of the practices and interviewees involved compared with previous qualitative studies enabling thematic saturation its limitations include a vignette that did not incorporate older children however clinicians were asked to identify differences in their approach to teenagers although some adult service users contributed to analysis a further limitation is the absence of childrens perspectives on how and when clinicians engage directly with them the study is consistent with previous research where gps were found not to engage directly with children and indicates the need to improve opportunities for children experiencing dva to communicate directly with general practice clinicians the actual and proposed practice of most clinicians interviewed would fall short of expectations outlined in english general medical council guidelines on child safeguarding these apply to all children including those in families experiencing dva they state that doctors working with children and young people have a duty to listen and talk directly to them to make sure they know who they can go to for help to seek consent for information sharing from those children with capacity and regardless of capacity to take account of childrens wishes when making judgements about their best interests previous research indicates that direct communication with children is facilitated by proactive child focused communication skills this study suggests that engaging directly with children experiencing dva relies on recognizing them as patients offering them opportunities to see clinicians on their own and establishing ongoing relationships with clinicians internationally lack of training is a barrier to family physicians recognizing and responding appropriately to child maltreatment while training may be a means of improving family physician competence and confidence in working with families experiencing dva it is important that training is appropriate and fit for purpose this study found that child protection training and lead roles did not necessarily coincide with greater confidence in working directly with children exposed to dva indeed current training may exacerbate fears about talking to children without highlighting the potential risks involved when engaging with dva perpetrators the impact of different forms of training could be explored in health systems where paediatricians with more focused training and experience of child communication are the first point of contact clinicians gender and professional role together with local deprivation and level of dva service provision may be barriers to engagement with children the only clinicians who said they would routinely engage with children experiencing dva were female gps in more affluent areas with higher levels of specialist dva service provision the link between low levels of specialist dva services and low levels of direct engagement with children underlines the importance of redressing the lack of service availability especially as children have called for communitybased services some respondents argued that they lacked the time to engage directly with children but many saw themselves as able to find the time to engage with adult perpetrators and couples together despite the risks associated with this if more clinicians including male practitioners and nurses are to direct their time towards working effectively with children this will also require supportive practice environments that challenge genderand rolebased constraints on practice conclusion as stated in uk guidance and the united nations convention on the rights of the child children should be viewed as competent to express views in relation to their health and support needs regardless of whether they are deemed to have capacity to make decisions training must therefore be designed to encourage appropriate direct engagement with children experiencing dva rather than feeding cultures of fear child invisibility or avoidance this could be enabled by supportive practice environments and more widespread provision of specialist dva services

background government and professional guidance encourages general practice clinicians to identify and refer children who experience domestic violence and abuse dva but there is scant understanding of how general practice clinicians currently work with dva in families objectives the study explored general practice clinicians practice with children and their parents experiencing dva and reflected on the findings in the light of current research and policy guidelines methods semistructured interviews with 54 clinicians 42 gps and 12 practice nursesnurse practitioners were conducted across six sites in england data were analysed using current literature and emerging themes data presented here concern clinicians perspectives on engaging with family members when a parent discloses that she is experiencing dva results when a parent disclosed dva clinicians were more likely to consider talking to abusive fathers than talking to children about the abuse perspectives varied according to whether consultation opportunities arose risks consent and confidentiality perceptions of patienthood relationships and competence shaped clinicians engagement perpetrators were seen as competent informers and active service users with potential for accepting advice and support clinicians were more hesitant in talking with children where this was considered children tended to be seen as passive informants only two gps described direct and ongoing consultations with children and providing them with access to supportclinicians appear more inclined to engage directly with abusive fathers than children experiencing dva clinician skills and confidence to talk directly with children experiencing dva in child sensitive ways should be developed through appropriate training

introduction the use of social media has grown exponentially over the last two decades particularly among young adults 12 these platforms have become an integral part of the lives of people all around the world with more than half of the world now using these platforms 3 usage rates are high in many of the advanced economies including twothirds or more of all adults in the united states australia south korea canada israel and sweden using social media platforms 4 developing countries are quickly catching up with middle eastern and north african countries reporting a median of 68 adult population using social media platforms 5 communication across these platforms range from private messages to group messages to public posts from sending texts to voice calls to video calls with almost all social media sites providing multiple modes for communication most social media platforms state that their aim is to connect people with their families and friends 6 arguably the increase in social mediadriven communication has been influencing interpersonal relationships such as parentchild relations 7 there is emerging evidence on how parentchild relationships are evolving in the everchanging social media landscape 7 findings from various studies highlight how unique social opportunities afforded by social media cultural norms and increasing diversity of communication options impact various ways in which young adults choose to communicate with their parents using social media platforms most studies have focused on parentadolescent child relationships and only a few have examined how these relationships differ across gender in context of social media use 89 sampasakanyinga et al 10 in their survey of 9732 adolescents in ontario canada found that heavy social media use was associated with greater odds of negative relationships between mothers and daughters fathers and daughters and fathers and sons but not between mothers and sons a handful of studies have also examined the impact of a parent connecting with adolescent children on social media on the quality of their relationships abar et al 11 and yang 12 in their studies found that adolescents frequently included parents in their social networks and granted them similar levels of access to their personal information as their friends however when it comes to parents sharing content about their adolescent children verswijvel et al 13 found that adolescents particularly boys viewed this negatively research on parentadult child connectedness using social media has not kept up to speed with increase in social media use a recent systematic review on the effect of social media use on family connectedness found that social media use between parents and adult children has generally been examined from a narrow viewpoint mostly focusing on monitoring by parents or coviewing and friending 14 a key limitation of existing evidence on the dynamics of social media use between parents and young children is its emergence from largely individualistic societies as in the united states united kingdom canada and australia in these societies parents emphasise childrens independence and there is a general expectation for adult children to leave home within a few years of finishing high school or college and be financially independent 15 less attention has been paid to patterns of social media use among parents and adult children from diverse racial and ethnic groups with varying family structures for example asian and latino families are considered classically as large patriarchal collectivistic and joint families such traditional families function as a dominant influence in the lives of their individual members 16 people who identify as collectivistic are individuals whose focus is the family or the group rather than the individual 17 it is possible that the influence of online and offline connections on parentchild relationships varies by culture particularly in those from collectivistic backgrounds however this supposition has yet to be fully tested in the published literature pakistan one of the most populated countries in the world traditionally had a joint family system however like many other asian countries over time balance is shifting towards the nuclear family system 18 despite the shift adult children are likely to live with their parents well into their adulthood until they are married this young adult group is the early and significant adopter of social media platforms pakistan had 7170 million social media users in january 2022 19 youtube and facebook remain the most popular social media platforms followed by whatsapp and twitter 19 most of the countrys internet and social media users are those aged 1835 and most facebook users and twitter users are male other studies on young adults in pakistan indicate that social media usage was higher among this cohort with almost 90 using social media sites 2021 facebook and youtube were reported to be the most accessed sites among this cohort 20 pakistan for its demographic cultural and strong religious ties has been a region of interest to examine the adoption of digital technologies and their social impact 22 like other south asian countries pakistan also has the highest reported gender digital divide with the widest gaps in mobile and internet usage 23 this also has implications on social media usage and as reported by schoemaker in his survey of 900 mobile data users 85 of the male respondents reported that they mostly use facebook compared to only 47 of female respondents by contrast 45 of women said that they used whatsapp compared to only 13 of men while preference for whatsapp among women can be seen for its financial affordance while enabling privacy and reinforcement of religious social norms there is limited evidence on how parents in collectivist societies like pakistan can influence social media use 24 in the evolving social media landscape and increased intergenerational usage of these applications pakistan offers a unique opportunity to investigate how social media use across gender can be influenced by parents who play an instrumental role in shaping the lives of their adult children 25 there is growing interest in exploring how social media is impacting family relationships in pakistan with a primary focus on exploring implications associated with its usage several preliminary studies have reported a common negative perception about social media and family communication among young adults a study across 175 young adults reported that 85 of participants agreed that social media sites made family relationships nonexistent 26 a recent study on college students in pakistan reported that around 74 of the participants perceived that people prefer spending more time on social media than with family however some also report positive perceptions around family social media use a recent study on 200 college students from faisalabad pakistan found that 75 of the participants believed that social media family groups play a vital role in family connectedness 27 while there are prevailing negative perceptions research is limited on whether and how young adults in pakistan engage with their parents on social media this includes exploring any potential links between social media interactions and the sense of connection between parents and children as well as young adults views on parental monitoring 2 human behavior and emerging technologies within the realm of social media usage therefore in this exploratory study we aim to investigate patterns of social media use among young adults and their parents and its perceived association with family connectedness and parental monitoring we also examine any differences in these perceptions across different gender groups materials and methods an online crosssectional survey was used to collect data from young adults in pakistan the survey was disseminated using convenience sampling strategies we used a convenience sampling approach due to its affordability efficiency and availability of participants we acknowledge that a random sampling approach would have produced more representative findings the link to the questionnaire was sent to eligible participants in a university where one of the authors is a fulltime academic the survey was also advertised via relevant group pages on social media platforms a total of 421 participants aged 1730 years took part in the survey the participants reported the following demographic information age gender marital status parental employment status participant employment status family income family size and living arrangement access to electronic devices shared computer at home shared computer at workuniversity personal computerlaptop smart phone and tablet frequency of use of social media platforms which platforms are used and frequency of their usage facebook youtube whatsapp instagram snapchat twitter linkedin tumblr tinder tango imo viber skype hangouts pinterest tiktok duo responses ranged from never to several times daily 28 use of social media with parents participants were asked if they connected with their parents on social media and if yes how often they used each social media platform with their parents those who did not use social media platforms to connect with parents were given a list of reasons for not connecting and ask to choose the options included my parents dont have smart phones my parents dont use social media i dont want to i like connecting with only my friends and i like my own privacy family connectedness and parental monitoring we adapted family connectedness 29 and parental monitoring scales 30 from existing studies where these have been previously validated as there have been no previous studies around this topic in the unique cultural context of pakistan these scales were adapted for specific age and cultural context therefore the psychometric properties of the original scale are not applicable we therefore measured the reliability of our adapted scales as reported in the next section participants family connectedness was measured by 7 items on a 5point likert scale ranging from strongly agree to strongly disagree this multiitem scale was adapted for young adults from the family connectedness scale validated by waters and cross 29 parental monitoring was measured directly and indirectly firstly participants were asked if their parents monitored their internetmobile phone usage or computerrelated activity secondly parental monitoring was measured using four items adapted from the good starts study 31 items in both scales were modified to suit the age and cultural values of the participants ethics approval for the study was obtained from the university ethics committee in pakistan and ratified by human research ethics at qut brisbane 21 data analysis a data matrix was produced from the completed questionnaires using sas 94 for windows descriptive statistics were used to present demographic data and to evaluate the frequency of use of social media platforms we summarized data as frequencies for categorical variables appropriate statistical tests were used to conduct analysis results were converted to mean values analysis of frequencies and associations using chisquare tests where required p ≤ 05 was considered significant total scores of family connectedness were summed to range from 7 to 35 with higher scores representing higher selfperceived family connectedness total scores of parental monitoring were summed to range from 4 to 20 and higher scores represented higher selfperceived parental monitoring to assess the measurement properties of the family connectedness and parental monitoring scales in a sample of pakistani young adults factor analysis with varimax rotation was performed this measured the unidimensionality of the scales cronbachs alpha was also computed for the factors the index for the family connectedness scale showed a moderate internal reliability with a cronbachs alpha of 065 the parental monitoring scale also showed an acceptable internal reliability with a cronbachs alpha of 08 the boxcox technique was used to find the optimal normalising transformation for both family connectedness and parental monitoring 32 multiple linear regression analyses were used to examine the relationship between social media use to connect with parents and family connectedness and parental monitoring separately both crude and adjusted beta coefficients are reported covariates include age and gender results the mean age of survey participants in this study was about 226 years about 61 of the participants in this study were male and 86 were current undergraduate or postgraduate students almost 96 of the participants were unmarried and about 72 lived at home with family all participants had access to at least one electronic device like smart phone or laptop more than 90 of participants had a personal smart phone and 82 had a personal laptop or computer 31 patterns of social media use all participants in the study were using at least two social media platforms with 884 engaging with more than five platforms irrespective of the types of devices participants accessed human behavior and emerging technologies whatsapp was the most used platform irrespective of gender or age with about 91 of the participants reporting daily usage all participants who had a personal smart phone were users of whatsapp this was followed by youtube instagram and facebook as the most popular social media sites used daily only 43 reported 4 human behavior and emerging technologies that they used snapchat and 7 used tiktok daily the use of facebook and youtube was significantly higher in males while female participants were more likely to use instagram and snapchat there was no gender difference in the use of whatsapp which was the most widely used social media app among this cohort of pakistani youth 32 patterns of social media use with parents overall 63 of participants connected with their parents using social media this varied significantly among male and female participants with 69 of female participants connecting with their parents on social media compared to 59 of males whatsapp was the most reported social media app used by participants to connect with parents with 71 reporting using it all the time to communicate with parents more than half of the participants reported using facebook to communicate with parents with 24 reporting using it very often youtube instagram and snapchat were the other commonly used social media sites that participants reported to connect with parents the platforms used to connect with parents did not vary by gender with males and females connecting on facebook youtube whatsapp and instagram however females reportedly used snapchat to connect with parents in significantly higher numbers than males living with or away from family was found to have no association with connecting with parents on social media for those who do not connect with their parents on social media when asked about the reasons for not doing so the most common reason cited by participants was that their parents did not use social media the second most cited reason was participants concerned about their privacy and preserving it by opting not to connect with their parents social media use family connectedness and parental monitoring family connectedness was measured using seven questions the median family connectedness score was 31 very high for this cohort of participants however it is reflective of the patterns in this region with family being a very strong unit the score did not vary with gender age family size or if coliving with family results from multiple linear regression analyses examining the association between the use of social media to connect with parents and family connectedness are presented in table 3 both adjusted and unadjusted models show no association between any of the social media platforms used to connect with parents and participants perception of family connectedness overall 19 of the participants reported that their parents monitored their internet device usage when asked directly parental monitoring was also measured indirectly using 4 items the median parental monitoring score was 180 and it varied with gender with more than 55 of females reporting experiencing higher monitoring compared to 45 of males parental monitoring did not vary significantly with age family size or if coliving with family table 3 presents results from multiple linear regression analyses examining the association between the use of social media to connect with parents and parental monitoring connecting with parents on both facebook and instagram was highly associated with participants perception of parental monitoring before and after adjusting for age and gender this was not the case for the most used platform whatsapp discussion our study is aimed at exploring patterns of social media use between pakistani adult children and their parents pakistans cultural context is notable for its prominent display of heritage and ancestral traditions like other densely populated south asian countries in the region it emphasises traditional collectivist values focusing on interdependence and community ties 33 young adults well into their adulthood live with their parents and obeying them is central to the family values 34 to the best of our knowledge this is one of the very few studies that explore the impact of social media platforms on parentchild relationships in the collectivist family cultural context of pakistan 35 our study advances the muchneeded evidence on how adult childrens increased social media consumption possibly relates to traditionally collectivist interdependent values and culturally relevant parental goals of south asian parents all participants were active social media users using diverse available platforms despite some variation in device access with 90 having a personal smart phone our findings confirm that although the percentage of men and women using social media is comparable there are gender differences in terms of preference and frequency on specific social media platforms whatsapp is the most popular social media platform irrespective of gender and age the nature of whatsapp which is mostly to communicate with your own contacts and not an unknown audience highlights that the principal role social media has is communication with others rather than entertainment the next most popular platforms were facebook and youtube which are mostly used for entertainment activities such as media consumption and sharing importantly facebook also includes a texting function that is used for communication when looking at gender differences facebook and youtube were more popular among males whereas female participants were more likely to use snapchat and instagram these patterns corroborate with those reported in other studies and reported social media statistics 3637 in terms of the use of social media platforms with parents 63 of participants connected with their parents on at least one social media platform our study provides insight into patterns of connecting with parents across specific social media platforms whatsapp was the most preferred platform used by adult children to connect with their parents and used frequently this pattern aligns with the ongoing research on how users choose different social platforms based on the presence of specific contacts 38 as highlighted by taipale and farinosi 39 in their examination of whatsapp for family communication the whatsapp platform offers many modalities which allow human behavior and emerging technologies choosing of the most desired and most suitable mode of communication for every family member individually in a safe environment 39 popularity of whatsapp between parents and children therefore may be indicative of their preference to keep the communication private as much as possible privacy is not usually afforded on that level by facebook and instagram and the other popular social media platforms are used to connect with parents but used less frequently privacy as a preference was also indicated as one of the most common reasons by those who do not connect with their parents on social media our findings also highlight gender differences in choice to connect with parentsfemale young adults are more likely to connect with their parents using social media this perhaps affirms the idea that females tend to use social media platforms to maintain existing social relationships as compared to males who use these platforms more for expressing their opinion 4041 in terms of family connectedness 72 of participants in the study lived with their parents and had very high perceived family connectedness this is indicative of how families are the strongest unit in pakistan driven by collectivist family values 42 this pattern of strong family connectedness is similar to that reported in studies examining family connectedness in other collectivist societies in the arab countries dwairy et al 43 reported high family connectedness in arab societies and when compared to the connectedness of american adolescents their study reported arab societies scoring higher than the american adolescents 43 the high family connectedness score in our study also 6 human behavior and emerging technologies adds to the evidence on a significant difference in the connectedness between the individualistic western and collectivist eastern societies as demonstrated by dwairy and achoui 44 in their study adolescents in france poland and argentina were less connected to their parents than adolescents in kuwait algeria saudi arabia bedouins in israel jordan and india 44 our findings also extend the evidence to support that despite the increase in urbanisation modernisation and industrialisation in collective cultures the closely knit family patterns continue to exist 45 our study found no association between adult childrens use of social media platforms with parents and their perceived family connectedness in line with the collectivist family culture young adults tend to live with their families in parental homes for a much longer time therefore bonding and relationship development is less reliant on social media technologies however the frequent use of social media platforms directed to communication such as whatsapp does show the importance for social media for broader communication process without being associated with family connectedness an implication of this finding is that technologybased solutions or interventions oriented to families might not be as widely accepted while participants in our study indicated a high degree of family connectedness they were conscious of maintaining their privacy and their parents monitoring their social media use this was indicative of the complexity and asymmetric nature of the parentadult child relationship meaning that parents and children have different roles and responsibilities in it 46 during adulthood the relationship is constantly changing due to the desires of independence and selfsufficiency of children and it presents challenges that are unique to this period parents go through a stage of acknowledging the child as an adult and there is an interplay of autonomy and dependency between both parties 4748 surveys conducted in the united states indicate a high prevalence of parental social media monitoring in the context of parent and their teenage children 49 it is likely that in asian cultures including pakistan where adult children tend to colive and be financially dependent for much longer parents monitor their adult childrens social media usage several potential limitations of this study should be noted as they also suggest opportunities for future research first because only crosssectional data were used the results of this study indicate associations between measures that should not be interpreted as causal relationships also the use of a convenience sample of participants limits the generalisability of the study results further as the study focused on young adults in pakistan a collectivist society at large that emphasise interdependence and family connectedness it is unclear whether the patterns of results can be generalised to other cultures and individualistic societies our findings also highlight the prevalence of parental monitoring of social media use previous studies have demonstrated that such practices may increase conflict in individualistic families 5051 the impact of such parental monitoring on family conflicts in collectivist cultures especially those with strong religious ties needs further investigation further it is important to consider that the sample in this study had the means to access the social platforms and internet frequently many families especially those living in rural regions in pakistan have limited access to the internet with some estimates suggesting 46 of all pakistanis accessing the internet daily 52 future research therefore should explore how the lack of access to the internet and social media platforms might affect the degree of family connectedness and their possible association with family conflicts another possible limitation of this study is that social media use with parents was assessed by a simple dichotomous measure and frequencies some variables of interest were measured using single items which might not fully capture the underlying complexity of the constructs however the use of single items improved the efficiency of data collection by preventing participant fatigue and minimizing incomplete responses and contributed to expanding the diversity and comprehensiveness of the sample an essential avenue for future research is to integrate qualitative indepth investigations and employ finergrained culturally relevant measures to 7 human behavior and emerging technologies comprehend young adults specific interactions with parents on social media platforms this will enhance our understanding of how social media usage influences parentchild relationships data availability the data is restricted as per the ethics policy of the study administering institutions conflicts of interest no potential conflict of interest was reported by the authors

an increasing number of young adults are using social media platforms in collectivist family cultures like pakistan but little is known about how social media use is associated with family connectedness in this population this study is aimed a at examining the social media usage patterns in pakistani young adults and how they use it to connect with their parents and b at exploring the possible association between social media use and perceived family connectedness and parental monitoring data came from an online survey conducted among young adults in pakistan patterns of use across various popular social media platforms were recorded additionally family connectedness and parental monitoring were measured multiple linear regression analyses were used to examine the relationship between social media used to connect with parents and family connectedness and parental monitoring a total of 421 participants responded to the survey all participants regularly used at least two popular social media platforms whatsapp was the most used platform irrespective of gender or age with about 91 of the participants reporting daily usage overall 63 of participants connected with their parents using social media this varied significantly among male and female participants with 69 of female participants connecting with their parents on social media compared to 59 of males connecting with parents on both facebook and instagram was highly associated with participants perception of parental monitoring before and after adjusting for age and gender the study highlights that while family connectedness in collectivist societies like pakistan is not associated with social media usage adult children perceive parents monitoring their social media activities

during a crisis intergroup communication or communication that flows within the group and other groups as well as from influential ingroup and outgroup sources plays an important role in framing and making sense of the crisis for group members during a national crisis for instance when nations struggle with questions about their future intergroup communication becomes especially pertinent in understanding social identity concerns pertaining to normative fit and ingroup future for example the european union has faced similar crises in recent times with respect to the integration of member states and immigrants into the larger superordinate union when such crises unfold the role of crisis communication becomes especially important one important source of intergroup information within a crisis and how it impacts ones social identity is the media the media serves as a vital source of normative information while group members seek ingroup media sources to confirm their existing attitudes and seek positive social identity validating information in the current study we examined the role of the media as a source of intergroup communication in the midst of the greek financial crisis we examined whether exposure to outgroup media sources in the midst of a national crisis heightened social identity uncertainty about ones national identity and its future the greek financial crisis that occurred between the years of 2009 to 2018 brought up several political economic and identityrelated policy concerns for greek citizens the crisis ignited discussions around grexit the possibility of greece exiting the eurozone the monetary union of 19 member states of the eu that had adopted the euro as their currency thereby raising questions and concerns about greek national identity and what it would mean to be greek in the future other related issues discussed in greek and international media highlighted greeces economic relationship with the larger international community and whether greece should seek economic help from other nations media narratives also focused on issues of border control and the entry of immigrants into greece such rhetoric whether focused on greeces status within the eu or its financial relationship with the eu and lenders consistently drew attention to questions of who we are as greek nationals and where we stand in relation to others thereby highlighting concerns about the distinctiveness of greek social identity within the superordinate eu identity and the broader international context in this context we examined the impact of media messages and rhetoric that consistently highlighted concerns regarding the future of greek national identity we were interested in whether media messages in the context of such a crisis could elevate uncertainty regarding ones social identity about what it means to be a member of a group how one stands in relations to others and what the future holds for the members of the group these media messages are conceived as intragroup communication within greek society where normative positions are discussed and negotiated and the outcomes and the effects of such communication can affect national identification itself as well as the perceived standing of the country in the broader european intergroup context we draw on uncertaintyidentity theory as our guiding theoretical framework in order to examine whether distinctive media sources namely prosystem or normative versus antisystem or nonnormative media narratives impacted identityuncertainty differently systemic media sources during the greek financial crisis supported and advocated majority rightleaning narratives whereas antisystemic sources presented minority leftleaning perspectives that questioned the normative narratives we examined the extent to which exposure to media sources that went against ones dominant worldview produced identityuncertainty about ones greek identity we predicted that when compared with their ideological counterparts those who typically chose systemic media sources would feel especially uncertain about their greek identity when exposed to antisystemic media sources and vice versa for those who typically chose antisystemic media sources we conducted two studies to examine how greeks with diverse ideological stances who chose different media sources responded when they felt uncertain about their greek identity we examined how identityuncertainty in this context was associated with support for different policy issues that were of prime importance in greece at the time this study was conducted in study 1 we measured mediaproduced identityuncertainty regarding what it means to be greek and the future of greece in study 2 we experimentally manipulated mediaproduced identityuncertainty in study 1 we examined whether exposure to ideologically discordant media heightened uncertainty about greek identity among leftversus rightleaning greeks we also reported how national identification political ideology and identityuncertainty produced by the media related to attitudes to different policybased issues that impacted greece during the crisis study 2 focused on greek nationalism which was measured as a composite of political ideology and national identification we examined whether the type of media chosen mediated greek nationalists attitudes toward grexit under conditions of high versus low identityuncertainty in the next sections we review the literature on uncertaintyidentity theory and its application to this research we follow with a review of previous research on implications of exposure to different types of media sources uncertaintyidentity theory news media narratives in greece during the financial crisis were predominated by questions regarding greeces potential separation from the eurozone and the economic and national future of greece we expected that such a narrative in the midst of a crisis that brings with it the possibility of rapid changes would be accompanied by a strong sense of uncertainty about what it means to be greek within the larger context of the eu uncertaintyidentity theory explains how uncertainty about the self and ones identity is a highly aversive feeling that individuals strive to reduce one way in which identityuncertainty can be reduced by looking to a social identity or group membership according to social identity theory when individuals identify strongly with groups and these group memberships are salient they come to frame the sense of self and act as guides in driving thoughts feelings behaviors and worldview of course while individuals seek groups to manage uncertainty about the self potential changes to the group its standing in relation to superordinate groups and shifts in relations with other groups should impact how the self is framed in relation to social identity thus possible upheaval and uncertainty regarding the position of the groups that individuals strongly identify with should provoke uncertain about identity this is what we expected in the context of the greek financial crisis while societal crises and the potential changes they bring can raise identityuncertainty we specifically examined the role played by the media in framing narratives that highlight such changes and raise questions about social identity especially during a period of crises one way of gaining information about identity is through communication that flows within the group especially from influential ingroup sources which act as an important means of conveying rich social identityrelated information in the context of intergroup crises when questions regarding what it means to be a member of a group and what the group stands for are rife influential and trusted sources such as ingroup leaders by emphasizing that they are one of us communicate social identityrich information and reiterate the groups central attributes by embodying them media communication from trusted ingroup sources serves a similar function by presenting information regarding who we are and what we stand for in relation to the larger intergroup landscape we expected that greeks who were confronted with a national and financial crisis would seek relief from identityuncertainty in media sources that were consistent with their political ideology while exposure to media sources that were discordant with their political ideology would enhance identityuncertainty the reason for the latter prediction was that during a crisis is exposure to an ingroup source that goes against ones political ideology should be especially disconcerting according to uncertaintyidentity theory uncertainty about the self and identity drives individuals to seek comfort in ultracohesive tightknit narratives that are based on singular worldviews with little inherent diversity and diffusion thus diverse opinions that disagree with a singular worldview should be especially unwelcome in the context of a crisis systemic and antisystemic media sources in the current study we examined the influence of two types of media sources that we categorized as systemic and antisystemic during a crisis when questions about social identity are salient we expected that exposure to ingroup voices on the other end of the ideological continuum would be especially likely to raise uncertainty about ones identity by questioning ones worldview a media source on the opposite end of the ideological continuum is still an ingroup source and therefore credible however exposure to an ingroupdiscordant stance should be especially disconcerting during a crisis when identityuncertainty is high individuals prefer their ingroups to band together tolerate differences within the ingroup to a lesser extent and prefer a singular worldview disagreement within the ingroup in the form of ideologically discordant positions should fuel greater identityuncertainty as a group in crisis struggles to deal with constant change and instability research on selective exposure to media sources has shown that individuals selectively choose to expose themselves to attitudeconsistent media sources as a means to validate their worldview and the self while media sources that are inconsistent with ones worldview are avoided exposure to attitudediscordant media is aversive as it produces cognitive dissonance and invalidates ones worldview people are typically driven to preserve their attitudes from challenge at the cost of gaining a valid view of reality by avoiding information that challenges their attitudes while seeking information that confirms it also known as the confirmation bias this phenomenon is likely to be exaggerated when media sources are polarized to partisan extremes partisan rhetoric highlights divisions between the ingroup and the outgroup and a lack of consensus is emphasized we argue that media messages on the left and the right that take partisan and polarized stances in the context of a crisis such as the greek financial crisis should develop loyal follower bases who depend on these sources for important identityrelated information exposure to the opposite side of the partisan divide should then produce a sense of uncertainty about ones identity while previous research has examined dissonance and discomfort caused by exposure to attitudediscordant information we built on this literature to examine whether exposure to attitudeor ideologydiscordant information also produces the aversive state of uncertainty about ones identity and its related worldview thus exposure to information that invalidates ones normative ingroup stance should drive one to feel uncertain about oneself and ones social identity the current study we present two studies that were conducted during the financial crisis in greece both studies were conducted during april and may of 2015 a few months before the third bailout program was agreed upon between the greek government and international lenders this was a period of increased conflict and frustration as the economic and social crisis had already lasted five years public discourse was dominated by the dilemma of either accepting or rejecting yet another bailout program with harsh terms proposed by the lenders drawing from this context of crisis wherein media narratives actively contested and debated issues related to economic national and identityrelated concerns we examined how exposure to intragroup ideologically discordant media shaped the experience of social identityuncertainty in study 1 we expected that rightleaning greeks who typically chose normative majority rightleaning media sources would feel especially uncertain about their greek identity when exposed to nonnormative leftleaning media sources we also present data on how levels of greek identification and political ideology related to support for different policy issues and support for different political parties giving us a descriptive picture from the time during the greek crisis in study 2 we examined the mediating role of type of media source in shaping greek nationalists views on grexit under high versus low identityuncertainty we predicted that greek nationalists attitudes toward grexit should be strengthened via type of media exposure especially under conditions of high uncertainty in both studies we measured greeks national identification selfreported political ideology support for different policy issues support for different political parties and the type of media that they chose there was one difference between the two studies in study 1 we measured identityuncertainty that is the extent to which news media made greeks feel uncertain about their national identity while in study 2 we experimentally manipulated identityuncertainty study 1 in study 1 we tested whether exposure to ideologically discordant media sources would be associated with an increase in identityuncertainty we also aimed to understand how greeks across different sides of the ideological continuum stood on different policy issues and support for different political parties social identity uncertainty during the greek financial crisis the role of media narratives method participants and design participants were greek citizens and included 146 males and 178 females recruited from the aristotle university of thessaloniki study 1 employed a correlational design and measured national identification political ideology political party support uncertainty produced by the media support for various political issues and choice of media source we conducted a power analysis to assess the adequacy of our sample size our final sample size comprised 298 participants in coding the variable of media source those who listed an equal number of systemic and antisystemic media sources were dropped from further analyses giving us a final sample size of 298 using the pwr2ppl r package we found that given our sample size and an α 05 power for the main effect of political ideology of 097 power for the main effect of media source was low while for the interaction between ideology and media source which framed our main hypothesis in the study we found power of 077 thus we had a sufficient sample size to proceed with our analysis to test a moderation hypothesis procedure and materials the study was introduced as aiming to understand greek citizens opinions and attitudes toward various political issues during the greek financial crisis once participants consented to participate in the study the following study materials were presented identification with greece seven items drawn from previous research on social identity theory were adapted to the studys context to measure the extent of identification with the greek identity participants responded on a rating scale ranging from 1 to 9 α 92 political ideology one item was developed to measure where participants positioned themselves on the ideological continuum from left to right participants responded by rating their political ideology on a rating scale ranging from 1 to 9 party support participants indicated the extent to which they supported seven different political parties on 7 items participants responded on a rating scale ranging from 1 to 9 uncertainty produced by the media drawing on previous uncertaintyidentity theory research seven items were adapted to measure the extent to which the news media made greeks feel uncertain about greek identity and the future of greece participants responded on a rating scale ranging from 1 to 9 α 92 policy support twelve items developed for this study by the authors measured the extent to which participants supported versus opposed policy issues that confronted greece at the time of the crisis participants responded on a rating scale ranging from 1 to 9 we created three separate policy support scales we developed the items with the specific purpose of measuring attitudes toward three pertinent issues that were actively discussed and debated in greek media and popular rhetoric at the time and that pertained to greeces need for autonomy economic help from lenders and border control the three separate subscales we developed were the greek autonomy scale the economic help scale and the border control scale further details on the factor structures of the scales are included below media sources participants were asked to list a maximum of six news media sources that they typically chose to expose themselves to a variety of media outlets consisting of newspapers tv channels and online news sites were reported independent coders categorized these media outlets into systemic media that clearly supported governmental discourse and antisystemic media that clearly supported antigovernmental discourse media outlets that produced mixed or neutral discourse were excluded from the analysis finally participants provided demographic data and responded to religious identity questions that asked about their religious affiliation and strength of religious identification participants were then debriefed and thanked for their time results in study 1 our main prediction was that exposure to media sources from the opposite end of the ideological continuum should produce heightened uncertainty especially given the nature of partisan media in the context of the greek financial crisis we had two main predictors political ideology ranging from the left to the right and media source which was either systemic and comprised majority rightleaning media sources or antisystemic and antinormative that comprised minority leftleaning media sources our key dependent variable was a continuous measure of the extent to which exposure to news media heightened social identityuncertainty pertaining to ones greek identity we also present data on how greek citizens across the ideological continuum and with different levels of national identification positioned themselves on various policy issues and support for different political parties scales and design we conducted a twoway betweensubjects analysis of variance to test our main prediction media source one of our two independent variables was a categorical variable independent coders categorized the participants responses into systemic and antisystemic media sources if participants listed predominantly antisystemic media sources they were coded as 1 while participants who listed predominantly systemic media sources were coded as 2 as noted above those who listed an equal number of systemic and antisystemic media sources were removed from further analyses we converted our second independent variable a oneitem continuous measure of political ideologyinto a categorical dichotomous variable through a median split with the values of 1 and 2 we conducted a factor analysis on the continuous measure of identityuncertainty our key dependent variable analyses revealed a onefactor solution a composite scale was computed by averaging item responses reliabilities means sds and intercorrelations of the variables are presented in table 1 we included all our 12 policy support items in one factor analysis four factors emerged with eigenvalues greater than 1 on further examination of the factor structure we found that five items loaded strongly on the first factor these five items measured support for austerity greek control over its economy support for a break in negotiation with lenders and grexit from the eurozone we averaged these five items to create the greek autonomy scale four policy support items loaded on factor 2 and measured support for help from international lenders and other countries and debt forgiveness we averaged these four items to create the economic help scale three policy support items loaded on factor 3 and measured support for greek control over its borders and policies to prevent immigration into greece we averaged these three items to create the border control scale we found that only two items loaded strongly on factor 4 how strongly do you oppose or support debtforgiveness for greece by the creditors and how strongly do you oppose or support german reparations to greece as a way to pay the debt theoretically we argued that these factors should fit well with the economic help scale therefore we ran an additional factor analysis wherein we forced a threefactor solution a more parsimonious picture emerged in this second analysis where we found that the two abovementioned items now loaded strongly on factor 2 therefore we retained the above three scales in further analyses we conducted two analyses with the demographic variables of age and gender to assess whether they should be included as covariates in further analyses a twoway anova with our predictors political ideology and media source as the independent variables and age as the dependent variable revealed statistically significant effects for age such that political ideology and media source both predicted age the mean age on the right end of the political continuum was significantly higher than the left end while the mean age for exposure to antisystemic media was significantly higher than the mean age for exposure to systemic media we conducted a logistic regression to test whether our predictors of political ideology and media source predicted gender we did not find statistically significant effects only age was included as a covariate in the test of the main hypothesis media source and uncertainty to test our key prediction that exposure to media messages from the opposite side of the political continuum would heighten identityuncertainty we conducted a twoway betweensubjects anova 1 wherein political ideology 1 additionally we tested our central hypotheses using a multiple regression since one of our predictors was a continuous variable that we converted into a dichotomous variable to conduct a twoway betweensubjects anova that helped us presents our findings with greater parsimony and clarity in study 1 the results of the multiple regression mirrored the results from the anova and indicated a statistically significant interaction between political ideology and media source to predict uncertainty β 34 t 464 p 001 and media source served as our predictors while identityuncertainty produced by the media served as the dependent variable we entered age as a covariate in the analysis and found that age did not statistically significantly predict identityuncertainty results indicated that the main effect of political ideology was statistically significant such that those on the right end of the ideological continuum experienced greater identityuncertainty from exposure to news media compared to those on the left end of the continuum the main effect of media source was not statistically significant f 20 p 66 η p 2 001 as predicted we found a significant interaction between media source and political ideology in predicting the extent of identityuncertainty produced by news media f 967 p 002 η p 2 04 an analysis of simple main effects indicated that those on the right end of the ideological continuum reported feeling significantly more uncertain about their greek identity when they chose antisystemic news media compared to those on the left end of the political continuum moreover those who leaned right felt more uncertain when they chose antisystemic media compared to when they chose systemic media among those who leaned left those who chose systemic media reported feeling significantly more uncertain about their greek identity compared to those who chose antisystemic media no statistically significant difference emerged in the extent of identityuncertainty between those on the left and the right when they chose systemic media national identification policy support and party affiliations in addition to our key hypothesis regarding the interaction between media source and political ideology in predicting identityuncertainty in study 1 we also examined the relationships between policy support and political party support variables with national identification identityuncertainty and political ideology table 2 shows that high identifying greeks those who leaned right and felt high identityuncertainty were less likely to seek greek autonomy from the eu while they indicated support for greater greek border control those who identified strongly with a greek identity also supported more international economic help for greece table 3 shows that those who identified more strongly with a greek identity were more likely to lean right on the ideological continuum and indicated greater support for the following political parties new democracy golden dawn river panhellenic socialist movement and the independent parties while those who leaned left were more likely to favor syriza and the communist party discussion findings from study 1 supported our main prediction that exposure to media sources from the opposite end of the ideological continuum heightens uncertainty regarding ones social identity especially in the context of a crisis research on selective exposure has examined a sense of aversiveness and discomfort that accompanies exposure to attitudinally discordant media communication we built on these findings to demonstrate that exposure to ingroup media that argues an ideologically contrary position also raises uncertainty about ones social identity rightleaning greeks who typically chose systemic or normative media sources reported feeling most uncertain when they chose antisystemic news media similarly leftleaning greeks who typically chose antisystemic news media reported feeling more uncertain when they chose systemic news media compared to antisystemic media this sense of uncertainty was especially heightened for rightleaning greeks when they chose antisystemic media as majority media sources were systemic and thereby normative we also examined how political ideology identityuncertainty and national identification related to political party support and policy support items pertaining to economic help greek autonomy and border control overall we found that those on the right end of the ideological continuum and high greek identifiers were less likely to favor greeces exit and autonomy from the monetary union in study 2 we built on these relationships to examine whether attitudes toward grexit one of the predominant issues during the crisis in news media were strengthened by greek nationalists choice of news media under high versus low identityuncertainty study 2 in study 2 our main aim was to introduce an experimental manipulation of media produced identityuncertainty with this experimental manipulation we aimed to understand where identityuncertain versus certain greek nationalists positioned themselves on the issue of grexit which dominated media rhetoric at the time of data collection in study 1 through an examination of the intercorrelations between the policy support national identification and political ideology measures we found that greeks who identified strongly with a greek identity and leaned right were less likely to support greek autonomy and grexit building on these findings in study 2 we created a composite variable of national identification and political ideology to measure greek nationalism and aimed to examine whether the type of media that greek nationalists chose mediated their attitudes toward grexit under high versus low identityuncertainty thus while in study 1 we examined the extent of identityuncertainty experienced by rightversus leftleaning greeks when exposed to systemic versus antisystemic media in study 2 we built on findings from study 1 to examine whether the experience of identityuncertainty shaped attitudes toward important policy issues through exposure to systemic versus antisystemic media method participants and design participants were greek citizens and included 107 males and 186 females from the aristotle university of thessaloniki study 2 had one manipulated variable the measured variables were national identification political ideology media source and attitudes toward grexit we conducted two separate power analyses to assess if we had adequate sample size using the pwr2ppl r package to test our hypotheses we conducted two mediation analyses one within the high identityuncertainty condition and one within the low identityuncertainty condition in the high identityuncertainty condition we found that power for the total mediation was 70 in the low identityuncertainty condition we found that power for the total mediation was 64 while power in the low identityuncertainty condition was lower than expected we proceeded with the analyses as our key prediction centered on the high identityuncertainty condition procedure and materials similar to study 1 study 2 was introduced to participants as aiming to understand greeks opinions and attitudes toward the ongoing greek financial crisis once participants consented to participating in the study they were presented with the study materials the measured variables were identical to the ones used in study 1 that is greek national identification political ideology and our main dependent variable attitudes toward grexit or greek autonomy which included the same items as in study 1 and measured attitudes toward greeces exit from the eurozone and the monetary union support for break in negotiations with lenders and greek control over its economy similar to study 1 participants wrote down six news media sources that they predominantly chose the novel contribution of study 2 was to introduce an experimental manipulation of identityuncertainty produced by exposure to news media the manipulation was introduced before the five attitudes toward grexit items were presented and participants were randomly assigned to either the high or the low identityuncertainty condition in the high identityuncertainty condition participants were asked to write down three ways in which news media made them feel uncertain about who they are their future their greek identity and the future of greece in the low identityuncertainty condition they listed three ways in which news media made them feel certain about who they are their future their greek identity and the future of greece similar experimental manipulations of identityuncertainty have been used in previous research on uncertaintyidentity analysis we tested two mediation models one under high identityuncertainty and one under low identityuncertainty under high identityuncertainty the fit indices indicated a good fit for the model χ 2 df 243 p 29 cfi 99 tli 97 rmsea 04 figure 2 panel a shows the relationships between the variables we found that all paths were statistically significant such that those who scored high on nationalism were more likely to choose systemic media and the choice of systemic media was related to greater opposition of grexit under high identityuncertainty high nationalists were less likely to choose antisystemic media and the choice of antisystemic media predicted greater support for grexit under high identityuncertainty under conditions of low identityuncertainty the fit indices again indicated a good fit for the model χ 2 df 120 p 55 cfi 1 tli 107 rmsea 00 figure 2 panel b shows the relationships between the variables we found that all paths were statistically significant except for the path from choice of systemic media to attitudes toward grexit similar to the high uncertainty condition nationalists were more likely to choose systemic media and less likely to choose antisystemic media and those who chose antisystemic media were more likely to support grexit discussion building on the intercorrelations between policy support items with national identification and political ideology that we examined in study 1 we aimed to understand how greek nationalism a composite variable of political ideology and national identity related to support versus opposition for one of the key political issues during the greek crisis namely grexit we were interested in understanding how the relationship between nationalism and attitudes toward grexit were framed by the mediating role of type of news media under low and high identityuncertainty produced by the media a test of our model indicated that under conditions of heightened uncertainty the type of media exposure did mediate the relationship between greek nationalism and attitudes toward grexit greek nationalists who typically chose system supporting media sources were more likely to oppose grexit whereas those who were low on nationalism and more likely to choose antisystemic or nonnormative media sources were more likely to support grexit general discussion we aimed to present a picture of the political situation in greece during the 20092018 financial crisis especially with regard to whether mediarelated communication can make people feel uncertain about their social identity in the midst of a national crisis media messages during this period consisted of intragroup communication that constructed and negotiated the normative policy decisions greek society should make in the face of the crisis it faced within a hostile intergroup international context the ways in which identityuncertainty is shaped by choice of different news media and the role identityuncertainty plays in shaping attitudes toward identityrelevant issues through choice of news media was of special interest in two studies in study 1 we examined whether the type of news media chosen moderated the relationship between political ideology and extent of uncertainty experienced about ones greek identity and its future in study 2 we experimentally manipulated identityuncertainty produced by news media and examined the mediating role of the type of news media in shaping attitudes toward grexit under high and low identityuncertainty we specifically focused on grexit since it was one of the political issues that dominated media rhetoric and narratives at the time the study was conducted the issue of grexit especially pertains to social identity concerns as questions about whether ones group should remain a part of the superordinate identity as opposed to returning to the national currency and leaving the superordinate identity should raise uncertainty about fundamental identityrelated questions we also chose to focus on two specific types of news media categories systemic or normative media sources and antisystemic or nonnormative media sources during a crisis in which uncertainty about social identity is elevated we typically look to influential ingroup sources such as ingroup media sources that provide rich social identityrelated information research has shown that during a national crisis group members seek social media to gain valuable information about the group and such media also helps mobilize and organize group members toward collective action and political participation resolving uncertainty and seeking valuable grouprelated information involves trusted ingroup sources in such contexts exposure to news media sources that are ideologically discordant albeit still ingroup sources should make one feel especially uncertain about oneself and ones social identity previous selective exposure research shows that individuals seek information that is attitudinally consistent to validate their worldview we built on this work and demonstrated that exposure to media sources that are typically chosen by ingroup members on the other end of the ideological continuum and are attitudinally inconsistent with ones worldview also relates to heightened identityuncertainty salient social identities help shape our worldview and inform us of the place we occupy in relation to others and exposure to ideologically discordant information does appear to heighten social identityuncertainty our findings in study 1 demonstrated that ideologically rightleaning greeks who chose predominantly systemic news media sources when compared with leftleaning greeks reported greater identityuncertainty about their greek identity when they chose antisystemic news media sources the mean for identityuncertainty was highest for rightleaning greeks who chose antisystemic sources on the other hand ideologically leftleaning greeks felt more uncertain when they chose systemic news media sources compared to antisystemic news media sources thus choice of media sources that are ideologically discordant but typically chosen by ingroup members on the other end of the ideological continuum heightens uncertainty about ones social identity through challenges to ones dominant worldview especially in the midst of a national crisis in study 1 we also examined how political ideology greek identification and identityuncertainty correlated with greeks positions on various political social identity uncertainty during the greek financial crisis the role of media narratives issues that were discussed frequently in the news media during the financial crisis the issues we examined centered on greeces quest for financial and national autonomy that is separation from the eu greek control of its borders and seeking economic help and a break in the negotiations with the eu these correlations overall indicated that rightleaning high identifying greeks were less likely to seek greek autonomy from the eu however they wanted more border control for greece such that they opposed asylum seekers and immigration into greece such attitudes are consistent with the dominant narrative in systemic and normative media sources in greece that portray immigrants as either threats to public health and national security or as victims who are dependent on the nations resources bivariate correlations in study 1 indicated that political ideology and national identification had similar relationships with greeks stances on various political issues therefore in study 2 we combined the two variables into a composite variable of greek nationalism we found that greek nationalism did predict attitudes toward grexit indirectly via type of media chosen when identityuncertainty produced by the media was high greek nationalists who were more likely to choose systemic or normative news media were less likely to seek grexit when highly uncertain about their greek identity in previous research gardikiotis et al found that when greeks felt emotions such as anger they were more likely to seek grexit whereas when they experienced fear and helplessness they were less likely to seek grexit while identityuncertainty is distinctive from the experience of fear and helplessness we can speculate that when highly uncertain about ones identity a sense of helplessness dominates greek nationalists possibly saw greek identity as fused or closely tied with the superordinate eu identity thus when uncertain about their greek identity and exposed to systemic media they were more likely to seek to maintain ties with the superordinate identity rather than disturb status quo this indirect relationship between nationalism and opposition of grexit via choice of systemic media was not statistically significant under low identityuncertainty in two studies we described greek attitudes towards some of the dominant political issues at the time of the financial crisis in greece our aim was to present the ways in which normative talk that flows from influential ingroup sources in the midst of a crisis that involves the group can heighten social identityuncertainty and the implications such uncertainty has for shaping group members attitudes toward important grouprelated issues our findings build on previous research on selective exposure and the role of the media and demonstrate that while ingroup media narratives function as important sources of normative information and social identity validation exposure to outgroup media narratives in the midst of a crisis also heightens identityuncertainty about who we are and where we are headed as a group our findings also add to the literature on crisis communication by highlighting that in times of major upheaval exposure to outgroup media sources can indeed enhance identityuncertainty the processes through which exposure to specific sources of information can enhance identityuncertainty and the implications that it has for the future of the group its members and the crisis situation itself can benefit from future research our findings also highlight how subgroups within a larger group respond when exposed to communication from the opposite side especially in the context of a crisis wherein divisions between groups are already highlighted as our findings show exposure to information from an opposing subgroup raises identityuncertainty especially when questions about ingroup position within a larger superordinate identity are being raised social identity uncertainty during the greek financial crisis the role of media narratives theory finally participants responded to demographic questions about age gender and religious identification were debriefed and thanked for their participation results in study 2 we tested the hypothesis that the type of media chosen would mediate the relationship between nationalism and attitudes toward grexit differently under high versus low identityuncertainty we experimentally manipulated one variable identityuncertainty produced by the media while nationalism choice of media source and attitudes toward grexit were measured scales and measures the test of our mediation model included nationalism as the predictor media source as the mediator and attitudes toward grexit was our criterion variable we used the number of systematic versus antisystematic media listed by the participants as the mediator variables in study 2 we wished to test a mediation hypothesis therefore we used a continuous measure of systemic and antisystemic media sources to test our prediction using path analysis we examined two mediation models one within high identityuncertainty and one within low identityuncertainty media sources were categorized as systemic or antisystemic by coders next the number of systemic and antisystemic sources mentioned by each participant was counted unlike in study 1 none of the participants mentioned an equal number of systemic and antisystemic sources the nationalism measure was created as a composite variable by averaging responses on the national identification measure and the singleitem political ideology measure a factor analysis with the national identification and political ideology measures indicated that one clear factor with an eigenvalue greater than unity emerged from the scree the factor loadings for each item on the single factor were greater than 050 we created a composite variable of five items that assessed attitudes toward grexit and greek autonomy these items assessed support versus opposition for austerity a break in negotiations with lenders greek control over its economy greeces exit from the monetary union and greeces exit from the european union factor analysis with the five items revealed that one clear factor emerged from the scree reliabilities means sds and intercorrelations of the variables are presented in table 4 media source identityuncertainty and grexit to test our mediation hypothesis we used amos and conducted a path conflict of interest disclosure the authors have no conflicts of interest to declare authorship details sucharita belavadi research concept and design data analysis and interpretation writing the article critical revision of the article final approval of the article antonis gardikiotis research concept and design collection andor assembly of data data analysis and interpretation writing the article critical revision of the article final approval of the article michael a hogg research concept and design data analysis and interpretation writing the article critical revision of the article final approval of the article social identity uncertainty during the greek financial crisis the role of media narratives

two studies set against the complex sociopolitical backdrop of the greek financial crisis 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 examined the role played by media narratives as intragroup communication within greek society in framing social identity uncertainty and the desired position of the country in the wider intergroup european context the extent of identityuncertainty produced by the media regarding greek national identity future and relations with the eu was measured in study 1 n 298 and manipulated in study 2 n 293 study 1 found that exposure to ideologically discordant media messages heightened uncertainty about national identity among rightand leftleaning greeks study 2 found that the type of media chosen systemic vs antisystemic mediated greek nationalists positions on grexit especially under heightened identityuncertainty implications of the role of the media as influential ingroup sources in providing valuable social identity information especially during a crisis are discussed

introduction the discourse about the indispensability of physical activities as a strategy for health promotion in physical education is recurrent in the literature particularly in brazil such a relationship is legitimized at the heart of the official documents that guide public policies aimed at democratization and access to services and programs that promote health care such as the national health promotion policy national diagnosis of sport volumes i and ii and by the national sports plan it is worth noting that these publications ratify the health proposal and its promotion as a right of all and duty of the state also based on its expanded dimension and in the model of social determinants in health which by the way gained notoriety in the preparation of the final report of the viii national conference on health in this report health is understood as resulting from food housing education income environment work transportation employment leisure freedom access and ownership of land and access to health services it is thus first of all the result of the forms of social organization of production which can generate great inequalities in living standards right to health means the guarantee by the state of decent living conditions and universal and equal access to actions and services for the promotion protection and recovery of health in this scenario what can be stated is that the expanded dimension and the model of social determinants in health proposed a resignification of the context now presented this fact brought to light the need for a new look at the relationships between health and illness especially with regard to its promotion in this context we highlight the relationship of health social and cultural factors of individuals through a complex network of factors that intersubjectively permeate them meeting the studies of buss and pellegrini filho carvalho minayo andpalma estevão andbagrichevsky at the heart of these reflections the social determinants of health understood in the light of that the living and working conditions of individuals and population groups are related to their health situation the hegemony of the biomedical model started to be questioned and the applicability of methods and work strategies based on the organicfunctional model especially when considering factors such as race creed gender andor social class of individuals in their varied interrelations as belonging to the health field this factor which in our view is better suited to the perspective of health promotion in a permanent dialogue with the human cultural dimension and its resignification through the pedagogical approach in this sense we corroborate with the view that no individual is devoid of their cultural relations therefore essential in dealing with proposals that are given through the promotion of health and such premises can even be justified in the conceptual horizon of geertz for which culture is a web of meanings that the human being weaves daily in this sense we note approximation with the health promotion since according to the national health promotion policy they are based on a mechanism for strengthening and implementing a transversal integrated and intersectoral policy that brings together the various areas of the health sector the private and nongovernmental sector and society however in the present study it is necessary to recognize that the intersectorality presented in the documents is based on the elaboration of different public policies in a macroscopic environment however we understand that in the daily life of physical education professionals especially those who are not linked to programs and services related to health such reference may be based on their pedagogical practice therefore the promotion of health and its applicability beyond the simple routine reproduction of protocols and training methods in a weight room should be one that considers the autonomy of practitioners from a critical perspective distancing itself from the biomedical model and organicfunctional logic as a hegemonic strategy for carvalho the issues inherent to the placement of the individual on a secondary plan throughout the practice of physical activity are limiting factors of the performance at work in physical education and health understanding therefore the pedagogical practice in physical education in the light of health promotion is first of all to consider the variability of forms of social organization and their respective cultural dynamics as susceptible to the resignification of projects programs and processes of care and permanent education in health thus based on eusse bracht andalmeida andbracht we understand the core of the discussion of physical education and its pedagogical practice based on two basic premises the why and the how therefore the objective of this study is to understand the cultural dynamics related to health promotion in the context of the pedagogical practice of physical education professionals of a public gym in the city of santossp brazil method this is an ethnography on the horizon of geertz fonseca magnani andnakamura for which it occurs in the immersion of the researcher in the research universe considering the different codes meanings and appropriations that are present in the constituent social relations and subject to the most diverse interpretive readings for oliveira and daolio ethnographic research is a rich process that leads to understanding the cultural dynamics of social groups therefore we understand that its choice as a method is welcome in the universe of qualitative research in health as pointed out by aredes et al silva and ferreira the study is part of doctoral research having been approved by the ethics and research committee of unifesp under opinion nº xxxx the field of research took place in the context of a traditional public sports equipment and its choice due to the organization and offer of events and various sports modalities free for the population our insertion took place with the consent of the municipal sports department of the municipality of santossp brazil and the recruitment of the subjects occurred in the initial moments of our approach 7 subjects participated in the study 2 physical education professionals and 5 users in the inclusion criteria professionals with a minimum experience of one year in that segment and with an academic education of at least two years were considered for the participants it was considered those who practiced the modality for at least one year uninterruptedly these criteria were elaborated based on the appropriation of the subjects to the studied phenomenon all volunteers signed a form of free and informed consent in its development participant observation was made over a semester totaling 36 visits the dynamics of observation took place in two ways in the first close to the actors in walks through and around the space as well as in our informal conversations now in the second in a distant way at which time we were following what was developing in the context of the research together with the professionals in their workstation the observations were recorded in a field diary this being one of the main strategies used in ethnography and thus pointed out by magnani andnakamura the observation script covered the following aspects the relations between the subjects the relations between the subjects and the space customs behaviors emotions values forms of social organization the practice of sports modalities the strategies and methodologies of action employed in the context of health promotion at the end of the fieldwork semistructured interviews were conducted which upon consent were recorded and transcribed in an electronic file for analysis the interview script was based on the socalled conversation with purpose based on studies minayo this concept is reinforced in the ideas of triviños stating that semistructured interviews make for the starting point in the listening process between the researcher and his research object the script of interviews with professionals covered the concept of health promotion the possibilities of action with the theme of health promotion in the area of physical education the systematization of the theme its contents methods and evaluation and the appropriation of the theme by the participants the interview script with the visitors covered the concept of health promotion possibilities of acting with the theme in their daytoday as a regular at the sports center the appropriation of this content the data analysis took place by the method of triangulation based on triviños using nonaprioristic categories that are based on campos about their implicit relevance when they arise latently in this process andor through attendance when they arise systematically allowing us to complement the reading of the data since both are not mutually exclusive results and discussion the set of responses regarding the concept of health promotion allowed us to identify a single category health promotion as individual responsibility here it is designed in the idea of physical wellbeing and the good functionality of the human body in the process of appropriation of such precepts by individuals possibly based on the practice of values intrinsic to the manifestations of physical performance sports in physical education as successful and which are massified by the media as pointed by kunz in it to promote health means to establish a set of actions and working methods that most of the time may be related to the standards of excellence experienced by individuals throughout sports regardless of their context so soon anchored in the studies of carvalho bracht and kunz having been justified in the following sections are small habits that you add up from the moment you wake up to the moment you sleep so in these small habits is that we are encouraging this condition of health promotion professional 1 health promotion for me it would be you to create all the conditions for people to be able to insert themselves in some way into a lifestyle where they can maintain their physiology their health parameters within normality professional 2 this category of analysis brings in its essence the effectiveness of the organicfunctional paradigm revealed in the speeches and interpretations of professionals in a way linked to health prevention and habitual both in methodologies strategies and evaluation of work in physical education sport and health however regarding the concepts used in health and their promotion such reading has been the target of criticism as pointed out buss czeresnia andwestphal what is also noted is the clash about normality to the detriment of pathology as described in studies carvalho andscliar when referring to the historicity of the concept of health it is necessary to put such understanding into perspective above all by recognizing it as a recurrent factor in the historical process of physical education itself as well as in the development of public policies in the field of health as well as in studies almeida oliveira andbracht andcastellani filho in their counterpoints about the strict operational influence with regard to knowing how to do tasks well as well as the reasoning of the area in the field of the health sciences through the use of medical rationality so dear to positivism in the formulation of methodologies and intervention strategies in this sense the criticism that is being made for now rests on the possibilities of resignification of such interpretations through the tacit explanation of such values as not unique and more likely in the work in physical education sport and health with this it is necessary to raise as an interpretive possibility the professional training and intervention processes that the research subjects went through reinforcing the biomedical model the strict concept for health as well as the dogmatization of the healthdisease binomial in their professionalities especially when related to a possible hegemony of human performance in this sense we can infer from the recurrent reading of conceptual definitions of health practice through strictly technical values that legitimize the contexts presented such as those drawn in the estrangement between researchers and their research objects and reported in the ethnographies of aredes et al silva and ferreira when placing their initial impressions on the approach to their respective fields of research and perceiving in the subjects territorial materiality the search for the effectiveness of responses consistent with their concerns given such an impression we realized in the answers that technicism as fundamental to the pedagogical practice of physical education in health emerged as a possible justification of those everyday rites the invitation to do some classes as a student in order to understand his work methodology finally arrived still according to the professional 1 himself only in this way would i understand his teaching dynamics only in this way i could understand how he teaches and how his students feel throughout his intervention although in a different context from those that precede us and support the referred cut we allow ourselves to infer an interpretative transference about such peculiarities because throughout our conversations the approach with the subjects occurred in the effectiveness of the descriptive survey of their professional profiles therefore eligible for their understanding in the field of practical interventions on health promotion the instrumentalization of theoretical knowledge of organicfunctional nature is recurrent in this dynamic and finds justification in what daolio pointed out as the exacerbation of the biologization of the human body the second question which dealt with the appropriation of this content in their actions allowed us a single category of analysis health promotion in the community as a physical education teacher i realize this in the students by their account we can even realize this on a daytoday basis professional 1 many students arrive most of the time seeking aesthetics health or performance although it is not our goal here our focus here is on quality of life and health professional 2 the listed understanding is based on the qualitative relativization of teaching knowledge and practices through the use of interpersonal relationships as a justification for action with health promotion in pedagogical practice in physical education in a process of collective construction it is also necessary to read the interpretation by professionals about the objectives of the work in that room to be focused on quality of life and health in the community a premise that must be increasingly aligned with the sociocultural context of individuals in the meantime the reports of the professionals suggest a point of tension between a strict conceptual definition at the expense of an expanded practice now how to understand quality of life and health from a dissonant perspective of those practices in some way both in the reports and in the pedagogical practice developed there one can affirm the existence of the concern in the sociocultural contextualization in the loom of the professionalities presented the third question was based on the daily relationships and processes of professionals about the planning and systematization and evaluation of content since directly or not they have revealed its importance in this sense we come to the category entitled health promotion as intrinsic content revealing itself in the decantation of theories and working methods as inherent to pedagogical practice in physical education and this impression gained strength in the following fragments for me this work is implicit in the smallest of the efforts that the students manage to make they already report it to me this there is no concern with method and these more specific things because the time i am already working here it is already inserted in my practice professional 1 in this work of health promotion ah i think well i already entered in a system that existed here and gradually you will try to change adapt according to your need we sometimes end up playing the role of a supervisor to know if the student brought the medical certificate if they the citizens arrive and enter their respective class schedules for me this is to systematize as soon as they arrive i explain the operation system talk about the weight room routines and about the benefits of practicing a sports modality like the same we make an individualized training sheet according to your goals professional 2 the assertiveness in directing a pedagogical practice as intrinsic and organic to the premises of content objectives method and evaluation anchored in bracht reveals that the concern with effective planning in the context of a proposal for health promotion probably occurs in the background and in an inherent way to its possibilities in this sense the dynamics of the work routines of the professionals and the usual transience of gym attendees may be considered eligible in the interpretation of such practices since the residents who attend the space have a characteristic of turnover in that daily life possibly corroborating with a watertight view of the process and which by the way may contradict the initial treatment declared by the interviewees therefore some teaching knowledge in pedagogical practice seems to be confirmed in the training process of professionals in the search for an apparent systematization of the procedures of their intervention we recognize however that this phenomenon is justified above all from the idea of teaching large and diverse groups even though the classes and the physical structure of that space are relatively lean in general there seems to be concern on the part of professionals in what refers to the full and satisfactory functioning of the room in concrete terms we see the instrumentalization and operability between planning and execution in the plot of the strictly biological dimension of individuals these impressions which are confirmed on the basis of the following segment of the field notebook in the early afternoon the frequency of residents is lower the few individuals present have apparent autonomy from their bodily practices this reading is also confirmed by realizing that there are wheelchair students who practiced weight lifting from their respective training sheets with few and occasional help from the other subjects there is a record assembled and made available by professionals which in our view needs constant reassessment there it is clear to us that the goal of a large part of the public is not aesthetics not at least at that time classes are heterogeneous according to gender age and skill level in the midst of such findings the professional tells me that in that place the basics are to be done and well done addressing the plurality of discourses regarding concepts and plans as well as the practical application of the values inherent in health promotion it is perceived in this context that the concern with it exists but in a nondirective way in the daily lives of those subjects this fact seems to us to serve as a more concrete question in those daily rites especially when they do not clearly report how their assessment instruments are given indirectly it can be inferred between the lines of the statements that it is intrinsic to their pedagogical practices probably from an empirical perspective about the processes developed there therefore to evaluate the work in physical education sport and health in that space is to observe and intervene if necessary it should also be noted that within the scope of actions of said municipal secretary there is no need for such records and specifically in the case of physical evaluations these are at the discretion of the usersresidents therefore validating or not such procedures the fourth and last question carried out goes to meet their understandings about the appropriation of content by the frequenters of that space in this sense it was possible to identify the category health promotion as practical knowledge in the scope of the instrumental desires of the daily life of the gyms and the improvement of physical fitness as the main counterpoint to the process of health and illness in addition to the fear of a premature death that hovers in the listed intersubjectivities arising i have several types of students each of them with a life expectancy with exercise and with respect to the teacher some are here only for recreational practice for example some have a health concern although a vague concern out of simple medical advice they come kind of without knowing what to do and with practice they get used to it until they begin to miss that routine professional 1 its complicated they appropriate master this knowledge i think not most of them do not i think a lot of them come here because of medical advice like the doctor says you need to move if not youre going to die it may seem like an exaggeration but i see it like this that way you know a lot of the students here i think they dont like what they do professional 2 the practice of physical activity as an alternative to states of health and illness is explicit in the positioning of professionals guided by the precepts of physical fitness although they reported their reproduction automatically by the users the content selectivity inherent to the organicfunctional dimension was recurrent at this point of the analysis also here we highlight the crystallization of values pertinent to a physical education that bases the promotion of health through a strict bias through health prevention and the reduction of mortality of individuals as explained by almeida oliveira andbracht andcastellani filho such triggers certainly appear as premises allied to the technicalscientific view of preventive medicine in primary health care as demonstrated by the studies of buss andczeresnia what do the users say in relation to the concept of health promotion the discourses of the users like the professionals go to meet the prevention in health in the responsibility of the individuals thus the concern presented was in the sense of the regular practice of physical activity combined with good nutrition and carrying out periodic medical examinations as subject to the state of health promotion to be achieved due to the proximity to the issues inherent to health at the biological level and in a certain way as exclusive to behavioral issues the category presented was named health promotion as inherent to the individuality of the subjects based on the following sections health promotion has a lot to do with health behaviors the best behavior for health promotion is prevention user 1 health promotion in my opinion are several things is to do physical activity every day whatever it is the second thing that is also fundamental is to have a good diet with a view to promoting health user 2 health promotion is all you need to take good care of your health making appointments and periodic examinations to monitor your own health do physical activity jog overall i think this is health promotion user 3 is the practice of physical activities goes through the habits of the daytoday for example i never drank alcohol never smoked never used drugs so i think it is a healthy environment is conducive to health promotion user 4 health promotion is all that part that involves us in before any disease arises right it is the ability to do physical activities have a good diet and good general habits without addictions health promotion comes in this sense there user 5 certainly the promotion of health permeates the subjectivity of individuals and constitutes an important example for its appropriation however here such meanings were given in a prominent way appearing as the only possibility in the view of the users and reinforcing the concepts initially defended by professionals including a reductionist understanding for the perspective of individualization of processes and consequent culpability as pointed out by costa garcia and nahas devide however in the above cuts it should be emphasized that the concern of health promotion as prevention has been reinforced from issues peculiar to physical impairment due to illness and as an example we can cite the cuts of the speeches of the users 1 and 4 the citizen user 1 is a regular in the bodybuilding classes and has never been late for any of them even with his apparent difficulty in getting around the places he does not quit his exercises at the end of each session he asks for the help of the professionals to perform his upper limb stretching limitation which was caused by an ischemic stroke in the case of user 4 the concern for the practice of bodybuilding occurs in the context of his physical limitation due to complications arising from type i diabetes and in the midst of them the subject ended up developing an associated case of depression according to him due to unemployment and continuous treatment needs that were costly for him and his family that helped him however we understand that this vision lacks proposals aligned with its resignification in the pedagogical practice of professionals as a power in educational structures and practices and this reading occurs once again through the reinforcement of issues inherent in prevention to the detriment of promotion in the convergence of strategies that base the autonomy of the subjects as a rule the healing character of that practice is largely reinforced which in a certain way can corroborate with the epidemiological look and with issues inherent to the individual culpability of the subjects regarding the possibilities of acting with the theme in the daily lives of the users the set of answers allowed us to infer in two categories of analysis the first of which is entitled health promotion inherent to the interpersonal understood in the alignment of the expanded dimension of health phenomenologically it meets the places and other environments of the bodybuilding practice as conducive to socialization and sharing in health among large groups justifying itself in the following sections what helps a lot is you to have an interaction with your fellow bodybuilders and with the teachers that helps you sic a lot user 1 here the sport provides this to make new friends to promote your health in general to live in a healthy environment with good but few friendships user 4 on the part of the professionals for their knowledge for all that they demonstrate in the weight room with the students yes thats why i see these possibilities they always guide us in this direction and give us various feedback on their part to us it does happen yes user 5 at this time the concern with health in a collective and dialogical plan gained prominence in the understanding of encounter as part of its social experiments already presented in the studies of carvalho carvalho e ceccim andpalma estevão andbagrichevsky it is also noted that for the first time the word sport emerged in the discourse of the interviewees as a possibility of appropriation dialoguing with the studies of kunz to respect any and all sports manifestation as worthy of this content including here being able to take place in the link of the networks of significance of that cultural dynamic the second category of analysis is the one that occurred in the strict context of the guidelines and other rites and practices in health promotion in which physical activities assume the healing character in prevention strategies here entitled health promotion inherent to practice arising on the basis of the following cuts there is research that says that when you do physical activities your blood pressure is controlled so thats super mega important since nowadays there are many people who are dependent on these medications user 2 for me there is and i think a lot depends on each one there is no point in not coming to the activities and then complaining user 3 the understanding of health promotion as belonging exclusively to the practical universe in the view of the frequenters occurs amid the discourse of its indispensability in todays society as pointed out in the introduction of this text once again the preventive character presented itself health and its promotion in this context are observed from the necessity of the practice of the modality disregarding the subject that the practice in the last question regarding the appropriation of the theme by the frequenters the set of answers allows us to infer in two more categories of analysis the first one entitled health promotion in practical appropriation which emerged in the following sections so physical activity is a duty and you have to face it that way you have to have a goal and that goal is the promotion of your health you know so even if something happens to you you go and soon resume to your goal your practice you understand in your goal you have to come here with a certain determination user 2 i seek all possibilities to improve my health of course as long as i also seek there is no point in us coming here and settling in thinking that things will happen on their own user 3 i can eat better have the habit of practicing physical activity at least a little a day take a walk leave the car aside ride a bike change some habits gradually that you asked me if it happens in the habit in the doing user 5 the direction of the speeches of the users once again meets the practice of modalities through the fundamentality of strategies in health promotion in physical education in his speech the preventive character is rooted in epidemiological issues being noted for values inherent in the culpability and individual responsibility of the subjects there is in this sense an exacerbated need for movement as the ultimate goal of those individuals the second category was the one that occurred in the collectivity of the subjects largely based on the socialization and capacity for dialogue between peers and here entitled health promotion in collective appropriation which brings in its core the antagonistic understanding to the previous questioning and preserving as a tool of appropriation of the content about health promotion the most possible interpersonalities justifying itself through the following cuts the context about the practice of this modality in a place that has health and its promotion as objectives as defended in the interview of professional 2 here it gained notoriety it should also be emphasized that in this environment questions about the pedagogical practice in physical education sports by the point of view of health promotion in addition to the characteristics presented and based on nondirectivity are largely crossed by issues that also occurred in an indirect format and this statement is based on the following cut from the field notebook even by the various posters for the dissemination of services and awareness of practitioners that are present in the environment about the importance of health and the harms of the use of anabolic steroids as main examples the nondirectivity of that context gains strength that is the information exists in a public and notorious way without however receiving mediation by the professionals who are there certainly there are several manifestations that refer me to the precepts of health promotion as well as to those impressions about the most diverse forms of organization of the collectivities of those subjects thus the set of categories leads us to the understanding that issues related to strength the cult of the body by the aesthetic view as supposed premises for that place were left aside thus escaping from stereotypes of bodybuilding gyms in the marketing perspective and alienating the pedagogical practice in physical education however it should be emphasized that such notes take place in that environment and in a format that sometimes bordered on reading about the practical application of the content objectives methodology and evaluation of pedagogical practice in physical education sport health and your promotion in a strict format in this sense it is possible to understand that in this environment the treatment for health promotion exists however in a nondirective format from the forms of collective organization of those subjects conclusion the daily practices and rites of the cultural dynamics of a public gym in the city of santossp are partially aligned with the promotion of health in the wake of westphal by understanding the links with the autonomy and emancipation of the subjects however they are echoed in the countrys official documents mainly in the national health promotion policy by distancing itself from the marketing practices of bodybuilding offered in large scale in urban centers in this sense the nondirective pedagogical practice of professionals although being a critical point also converges in prominence given the various arrangements that the place and the diversity of the public entail in summary it is possible to state that the investigated daily life although it responds to certain traditionalisms of physical education also allows a humanized look at physical activity in the context of health which is promising

the objective of the study was to understand the cultural dynamics related to health promotion in the context of the pedagogical practice of physical education professionals working in a public gym in a municipality of baixada santista state of são paulo brazil in the method an ethnography was proposed which used participant observation over a semester as well as conducting semistructured interviews with two physical education professionals and five local residents and gym users in addition to daily notes in the field notebook data analysis was done through triangulation and the use of nonaprioristic categories thus the use of such strategies allowed us to immerse ourselves in the field of research and revealed the customs practices values and diversity of work inherent to the concepts meanings and meanings attributed to that pedagogical practice finally what can be stated is that in the daily rites of that cultural dynamic the treatment given to the promotion of health is understood in a nondirective format about the steps that make up the pedagogical practice in physical education

introduction children begin to absorb gender stereotypes and expectations in early childhood by early elementary school girls are less likely than boys to say that their own gender is really really smart they are also less likely to opt into games described as intended for supersmart kids this pattern continues throughout the educational trajectory there is growing interest in disrupting gender stereotypes and expectations most americans believe exposing children to toys and activities typically associated with another gender is a good thing they also believe more emphasis should be placed on encouraging boys to talk about their feelings and teaching girls to stand up for themselves yet attempts to lessen gendered constraints are often less successful than intended how does this gap between the desire to undo or at least reduce gendered expectations and the continued maintenance of gendered expectations and outcomes persist we focus on the mismatch between expectations and outcomes in the context of gender and leadership despite increased participation in sports higher education and the workforce women are underrepresented in leadership positions our research seeks to advance our understanding of this underrepresentation by examining how childhood leadership programs may affect future gender leadership disparities how do the adults creating and implementing childrens leadership initiatives reproduce or challenge gendered leadership behaviors and outcomes to address this we engaged in participant observation of two childrens leadership day camps which we refer to as gleam and beam 1while there have been excellent studies looking at childrens conformity and resistance to gender expectations at camp this research addresses the role adults play in maintaining childrens gendered expectations and behaviors both camps explicitly focus on developing leadership skills and selfconfidence as well as encouraging children to defy gender stereotypes given this focus we were interested in how camp activities and counselors statements subverted or reinforced gender stereotypes how for example do camp authority figures stated attitudes toward gender and socialization intentions line up with the messages they actually send to children counselors and directors at gleam and beam frequently downplayed the role of gender in leadership development they framed leadership obstacles as individual level phenomena and assured campers they could do anything they put their minds to regardless of gender as a result campers learned simplistic and individualistic strategies for developing leadership skills such as cultivating a positive attitude and finding strong role models this focus may provide helpful tools for individual boys and girls but it fails to address broader structural and cultural constraints that impact gender inequality in leadership as we will discuss there were surface level similarities in how gleam and beam counselors discussed leadership but the underlying styles content and supporting messages that made up the substance of leadership lessons were strikingly different ultimately these differences reflected divergent ideas about gender and leadership if taken seriously these differences will continue to socialize children in gender stereotypical ways and reproduce gender differences in leadership styles and opportunities in the following sections we describe the camps in more detail and review the relevant scholarship pertaining to gender leadership and barriers to and advancements in gender equality we then discuss our data methods and findings we conclude by discussing the future implications of our results theoretical orientation even when parents want to expand the boundaries of gender they often feel pressure to teach their children to do gender correctly by conforming to the gender binary yet parents authority figures and other adult role models can also disrupt gendered beliefs especially for girls gender socialization has important implications for leadership the gender socialization messages children receive and the gendered nature of the resources and opportunities they have access to affect perceived leadership ability and future leadership opportunities for example boys still spend more time in formal competitions than girls competition helps children develop confidence independence ambition and strategizing skills all of which are associated with leadership because boys compete more frequently they are more likely to acquire skills and characteristics associated with strong leadership gender stereotypes prejudice and discrimination also affect the assessment of leadership potential authority agency rationality and other characteristics associated with successful leadership are seen as masculine contributing to perceptions of men as more natural leaders than women we examine what happens when adults attempt to disrupt these inequalities by teaching boys and girls leadership skills do leadership camps that try to teach children to be strong leaders and challenge gender stereotypes succeed or do they reproduce these stereotypes despite their intentions adult attitudes cultural messages and childrens understanding of gender equality even when they do not intend to adults often socialize children in a gender stereotypical manner kane finds parents can fall into a gender trap a set of expectations and structures that inhibit social change and reinforce the limits of gender research on the mothers of gender questioning nonconforming and transgender children finds many mothers provide trans affirming messages and challenge dominant gender beliefs to a degree they help children imagine alternative gender possibilities provide children with knowledge and confidence to challenge gendered logics and support their childrens identities and choices yet the way they talk about gender sends the message that while it is okay for boys to like girl things and vice versa there are in fact boy and girl things and children normally like gender typical things on the other hand authority figures and role models can disrupt gendered beliefs especially for women high school and college women who learn about successful women in stem fields are more likely to do well in stem classes feel a greater sense of belonging among stem classmates and have scientific career aspirations girls who see other women in stem fields are less likely to associate these subjects with masculinity and display more confidence in their own abilities yet girls must see similarities between themselves and role models to receive these beneficial effects when girls do not identify with role models their aspirations and selfperceptions can be negatively affected when they do intentionally address gender parents are often more interested in lessening feminine gender socialization one reason for this may be that masculine characteristics are more frequently associated with professional success another is that a soft essentialist understanding of sex and gender frames girls nature as more potentially malleable than boys nature which is understood as more rigid and driven by biology adults are more likely to see girls as flexible choosers with the freedom to decide whether or not to participate in formerly masculine arenas this view portrays girls as bridging two realms their natural realm of home and family and a chosen public realm of culture politics career and sports boys are more frequently seen as defined by biology their participation in sports and public life is attributed to their rowdy hyperactive testosterone fueled nature such beliefs persist into adulthood as when middle and upper class womens work outside the home is seen as a choice but mens is not soft essentialism also manifests in cultural messages encouraging girls to cultivate a mix of stereotypically masculine and feminine attributes magazines aimed at teen and preteen girls encourage readers to conform to some traditional norms of femininity while also asserting individuality girl power femininity implies girls are powerful and can do anything they want but also strongly encourages them to appear heterosexual and feminine in order to sustain gender complementarity and hierarchy this understanding of power and femininity emphasizes individual choice and ability obscuring and the role of broader structural forces in maintaining gender disparities emphasizing individual choice reconciles the dominant discourse of gender equality with patterned gender outcomes gendered inequalities are explained away as different preferences while adults attitudes organizational initiatives and cultural messages influence children children can accept reject or repurpose what they learn this combination of accepting resisting and repurposing cultural dictates persists across the lifecourse for example in their study on womens participation in fantasy sports kissane and winslow found participants simultaneously resist and reproduce gendered dynamics by questioning gender stereotypes in some cases and accepting some level of gender inferiority in others players often accepted gender stereotypes about women as a group but positioned themselves as atypical women who defied these stereotypes although our research examines the initiatives adults create to teach children about gender and leadership it is important to remember that children can interpret and react to these initiatives in unpredictable ways gender emotions and perceptions of leadership ability the camps we examine are a response to the growing interest in gender and leadership as well as the push for more women to enter leadership positions so why despite interest in increasing the number of girls and women in leadership positions arent there more women leaders some research focuses on the role leadership capital plays in selecting leaders high levels of early leadership capital lead to future opportunities that give access to further leadership capital and opportunities gender affects childrens leadership capital accumulation growing up girls still spend less time in formal competitions such as sports tournaments and debate competitions competition helps children develop leadership capital in the form of independence selfconfidence ambition and strategic decision making skills because boys compete more often they are more likely to acquire skills and characteristics associated with strong and decisive leadership other research focuses on how gender stereotypes prejudice and discrimination affect leadership opportunities cultural beliefs about masculine and feminine characteristics disadvantage women in leadership evaluations men are more frequently seen as natural leaders because authority agency rationality emotional self control career motivation and other characteristics associated with strong leadership are seen as masculine many characteristics linked to poor leadership such as passivity low ambition irrationality a preoccupation with emotions and lack of emotional control are associated with femininity cultural beliefs affect how people are perceived and evaluated aspiring women leaders encounter more skepticism than men about their ability to control emotions be appropriately competitive and make rational decisions gendered beliefs also affect how individuals see themselves and the choices they make hierarchies are created and sustained through relational dynamics men and women must see themselves as sufficiently different in a way that justifies mens increased power and privilege for gender inequality to persist to achieve a more complete change gender expectations must be disrupted simply providing new opportunities and positive messaging for girls and women is not enough if outdated cultural expectations regarding the obligations for girls and women persist in the face of new opportunities change will remain elusive and incomplete our study helps to uncover how childrens leadership training and the presence or lack of gendered messaging associated with this training can make change or stasis more likely is also a local middle school teacher and the gleam camp director given her position as director of all educational outreach programming she technically oversaw mike the beam camp director and all beam activities nonetheless mike and the beam counselors seemed to have autonomy over beam programming and activities we never heard mike or any of the beam counselors mention courtney or any other source of external expectations placed on them gleam began in 2009 and beam began in 2013 when we started our research in 2015 gleam had 400 campers 12 counselors and 13 assistant counselors beam had 150 campers 6 counselors and 7 assistant counselors2 all gleam and beam staff identified as heterosexual and cisgender over 90 percent of the staff at both camps was white reflecting the demographics of the surrounding community gleam counselors were all state certified teachers in their mid to late twenties working at elementary and middle schools during the academic year most were in longterm relationships recently engaged or recently married none had children gleam assistant counselors were local high school and college students many of them planned to become teachers after college beam counselors were also state certified teachers working at local elementary middle and high schools during the academic year many coached school sports teams as well counselors ranged in age from their mid twenties to mid thirties the majority were married and had children the assistant counselors were students attending nearby high schools and colleges during the academic year these counselors varied in career aspirations some had plans to become teachers or school counselors others planned on going into law medicine or business many of the assistant counselors went to the same college and learned about the camp because they had run track with one of the counselors who had graduated the year before and now worked at a local elementary school beam and gleam campers ranged in age from six to 13 and attended local elementary and middle schools during the academic year because they were not the direct focus of our research we did not ask campers about their race gender or sexuality but the majority of campers appeared to be white counselors told us the majority of campers were middle class reflecting the demographics of the surrounding community the names of the camps have been changed but were picked deliberately gleam is meant to have a slightly feminine ring to it beam is meant to have a slightly more masculine connotation the real names also had these elements all gleam and beam activities were chosen and planned by the camp director and camp counselors during a series of planning meetings at these meetings the director and counselors planned each weeks activities and events they also decided the age of the campers each counselor would work with who their assistant counselor would be and what extra activities they were responsible for at both camps counselors began and ended the day with their core group of campers they also did activities with their core group before and after lunch during the rest of the day assistant counselors would accompany campers from activity to activity while counselors would stay in the same room or area to run an activity with rotating groups of campers at gleam these activities were divided into the themes of math and science technology drama and expression at beam the activities were divided into strategic games and problem solving physical games and activities engineering math and science projects and leadership skills 3 each counselor was in charge of one of these four sets of activities and would implement an activity with various groups of campers throughout each day camps were an ideal site for this research for many reasons first the camps we observed were explicitly focused on leadership second the camps encompassed a mix of formal learning based activities social activities project based activities and physical activities allowing us to see approaches to leadership across a variety of contexts finally we were able to watch many counselors and many groups of campers do the same things multiple times over multiple weeks this gave us a sense of which exchanges were idiosyncratic or anomalous and which were more patterned and pervasive in a relatively brief amount of time we engaged in over 200 hours of participant observation we primarily observed camp sessions held in june and july of 2015 and 2016 we also observed camp planning meetings held four weeks and two weeks prior to the first camp session each year and counselor debriefing sessions which occurred at the end of the day throughout the first week of each camp we supplement this with information gained from camp websites lesson plans the daily emails sent home to parents summarizing each days major activities and camp social media posts we took a grounded theory approach to our observation and analysis both authors recorded their observations these notes were read multiple times and memos were written to help identify significant events and patterns memos and notes were then coded according to themes that inductively emerged throughout the research process as research progressed we began to narrow our focus to examine how gender influenced the leadership lessons taught at the camps gender is our primary focus although relevant less significance was placed on camper age class race or sexuality while we often refer to campers ages in activity descriptions age is not a major focus of this research 4 there were situations where age class and sexuality became more salient in interactions and we describe a few such occurrences it is possible our position as white heteosexual middle class cisgender women influenced what we observed as well as what camp staff and participants revealed to us making us less sensitive to issues of class race and sexuality it is also likely that race class age and sexuality appeared less relevant because while camps were gender segregated the race class age and sexual orientations of staff and participants was largely similar across camps counselors generally seemed untroubled by our presence there are likely a few reasons for this first despite the extensive amount of planning and organization that went into the camps parts of each day could also be hectic and unpredictable early on in each camp session counselors did not have much spare time to think about our presence and once things slowed down and routines were better established we had become familiar and unremarkable additionally camp activities occurred across the college campus college faculty and staff frequently slowed or stopped to briefly observe camp activities as they walked by although our presence was more consistent campers and counselors were used to being observed by outsiders the major difference we observed in counselor reception was that beam counselors were more likely to initiate conversations with us while campers were busy with activities they asked follow up questions about our research and shared their perspectives on the camp and campers this is probably partly because as cisgender women researchers we stuck out more at beam another likely contributing factor is that beam counselors frequently talked to each other when campers were doing activities whereas gleam counselors typically participated in activities with the campers or circulated among the campers and talked to them beam counselors were also more likely to assume we were bored5 and a few seemed to initially feel an obligation to entertain us as if they were our hosts nothing we observed at gleam suggested that counselors worried about whether we were bored or felt any need to entertain us campers initially took more interest in us we each followed a different group of campers every day while our presence was less noticed and commented on at gleam campers at both camps were initially curious we found the best strategy was to introduce ourselves to the group we were shadowing first thing in the morning we told them we were doing research on the camps and said we would be following their group for the day and that they could ignore us or ask questions if they wanted most campers at gleam treated us like a cross between an older camper and temporary visitor campers did not assume we were experts on camp and many were eager to tell us about it they never asked us questions about camp rules schedules or expectations suggesting that they did not see us as authority figures at beam we were treated like outside observers but typically quickly ignored once we introduced ourselves there were a few exceptions for example one boy came up to the second author and asked how she was allowed at camp since she was a girl another time a counselor told boys not to make jokes about nuts in front of a lady finally when one boy became separated from his group and distressed he approached the first author and asked for help he looked like he was holding back tears and we suspect he approached her because he did not want boys or men to see him cry not because he saw the researcher as an authority figure before the first author could do anything a counselor saw the interaction and intervened all of these interactions happened on the first day of camp we became less of a source of novelty for campers and were accepted as an unremarkable feature of the camp as each week progressed findings and discussion gender and conceptualizations of barriers to leadership gleam and beam had similar objectives including building leadership skills developing selfconfidence fostering an understanding of diversity and respect for others and promoting healthy lifestyles yet campers gender influenced how counselors thought about leadership gleam counselors confidently discussed their perceptions of the biggest leadership obstacles girls faced low selfesteem mean girls and bullies shyness and the inability to express ones thoughts and blatant gender stereotypes beam counselors rarely linked leadership obstacles to gender they saw goofing off being disrespectful and lacking initiative as genderless leadership impediments the absence of an involved father was the only gendered barrier beam counselors discussed this emphasis on uninvolved fathers allowed beam counselors to reconcile their views of boys as natural leaders with their participation in a boys leadership camp despite differing perspectives counselors at both camps suggested simplistic individual level solutions for overcoming leadership obstacles these solutions imply leadership deficits are best conquered by cultivating a positive attitude and finding a strong role model all campers were elementary and middle school aged limiting the complexity of genderrelated discussions yet these simplistic individuallevel portrayals of gender obstacles inaccurately frame gender as largely inconsequential and the barriers to gender inequality as minimal and easily overcome the individual level focus emerged during the precamp planning meetings here counselors chose daily themes brainstormed role models and activities to pair with each theme selected the role models and activities they liked best and then spent the majority of their time ironing out details related to when activities would occur how much time was needed and what supplies were necessary the specifics of each camp day were extremely well organized as a result yet there was no discussion of systemic social or political issues affecting gender inequality in leadership counselors capitalized on their preexisting knowledge of cultural role models childrens books and educational activities that could embody their positive believe in yourself and you can do unbelievable things style messages counselors did not receive training or resources to learn about how larger structures of inequality might contribute to gender biases and unequal outcomes in leadership if they were familiar with any of the broader research on gender and leadership they did not mention it 6this produced a very narrow narrative regarding the relationship between gender and leadership that positioned leadership success or failure in the realm of the individual gleam counselors viewed low selfesteem bullies shyness and blatant gender stereotypes as the biggest barriers to leadership for girls they taught girls to change the way they thought about themselves to overcome these barriers the lessons and activities on the third day of camp were related to the theme of perseverance in one activity girls were given a sheet with negative statements like im not good at this and i give up they had to rewrite each statement in a positive and encouraging way girls wrote things like ill be better if i try harder these activities were then connected to girl power statements about how girls could do anything in their concluding remarks to the reframing activity counselors said things like dont ever let anyone tell you you cant do something because youre a girl gleam counselors discussed the role gender played in girls leadership abilities and opportunities yet gendered obstacles were framed as easily overcome counselors pointed to role models as proof girls can do anything if they ignore other peoples negativity one of the featured role models was misty copeland the first black principal dancer at the american ballet theater 7 counselors said copelands commitment and perseverance were the keys to her success as part of the lesson we observed miss carly8 read misty copelands book firebird to a group of fourth and fifth grade campers in this picture book copeland encourages a young black girl to become a ballerina after she finished carly asked what the girls thought of the book the first camper to respond said i like her outfit another asked if misty was married the girls discussed whether misty was married one said if misty is married then the girl in the book could be her daughter carly eventually redirected the conversation emphasizing that mistys story was about perseverance and overcoming obstacles carly then played an under armour commercial featuring copeland the commercial zooms in on copelands lean and muscular form as she warms up and energetically dances in an under armour sports bra and underwear while we hear a series of girls read portions of a mock rejection letter informing copeland she will not be admitted into ballet school because she does not have the right body we observed this lesson with four different sets of campers and counselors counselors emphasized the same individualistic girl power message in every discussion that girls should follow their dreams and ignore criticism misty copeland clearly faced larger structural and cultural barriers especially related to racism in the ballet world and culture at large in the authors note at the end of firebird copeland explains she never saw girls with brown skin or curly hair in the ballet books she read as a child yet race was not mentioned in any of the gleam discussions the lesson was to keep trying and ignore negative comments this classless raceless gender messaging which assumes a common feminine experience is characteristic of empowerment messaging aimed at girls it suggests a commonality among girls experiences that ignores intersectionality and obscures the role cultural and structural dynamics in maintaining gender relationality hegemony and inequality it also gives campers a limited and inaccurate understanding of the complex obstacles women leaders face any success or failure they encounter will likely be attributed to their individual abilities ignoring the very real but less visible forces that sustain inequality counselors referred to beam as a mini boot camp for boys to learn social physical and leadership skills especially if they were not learning these skills at home the most experienced counselors were especially likely to discuss connections between a lack of masculine role models and low levels of leadership capital the following observation of outdoor team building activities illustrates this perspective during alexs activity the boys seemed particularly uninterested half of the group sat on the side and did not participate when the boys moved on to mr aarons activity alex followed he told the boys they were being disrespectful and that they better start behaving aaron then continued telling the boys that they need to listen and participate one boy started to giggle aaron pointed to him and said you need to grow up go sit over there and motioned to a nearby tree the boy sheepishly walked over to the tree and sat down aaron continued his lecture he called out some boys pointing to them and saying things like i know you can get sucked into the negative behavior or youve been instigating the group all day he then told the boys they could turn their day around once the boys started the next activity aaron came over to talk with me he told me this group is a bunch of screwballs and that hes had some of the boys in his group of campers before so he knows not to take crap from them he said that beam functions like a boot camp and that some of these boys need it and have problems because they dont have dads who are involved in their lives other counselors echoed these sentiments they felt the fatherson relationship was integral for developing a boys character and leadership potential beam counselors saw themselves as role models who could foster or supplement the skills boys might otherwise learn from men at home counselors did not distinguish between boys raised by single mothers and boys that had uninvolved or very busy fathers they believed boys were harmed regardless of whether their fathers were physically absent or present but uninvolved therefore although their understanding of leadership development could have been framed in terms of class and gender it was not yet counselors concerns about uninvolved fathers were based more on vague cultural narratives than campers actual experiences or living conditions when the third counselor brought up the uninvolved fathers issue with the second author she asked if this was a problem a lot of boys at beam faced ethan seemed surprised by the question and said that on the contrary most of the boys were from really solid families with involved parents when asked if he was thinking of any campers in particular ethan seemed slightly annoyed no its not like that he said its not usually any one of them its just happening more and more these days in another interaction ben one of the first counselors to work at beam told the first author about his participation in camp yeah when mike the camp director first asked me to do this i wasnt sure if i wanted to give up part of my summer but now i couldnt imagine not doing it its great and theres such a range of boys some have dads but they dont do much with them at home so they come here and some dont have dads but a lot have dads that are really involved theyre really involved with their family and you can tell dads and moms everyones involved in the family this vague and slightly confused statement was characteristic of beam counselors discussions of uninvolved fathers beyond these statements nothing we observed suggested absent or uninvolved fathers were a particular problem for campers boys were dropped off at camp every weekday morning at 8 am and picked up around three in the afternoon mothers and women babysitters were more likely to drop off and pick up but we also saw many fathers picking up campers on a daily basis fathers were especially likely to drop beam campers off on the first day and arrive an hour or two before the end of the last day of camp to watch the closing ceremonies and take campers home the family friendly reputation high rate of marriedcouple headed families and favorable quality of life ratings of the area in which the camps took place also serve to complicate counselors narratives about absent and uninvolved fathers 10 beam was created four years after gleam and imitated gleams model of providing leadership training in a single gender environment yet beam counselors did not believe gender presented many leadership obstacles for boys they saw boys as natural leaders who would benefit from fine tuning and practicing their skills the research on gender and leadership shows this view of boys and men as natural leaders is fairly common the emphasis on uninvolved fathers allowed beam counselors to reconcile their views on gender and leadership with their participation in a boys leadership training camp framing leadership training as necessary for boys raised in overly feminine or resource deprived environments allowed their participation in boys leadership training to coexist with their view of boys as innate leaders in order to avoid contradictions between their thoughts and actions however they had to ignore the competing perception that most of the campers came from solid families with involved fathers challenge competition and differential skill development most activities at gleam were collaborative competition was rarely involved girls were taught to encourage one another and create a supportive communal atmosphere most beam activities had winners and losers boys were trained to use competition to motivate themselves and others throughout this 9 in reality the first citation contains the name of the county in which the camps took place and the second citation contains the name of the town in which the camps took place for confidentiality reasons we have replaced the town and county names with area 10 in 2016 married couple families made up 82 percent of all families in the area femalealone headed households only made up 11 percent of families we do not have information on the marital status of campers parents but there was no evidence that campers came from families that were significantly different from the general population in the area we also do not have information about the average hours parents especially fathers worked per week but we cannot find any evidence that fathers or any workers in this area work a higher number of hours per week than the national average in 2016 study on the area community members rated their quality of life as an average of 85 on a 10 point scale indirectly suggesting that overwork is not a major problem section we discuss how variations in challenge and competition reinforce gender differences in leadership capital and potentially influence future leadership styles because leadership is correlated with masculine characteristics and skills boys are more likely to benefit from gendered leadership training reproducing gender gaps if the socialization elements of these activities are not acknowledged differences in training and the differential skills acquired from this training may reinforce beliefs that boys are naturally more competitive and girls are naturally more communal competition pervaded beam even when in groups boys competed against other groups for the best time strategy or performance running out of time was common during beam activities most activities were challenging and had a clear outcome signaling the group was finished a few activities were only completed by a handful of groups one example was a code breaking activity each group was given a lockbox and piece of paper containing a clue a series of letters and the equation a10 campers had to figure out the numerical value of other letters and translate the letters in the clue into numbers to unlock the box inside the box was a code and a smaller lockbox the lockbox contained more locks the boys had to use the clues in the boxes and other clues hidden around the room to open each lock this was especially difficult because some of the clues placed around the room were intentionally misleading and others were hard to decipher less than a third of the groups were able to unlock all of the locks by the end of the allotted time there was always enough time to finish activities at gleam girls often had extra time which they spent sitting around talking or watching music videos with educational or girl power themes this was partially because most gleam activities were participation based girls were expected to do something but there was rarely a clearly defined winning outcome for example in one drama session girls played a game called the doctors the five girls who volunteered to be doctors sat on a bench the rest of the group sat on the floor facing them and asked nonsense medical questions the doctors answered by each saying one word at a time until one said the end this usually produced a funny nonsense answer for example the response to the stripes question was girl 1 a girl 2 bad girl 3 case girl 4 of girl 5 the girl 1 stripes girl 2 is girl 3 cured girl 4 by girl 5 eating girl 1 apples girl 2 and girl 3 drinking girl 4 polkadots girl 5 until girl 1 you girl 2 puke girl 3 the end counselors encouraged girls to participate and demonstrate effort but whatever that effort lead to was seen as a valid outcome as a result however gleam campers were rarely clearly challenged by activities counselors talked about perseverance and recovering after making mistakes but campers were not given opportunities to test out these skills research suggests some degree of failure and disappointment in the face of challenging circumstances can enhance resilience and personal growth dealing with complex situations where success is not guaranteed can foster leadership development while encountering adversity or failure can produce feelings of cynicism and victimization leaders who are able to reflect on the adversity they face report that difficult situations helped them to mature adapt and fine tune their skills combining some of beams competition and challenge with gleams open discussion and reflection would likely help both groups of campers develop leadership skills another way to understand how gleam and beam approached challenge and competition is to compare each camps final activity at both camps there was an activity campers participated in every day throughout the week and performed for their parents on the final day of camp at beam this was an athletic game called tchoukball it requires a foam ball and two square shaped frames laced with netting and bungeecords the rules state no one can run with the ball so teammates pass to one another to move the ball across the field each team tries to move the ball down the field and throw it at a frame a team earns a point if the other team fails to catch the ball when it bounces off the frame the space surrounding the frame is offlimits if the ball bounces in this area or if a player enters it the other team gets the ball the boys learned and practiced the game throughout the week on the final day of camp parents watched the boys play in a tchoukball tournament on the first day of each session counselors played a brief demonstration game they often used this opportunity to show off for the boys and one another throwing the ball harder than necessary jumping higher than they needed to to catch passes and passing the ball behind their backs a few minutes into the game mike stopped the counselors and told them to tone it down addressing the campers he said you dont have to play that way theyve been playing for a week start with focusing on solid passes he told the boys they were learning and shouldnt give anyone a hard time for dropping the ball instead they should just say well do better next time as the week wore on however counselors increasingly encouraged their campers to compete hustle and display athleticism in practice if there was a lack of effort some counselors would try to motivate players by yelling are you being the best you can be or is this helping your team they also made sarcastic comments such as wow guys one heck of a game we got here when boys were moving slowly they loudly celebrated when their campers beat other teams during practice games the assistant counselors were the most vocal in their celebrationsyelling flexing muscles and hurling the foam ball to the ground in the style of profootball players touchdown celebrations the overarching activity at gleam was very different throughout the week girls rewrote lyrics to the tim mcgraw song humble and kind they performed their rendition of the song for their parents on the last day of camp everything started with a lesson on being humble miss carly asked her group of third and fourth grade girls what humble meant the girls answered with responses like dont brag and being nice carly said it also meant not having a big head she then gave an example what if i said you were the best at kickboxing she asked what would you say if you were humble everyone was good one girl said yes or maybe you would say thank you but you would not be telling everyone you are the best said carly she then played a cover version of humble and kind a gleam counselor had recorded throughout the week this song was played when there was downtime and while campers worked quietly on projects each group of girls rewrote a stanza of lyrics to create a new version of the song that reflected the humble and kind theme near the end of the week the teachers passed out the new lyrics for the final performance the first lines of rewritten lyrics were no act of kindness is ever wasted no matter how big or how small help others to shine always stay humble and kind the lessons girls learned from rewriting singing and performing humble and kind were to be confident to be a force for good in the world and above all to always stay humble and kind we do not want to minimize the quality of either camp both were very well run and taught important lessons the potential problem is that boy and girl campers learned different lessons about selfconfidence personal expression teamwork and leadership these differences are divided down gender lines reinforcing gender divisions and potentially maintaining gender stereotypes take the differences in competition the choice of tchoukball was the result of a thoughtful decision tchoukball is not a full contact sport it is not hierarchical since there is not a set division of positions everyone does the same things it is also collaborative players cannot run with the ball and rely on passing to score goals these reasons along with the assumptions that it is easy to learn and most of the boys were not familiar with it before camp made it a good choice of activity nonetheless the skills taught in tchoukball align with gendered expectations that boys should be assertive competitive and athletic again there is nothing inherently problematic about developing these skills the problem arises when we compare these skills to the very different skills such as singing about being humble and kind that girls develop at gleam these differences will likely reproduce gendered patterns of leadership capital accumulation and skill development these findings coincide with research that shows girls are less comfortable with competition than boys are still socialized to downplay aggressiveness and competitiveness and experience difficulty balancing competition with being a nice girl this is one way organizations and authorities that are attempting to minimize gender disparities and develop strong leaders actually reproduce differences and inequality camp organization perpetuated gender differences in competition and skill development most counselors were unaware of the leadership training children on the other side of the binary received as a result counselors did not have a clear opportunity to identify differences between gleam and beam or reflect on how these differences might contribute to gender inequality differences in training and skill development can lead to future gender disparities in leadership if the majority of authority figures when campers enter the workplace continue to be men it is likely that the more assertive competitive taskoriented style of leadership taught at beam will be privileged if this is the case while gleam campers are learning important lessons about personal development selfconfidence kindness expression and empathy the style of leadership they have been socialized to embrace may be seen as inappropriate or not the way things are done in masculine or gender neutral environments furthermore if men and women do not realize they have been taught different styles of leadership differences in how they approach challenges and manage others may reinforce gender essentialist beliefs they may see leadership differences as natural instead of recognizing how differential gender socialization and leadership training contributed to these outcomes emotions and gendered expectations for leadership in this section we examine how gleam and beam counselors discussed emotions and how emotions relate to perceptions of leadership ability beam counselors rarely discussed emotions when they mentioned emotions it was usually during brief statements at the end of an activity gleam counselors discussed emotions in an elaborate manner in varied contexts and at multiple points every day while gleam campers will likely develop more emotional awareness and competence as a result of their training these qualities are not typically associated with strong leadership instead gleam campers may be seen as more communally oriented and more emotionally inclined these perceptions reinforce beliefs that girls and women are better suited for taking care than taking charge many gleam activities required campers to imagine what others were feeling this was seen in the cotton and sandpaper words activity which occurred on the second day of camp kindness was the days theme one of the authors observed miss carolines group of first and second grade campers the following description is from her notes caroline explained that some words were mean and hurtful and felt like sandpaper when you heard them and other words were nice and soft and fluffy and felt like cotton she passed around pieces of cotton and sandpaper so the girls could feel each then she asked the girls to think of examples of cotton and sandpaper words miss jen asked the girls to shout out sandpaper words they said things like youre fat youre ugly get lost you suck you cant play with me youre gross jen had a tube of toothpaste she squeezed toothpaste onto a paper plate every time a girl said something mean until all the toothpaste was out of the tube caroline and jen compared the difficulty of putting toothpaste back in the tube to regaining trust and friendship after you say something mean they said it takes a lot of work to make someone feel better after youve made her feel bad so the girls should all think about what they say before they say it and use cotton words instead of sandpaper words following this discussion each girl was given a paper doll called ginger caroline read a story about how ginger moved to a new school and was teased and bullied campers were instructed to rip their dolls every time someone in the story said something mean to ginger when the story was over and the gingers were ripped to pieces the girls glued their dolls back together on sheets of construction paper then they were asked to write kind words on one side of ginger and mean words on the other most girls wrote the same things the mean side listed phrases like youre ugly youre fat youre stupid you cant sit with me whats wrong with you youre weird the nice side had phrases like i like your hair youre pretty youre smart you can play with me you look nice the lesson was that even though ginger can be put together again she is scarred by the mean words the counselors told the girls that they have the power to make others feel good or bad so they should use their power to make others feel good the theme of kindness was reiterated in every activity that day for example it was incorporated into a science activity described in one authors notes for this activity the girls went outside they were in groups of five each group had a small container the size of a film canister filled with citric acid another filled with baking soda a large plastic bowl with liquid soap and a cup of water they were supposed to mix the ingredients together to make a foamy explosion the group i was with produced a large and foamy bowl of bubbles the mixtures of the other groups did not react as anticipated and stayed liquidy instead of bubbling up after this happened miss ashley said sometimes experiments do not work and that is ok we came back inside and ashley talked about how feelings can explode or build up like bubbles if you dont express them and how if someone says something mean you need to tell a friend so that your feelings do not build up and cause an explosion ashley reinforced the message by talking about how mean words can mix and amplify like the ingredients combined in the activity although this discussion occurred in a science session it did not focus on chemical reactions there was no discussion of why the combination of ingredients might produce a foamy explosion instead the lesson focused on the importance of expressing feelings these extended lessons on emotions and how to treat others sharply contrast with the way beam counselors dealt with feelings and the power of words there were not explicit lessons devoted to emotions instead counselors would occasionally intervene when they heard campers say things they judged to be excessively inappropriate or insensitive the following example occurred during a fitness session the owner of a local crossfit gym visited camp demonstrated proper technique for pushups squats burpees and running and led the boys in a workout during the squats portion of the workout some campers complained that they were hot and tired jonah one of the assistant counselors told the boys to stop being a bunch of babies another counselor ethan acted like he was going to climb on the back of a boy who was complaining do squats with me on your back ethan said it seemed ethan wanted to distract the complaining boys by joking around thats gay said the boy dont say gay ethan said immediately thats retarded the boy said dont say retarded ethan said ethan then walked away ending the interaction when beam counselors did directly address emotions a brief or nonverbal response sufficed on the first day of camp mr jake asked his group of campers to rank their level of enthusiasm for the upcoming week from one to 10 campers were hesitant to answer and looked around nervously or stared at the floor cmon jake urged everybody hold up your hands to show me your answer indicating the boys should hold up 110 fingers to demonstrate their level of excitement one boy held up 1 finger the rest held up 510 thats ok thats cool jake said by the end youll all be 10s youll be stoked then he moved on to outlining the plan for the day this interaction was characteristic of the cursory discussion of feelings at beam gleam programming presented meanness and negativity as problematic for advancement and development to be a strong leader girls were told they need to recognize their own emotions and consider others feelings they were repeatedly encouraged to be kind and required to participate in acts of kindness throughout the week in this way they were taught a slightly more enlightened version of what middle class white women have been taught for centuries feminine power is still framed as stemming from womens ability to relate to others to be kind and to nurture emotional needs this framing was omnipresent at gleam beam campers learned to treat one another with respect or at least not to actively disrespect others they were not explicitly encouraged to think about their own emotions other peoples feelings or how their actions might influence others these observations are in line with research that shows boys and men often avoid discussing or displaying emotions because they see them as stigmatized and feminine if emotions are not addressed or portrayed as important it is likely this stigma will remain this very different treatment of emotions in the context of leadership may lead to future difficulties when men and women work together or when a woman is in a position of authority over a man or vice versa differential leadership training regarding the management of emotions may lead men and women to see contrasting leadership styles as ineffective or illegitimate a man may see his woman bosss concern for employees feelings as coddling and inappropriate for the workplace a woman may see her man bosss reluctance to address emotions as evidence that he is emotionally stunted immature or unconcerned with employee wellbeing this judgement prevents the development of mutual respect and authentic relationships different leadership styles may also prevent people from seeing someone of another gender as a valid role model and maintain gender disparities in mentoring hiring employment we do not believe the solution to the gender disparity in emotional training and stigmatization of emotions is to stop discussing emotions with girls instead the best course may be to acknowledge emotions are not masculine or feminine they are human some boys and men may resist discussing emotions as long as they are seen as feminine work needs to be done to overcome this resistance but change is possible essentialist beliefs about emotion can be disrupted by pointing out the contrast between the belief that men are inexpressive and real life examples of men expressing many different emotions there is concern that men who do address emotions will be just as stigmatized as women yet some leadership research suggests this is not the case men can be attuned to emotions and communicate in a warm manner without having their leadership ability questioned suggesting a greater emphasis on emotions for men would not negatively affect perceptions of them or their future opportunities this is not a perfect solution it does not address the general cultural devaluation of the feminine yet emphasizing the omnipresence of emotions may help to disrupt beliefs that women are too emotional to be great leaders therefore this may be a practical step toward better incorporating emotional competence into boys leadership training without simply masculinizing emotions conclusion this research contributes to our understanding of how wellintentioned actors reproduce gender inequality gender is a stratification system that cannot be reduced to individual choices yet counselors taught simple individuallevel strategies to develop leadership skills including cultivating a positive attitude and finding positive role models they portrayed gender inequalities as primarily a thing of the past obscuring the dynamics maintaining modern gender hierarchy there are limits to what can be accomplished in a fun and extracurricular summer environment there are also limits to what elementary and middle school aged children can understand when it comes to gender inequality yet the singleminded emphasis on free choice obscures the chronic problems people face when they run into unacknowledged gender barriers a more nuanced discussion of gender inequality beyond the individualistic dont listen to other people when they say you cant do things messages could help campers to recognize understand and potentially chip away at gender boundaries finding ageappropriate ways to address more complex gendered leadership issues head on would help campers to understand and deal with these issues a more intentional and enlightened manner even on the individual level however these camps will likely contribute to gender disparities in leadership emphasizing competition at beam while avoiding it at gleam means boys are more likely to accumulate the leadership capital competition has shown to produce in the form of confidence independence ambition and strategizing skills as a result boys will continue to be seen as more natural leaders than girls the emphasis on emotions at gleam but not beam reinforces the association between emotion and femininity this is problematic because being emotional or concerned with the emotions of others is associated with poor leadership overall the skills boys learn at beam are much more clearly correlated with leadership than the skills girls learn at gleam this means camp training will likely reproduce gender gaps in leadership one way to disrupt gender stereotypical leadership training would be to integrate the camps gender segregation works to normalize the gender binary and conceal evidence that might otherwise challenge essentialist beliefs spending large amounts of time with same gender peers exaggerates gendered behaviors and attitudes and reduces opportunities for cross gender interaction gender segregation also guarantees that gender will act as a salient organizing principle coed sports educational and leadership programs help counter the gender essentialist attitudes children develop in gendersegregated arenas on the other hand counselors and camp directors were committed to single gender environments in informal conversations gleam counselors discussed their beliefs that gender segregation helped build girls confidence and created a safe space where they felt freer to be themselves and make mistakes beam counselors rationales for gender segregation reflect cultural tropes of feminine stigmatization and masculine privilege they felt enrollments would drop if camps were integrated because boys would be less interested in a coed camp teachers and other stakeholders at same gender schools express similar beliefs given the commitment to gender segregated camps we believe the most viable option for decreasing gender disparities in this type of leadership training involves a more concerted effort to decrease gender stereotypical messaging a clearer discussion of the role gender plays in leadership opportunities and more hands on training for recognizing and navigating gendered leadership outcomes data and methods gleam and beam take place on a midwestern college campus both camps are nonprofit and affiliated with the colleges educational outreach program which provides programming for interested area primary and secondary school students the director of the educational outreach program courtney west candace and don h zimmerman 1987 doing gender gender society 1 12551

recent leadership initiatives encourage children particularly girls to defy gender stereotypes yet those creating and participating in these initiatives like all members of our culture have their own gender biases have received gender socialization and live in a society where the masculine is more valued than the feminine we conducted participant observation of two gender segregated leadership summer camps to examine how camp counselors and directors teach leadership to boys and girls we find counselors unintentionally reinforce gender stereotypes and promote gendertypical behavior while attempting to break down these same stereotypes and behavioral expectations we argue the gender segregated environment leads to a problematic separate but equal approach to thinking about leadership that advances the individual abilities of boys and girls but does less to decrease gender disparities in emotional development physical competition or leadership styles this research contributes to our understanding of how wellintentioned organizations and authorities seeking to minimize gender disparities and develop strong leaders unwittingly reproduce gender differences and perpetuate gender inequality

introduction during the last decade eating outofhome has become habitual and contributes considerably to dietary habits and nutritional status worldwide 1 2 3 food prepared outofhome tends to be less healthful than food prepared at home and is associated with both increased dietary fat intake and body fatness 4 5 6 eating outofhome is not confined to adults with adolescents in the us consuming onethird of their energy outside of the home 7 school and other educational establishments and local food outlets especially fast food and convenience stores are common sources of food for adolescents in the us uk and ireland 7 8 9 10 11 the surge in eating outofhome has seen a parallel increase in research exploring the type and impact of food environments in and around homes schools and workplaces 4 12 13 14 15 the food environment is defined as the collective physical economic policy and sociocultural surroundings opportunities and conditions that influence peoples food and beverage choices and nutritional status 16 different components of the food environment include the variety quality and price of available foods and also structural aspects such as the spatial accessibility of retail outlets 17 studies of these contextual determinants of diet have predominantly considered associations with food availability measured in terms of proximity to or density of retail food outlets or the instore environment including the cost and store location of healthy and unhealthy foods 1819 the association between characteristics of the food environment diet and obesity remain equivocal 20 with heterogeneity in approaches to measuring the built environment as just one contributory factor 21 subjective measures include perceptions of individuals nutrients 2021 13 1043 2 of 11 living or working near food stores and objective measures are derived from observations audits or are calculated from existing spatial data using geographic information systems poor or moderate agreement between perceived and objective measures have led to suggestions that these measures should not be seen as comparable 21 according to caspi and colleagues 22 perceived measures of the food environment may be more strongly related to dietary behaviours than objective measures and may incorporate dimensions of food access not captured in available objective measures research on the impact of school and community food environments on adolescent food choice is heavily reliant on objective rather than subjective measures of food outlets around schools or homes gaining the perspective of adolescents and how they perceive and use food environments will help us understand how they navigate to and choose particular food outlets caraher and colleagues 23 using a mixedmethods approach found that unhealthy food options were a feature of the streets surrounding schools in a london borough and that cost and attitude to school meals and shopbought products influenced adolescent choice these types of data serve to help us with the development and refinement of behavioural interventions addressing food eaten outofhome as well as providing estimates of the likely impact of environmental or policy interventions the dearth in qualitative research on food environments 24 specifically a lack of subjective measures of adolescent food environments and existing data demonstrating that close to threequarters of postprimary schools in ireland are located within 1 km of fastfood restaurants 25 provided the impetus to explore how youth perceive and use food outlets close to their schools the current study contributes to the extant literature by exploring young peoples perceptions of external school food environments without restricting the discussion to fast food or takeaway outlets alone additionally this study aimed to explore what barriers and enablers if any are at play for young people when accessing food stores this study focuses on adolescence a time when young people have greater autonomy more pocket money and independence travelling to and from school than younger children 926 this study was underpinned by the recognition that children are active social agents and experts in and of their own lives 27 and have a right to participate in research likely to affect them 28 the objectives of the study were to explore adolescents perception of the external school food environment to understand the barriers and facilitators of food outlets and food choice and whether and what type of changes they would like to the food environment surrounding their schools methods and materials a qualitative research design was adopted due to the limited knowledge available on adolescent perceptions and experiences of using external school food environments objective quantitative measures of food outlets surrounding schools were not collected as our previous work showed that the number of food outlets within a 1 km radius of 63 postprimary schools was an average of 389 coffee shops and sandwich bars 365 fullservice restaurants 260 asian and other ethnic restaurants 403 fastfood restaurants 195 supermarkets 671 local shops and 073 fruit and vegetable retailers of the schools surveyed 25 sampling and recruitment purposive sampling 29 was used to recruit schools single and mixedsex schools located in cities and towns were approached and provided with information about the research both younger and older children were also included in the sampling strategy principalshead teachers were initially contacted by mail and telephone if they agreed to participate in the study researchers provided information sheets and consent forms to be distributed to students and their parents or guardians at home information sheets comprised an optout or optin consent process depending on the school managements preference all students provided informed parental consent and individual assent before participating in the study multiple methods were used in this study to meet the objectives and were based on participatory mapping techniques 30 photographs used in related school food environment research 31 and group discussions materials preparation the researchers walked the external school food environment prior to the workshops taking note of the types of food premises within walking distance of the school a smartphone and ipad were used to take photos of the food outlets three methods were used to collect data 1 workshops were conducted with groups of children within the school building large maps that detailed the location of the school and the surrounding areas were prepared in advance and pinned to the room walls working together the students were invited to place photographs of landmarksbuildings onto the map that had been prepared by the researcher this exercise was used to encourage active participation in the research to create debate and to enable students to locate themselves and their school within their external school food environment 2 each student worked alone on a smaller version of the map described above and wrote the names of food outlets within walking distance of their school onto the maps students then highlighted the food outlets they personally use and also drew a route on the map to illustrate how they interact with their own food environment 3 facilitated discussions with adolescents were conducted using a semistructured guide students could refer and reflect on the map exercises during the discussions students were in discussion groups with peers from their own year group the age varies within year groups in ireland nutrients 2021 13 x for peer review 3 of 12 by mail and telephone if they agreed to participate in the study researchers provided information sheets and consent forms to be distributed to students and their parents or guardians at home information sheets comprised an optout or optin consent process depending on the school managements preference all students provided informed parental consent and individual assent before participating in the study multiple methods were used in this study to meet the objectives and were based on participatory mapping techniques 30 photographs used in related school food environment research 31 and group discussions materials preparation the researchers walked the external school food environment prior to the workshops taking note of the types of food premises within walking distance of the school a smartphone and ipad were used to take photos of the food outlets three methods were used to collect data 1 workshops were conducted with groups of children within the school building large maps that detailed the location of the school and the surrounding areas were prepared in advance and pinned to the room walls working together the students were invited to place photographs of landmarksbuildings onto the map that had been prepared by the researcher this exercise was used to encourage active participation in the research to create debate and to enable students to locate themselves and their school within their external school food environment 2 each student worked alone on a smaller version of the map described above and wrote the names of food outlets within walking distance of their school onto the maps students then highlighted the food outlets they personally use and also drew a route on the map to illustrate how they interact with their own food environment 3 facilitated discussions with adolescents were conducted using a semistructured guide students could refer and reflect on the map exercises during the discussions students were in discussion groups with peers from their own year group the age varies within year groups in ireland the discussions were recorded transcribed and analysed using nvivo 12 qualitative data management software which was the discussions were recorded transcribed and analysed using nvivo 12 qualitative data management software which was also used to manage the data thematic analysis was used to analyse the data inductively 32 data were initially reviewed for interesting features with memos being used to record identified themespatterns further analyses focused on more detailed line by line coding followed by interpretation of the meaning of and relationships between the initial themes and patterns within and across schools differences by school year group and gender were also explored the maps were collated and together with the photos taken by the researchers were used to visualise the food outlets and to help understand what young people described in the focus groups these data helped the researchers to visualise the food outlets that young people described in the workshop discussions and provided additional insights into the contextual factors described by students this also enhances the trustworthiness of the data and findings collectively the authors have backgrounds in nutrition health promotion and geography reflexivity was used to reflect on the role of the researcher and key decisions made ethics full ethical approval was obtained from the institutional research ethics committee all students provided informed parental consent and individual assent before participating in the study results in total 95 students from six schools located in towns and cities from years 12 and years 4 5 and transition year took part transition year is a oneyear programme before students enter their senior cycle all data collection sessions lasted a class period the internal food environment differed across schools some with canteens vending machines or tuck shops and others with no or very limited facilities while most students had a choice whether to leave school at lunchtime children in one school were required to do so most students brought some food from home to school each day especially for small break which is typically at 11 am packed lunches were also often brought in for the longer lunchtime break almost all students described using retail food outlets at least once a week with many going 23 times a week and some students going to these outlets every day students went to the shops before during and after school and the vast majority walked at these times food was purchased after school if they were hungry waiting to be collected or had extracurricular activities such as sports or study periods the frequency of going to the shops depended on many factors such as whether lunch was brought in from home the amount of money they had the weather for a variety of food or if they wanted something nice the perceived number of food outlets within walking distance of schools varied with between four and fourteen outlets recorded on the maps and between three and four outlets used routinely by students the themes that illustrate the types and use of external school food outlets and the barriers and facilitators relative to food outlets are described below the quotes from children are faithful to their use of language parentheses are placed around the word like where it is being used as a functional pause in their quotes theme 1 cost of food discussions about food were synonymous with cost and students were less likely to use a food outlet if the prices were too high or deals on meals were no longer available its too expensive y can be really expensive and youve to cut costs in particular students were attracted to meal deals and they sourced the cheapest option across shops and everything in xxx is cheap as well so you get better value for money because theyre cheap and you get enough bon bons that would last the day xxx have cheaper ice pops the cost of food also determined food choice in the x you get soup and brown bread for €3 or else you can get a toasted sandwich with that for a fiver its good including healthy or less healthy options its hard to make good choices and it costs more everything is on offer that you really like yeah it would take a lot of effort because if youre going youd have to buy the wraps and then youd have to go buy the other stuff separately getting value for money was an important determinant of the choice of food outlets and of the food itself theme 2 convenience students favoured food outlets that were convenient such as close to the school on route to schoolhome outlets that provided shelter from the rain and provided fast service its just handy to get there theyre convenient to go to theyre just quick because theyre near to school and fast its within walking distance subtheme time pressure students were under pressure to eat and return to school within the time allocated for lunch and so they avoided going to food outlets that were further away from the school and take more time to get to i wouldnt go to x because its a longer distance maybe x you wouldnt have time to get back to school since we only have 40 min for lunch you dont really have time to be trying new places when you think about it thats the kind of thing for the weekend if you know that youre going to like something in x youve 40 min so youre going to go and get it there subtheme too busy some food outlets were very busy which means the students had to wait longer to be served within the lunchtime limit its too packed maybe because of all the other students going well say if theres loads of people i could spend my 10 min break to get served theme 3 choice students described a variety of food outlets and types of food available for purchase food outlets close to the school included large supermarkets smaller outlets petrol stations newsagentssweet shopscorner shops as well as discount stores fast food outlets included chain fast food outlets takeaways local fast food outlets as well as pizza outlets restaurants hotels cafes and pubs were also described students felt there were a lot of food outlets close to their schools with some estimating between six and seven stores and others felt there were over 1011 outlets to choose from popular outlets ranged from large supermarket chains and smaller chain stores deli counters were a particular attraction of these stores which were also a draw for students in local independently owned cafes larger supermarket stores with fruit and yoghurt as options were mentioned but shops whether supermarkets discount stores or local sweet shops that sold sweets were very popular students were not loyal to any particular shop subtheme food options while there were a variety of food outlets as described above the foods chosen were similar across students groups the food frequently described by students were hot chicken fillet rolls wedges chips pizza and sausage rolls other products frequently discussed were sweets crisps chicken curries burgers pot noodles hot dogs chocolate biscuits cookies donuts and buns other food for sale in the shops included pancakes crepes bread rolls with a filling of choice soup and sandwiches drinks commonly consumed included energy drinks coke 7up lucozade flavoured water tea coffee and miwadi which was often offered as a free drink with a hot food product students discussed food and beverage options they perceived as more healthy such as water milk fruit salads fruit salads wraps sandwiches soup brown bread lasagne chicken curry and rice volauvents nuts sesame sticks popcorn yoghurts and health bars subtheme quality and variety of food students made food outlet choices based on the quality of the food on offer they clearly had preferences for some stores over others because of how fresh indate andor tasty they perceived the food to be well i kind of like going to xxx because its kind of just everything is tasty stuff because most things over in xxxs are out of date so but also i feel like the deli is way fresher than in xxx because i compared kind of i bought the same thing in x and in y and it was way better in y it was way fresher the fruit in the corner shops theyre not as good as in xxx yeah the popular things like the bon bons and drinks theyre not but the bars theyre left there for months if you check the date theyre 4 months out of date xxx is really greasy some of the little shops are small a little small so they dont have that much stuff its the same stuff you kind of get sick of the same stuff all the time 333 subtheme food environment is more unhealthy than healthy students had mixed opinions of their food environment with some being satisfied with what was available in and around their school theres plenty of choices yeah different types of food in places so like fast food or chicken fillet rolls or subs or any of that theres just a lot of different choices others highlighted a need for a greater selection of food outlets that serve healthier foods if you were getting food out its more unhealthy than there is healthy just something more healthy coz everything else is not too great coupled with this was a need for food that is more affordable the healthier you buy stuff it kind of tends to be more expensive youll go to xs and get a soup or something itll be really expensive whereas you can get a drink a roll with chicken in it already for the same price if not cheaper with a drink theme 4 social relationships food was not the only reason for going to food outlets at times it was to buy supplies for school but invariably it was because they wanted to go for a walk or to spend time with their friends who were going and to meet others a lot of people just stand outside x rather than go in and buy something sometimes you dont sometimes your friends would be buying so then youd just wait with them or something your friends want to go well mostly people are going there anyway so you go subtheme food outlet staff students avoided food outlets if staff were unfriendly or if rules are in place that will require them to leave the premises if they do not buy food xxx youre only allowed in if youre buying something theyre really strict about that i just dont like the shop because the shopkeepers are mean 342 subtheme space and seating some outlets are deemed to be too small by the students with no place to sit and eat comfortably so youve time to eat it and sit down and stuff its easier you go to xxx you can come down and actually sit down and eat it rather than walking and eating at the same time yeah and i like it because and you have a place to sit there so differences between schools were only evident for the social relationship theme whereby students in schools that could not leave at lunchtime did not describe data relevant to this theme because of the age range in year groups differences by age were not discernible from the data collected and analysis by year group did not illustrate clear differences between younger and older year groups gender differences were found for the social relationships theme whereby only female students reported food outlet staff and space and seating as important factors influencing their choice of food outlet all of the remaining themes were identified from data collected across school types year groups and gender discussion the availability type and nutritional quality of food available in and around postprimary schools have been well documented in ireland 9253334 yet this is the first study to explore adolescents perception of their external school food environment qualitative data from 95 young people in six schools were collected using mapping tool exercises and discussion groups to capture their perception of the school food environment students describe a variety of food outlets surrounding postprimary schools this supports existing data from both quantitative and qualitative research 92533 there is a range of large and small outlets and adolescents are not loyal to particular shops however the appeal of outlets with deli counters was clear and especially those with hot food such as those that sell hot chicken fillet rolls this is similar to other studies of local retail outlets in ireland 9 and in the uk 35 purchases from corner shops in the us illustrate that beverages are the most popular item among adolescents although this data involved younger children than our study and included purchases over the year not just during the school term 36 the popularity of sweets was also evident in our study and is supported by other work in ireland 9 and the us 36 studies that have captured the density of fast food outlets close to schools are likely to miss the availability of fast food in other outlets be that small corner stores or supermarket chains similarly the availability of sweets in a variety of stores in our study questions the protocol of categorising supermarkets as healthy and fast food outlets as unhealthy in food environment studies 10 37 38 39 factors can act as both facilitators and barriers and this is evident in our data related to adolescent food outlet use and food choice factors such as proximity and convenience time pressures and familiarity are difficult to change and would require changes to school timetables to enable longer lunch breaks giving flexibility for students to explore other shops and food outlet options and to sit and eat factors more amenable to change include the cost of food and given the explicit desire to get value for money pricing and food marketing are likely to be important intervention functions the influence of marketing on the choice of food outlets and foods themselves was also evident and is related to adolescents getting value for money getting value for money was important for youth from low socioeconomic status backgrounds but not mixed ses backgrounds in the uk 31 these attributes of sourcing better value for money and awareness of price and promotion should be valued among adolescents and are likely to reflect what educators teach and families discuss of particular interest is how youth appreciate and seek out outlets that regularly change their menu options providing them with a variety of food options quality produce also featured heavily in the discussions with adolescents citing fresh produce and taste as factors that determine their choice of outlet and food taste has long been a clear determinant of food choice but the emphasis on quality and variety as important factors for adolescents is not clear in the literature a deterrent for some students relates to the internal architecture of the food outlets with a lack of seating and limited space an obstacle to frequenting certain food outlets this has also been described as a barrier to the use of school food canteens 3134 and highlights the importance of physical factors on adolescents use of food outlets and consequently their related food behaviours in addition the rules imposed by staff and the unkind attitude of staff to students are also barriers to the use of some food outlets this may come from a generally suspicious attitude towards teenagers which has also been reported elsewhere 31 interestingly shop staff in the latter study treated young people from low ses areas with respect valuing their custom the influence of peers was noted in terms of going to shops with friends but peerpeer group influence on food choice within stores was not explicit in our study choosing and eating food are shared activities through which young people can express affinity to preferred peer groups and thus fit in 40 41 42 our data illustrate that both the physical food environment and the social aspect of food and how these interact play a role in how adolescents navigate their external school food environments indeed the social aspect of food is thought to need more emphasis when exploring and intervening in adolescent food environments 43 the data from this study clearly shows that teenagers are primarily driven to certain outlets by the price of food while fast foods and sweet snacks were popular among adolescents healthier options equated to higher cost perhaps because the offers or deals were on highfat highsugar foods and nonperishable goods within schools the mean price of healthy lunch items has also been shown to be greater than less healthy items highlighting an opportunity for pricing strategies both within 12 and outside schools while some were content with their current food options others wanted to see a change with more variety and more healthy options at affordable prices a requisite a range of interventions that manipulate price suggest swaps and manipulate item availability in shopsgrocery stores have examined changes in food purchasing behaviours 44 or healthrelated outcomes 45 albeit among adults or families 46 little is known about the impact of store interventions on adolescent food purchasing behaviour our study can help us understand why adolescents use certain outletschoose certain foods and their interest in changes to the food environment adolescents attitude to change has also been lacking in related interventions in school settings 47 even though the effect of interventions is highly influenced by peoples attitudes towards them 48 there have been calls for the involvement of youth in the design and implementation of school food changes 333449 with some progress in their involvement in policy development related to food environments 50 interventions to improve food choice options in stores and that target food purchasing behaviours should also involve youth to effect behaviour change this is the only study focused specifically on irish school childrens perception of the local school food environment one other study focused on stakeholders perception of school food generally 34 it also incorporated the use of maps with youth so they could work individually and collectively which enabled debate but also provided an opportunity for each child to contribute the maps and photos provided a perspective of the food environment close to schools while the group discussions provided insight into their reality a strength of this study is reporting in line with the standards for reporting qualitative research guidance 51 however there are some limitations to the study including that data on the availability and cost of school meals or the average spend on food inside and outside of school were not collected similarly data on whether subsidised school meals were available in schools was not collected our data cannot provide insight into whether food options within schools influence food choice outside of school the food outlets mapped by participants were not checked for accuracy nor was the distance travelled by students school policies differ across ireland on whether children can remain or leave school at lunchtime in our study just two groups of children out of the twelve discussion groups were not allowed to leave school at lunchtime indeed some schools often due to lack of catering facilities and limited space mandate children to leave the premises at lunchtime all of these issues pose challenges for those offering guidance toolkits or implementing policies on healthy eating for schools 34 indeed school food policies and practices that are limited to foods sold at school can only go so far in influencing the dietary behaviours of students 952 and changes to the external school food environment are also needed to enable healthy food choices adolescents frequent the external school food environment regularly and the food choices made can contribute to nutritional habits and nutritional status understanding the drivers and facilitators of food outlets and food choice for adolescents is key to developing effective and sustainable interventions our study provides insight into the perception and use of food environments around schools and gives a nuanced understanding of the food environment from young peoples perspectives the human perception of environments should be considered 53 when exploring related behaviour or changes to the local environment and understanding young peoples perspectives should also be valued 54 our data also supports the value of qualitative studies of the food environment to generate a comprehensive picture of food availability and food choice data availability statement the data presented in this study are not publicly available in accordance with the type of consent obtained about the use of confidential data funding this research received funding from the national university of ireland galway millennium fund the funders had no role in the conceptualisation of the study study design data collection analysis or interpretation institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the institutional ethics committee of nui galway amendment to original ethics application code 13nov14 approval granted march 2015 informed consent statement informed consent was obtained from all subjects involved in the study

research on the impact of school and community food environments on adolescent food choice is heavily reliant on objective rather than subjective measures of food outlets around schools and homes gaining the perspective of adolescents and how they perceive and use food environments is needed the aim of this study was to explore adolescents perception and use of the food environment surrounding their schools purposive sampling was used to recruit schools mapping exercises and discussion groups were facilitated with 95 adolescents from six schools thematic analysis showed that adolescents are not loyal to particular shops but are attracted to outlets with price discounts those with deli counters and sweets cost convenience and choice are key factors influencing preference for food outlets and foods quality variety and health were important factors for adolescents but these features especially affordable healthy food were hard to find social factors such as spending time with friends is also an important feature of food environments that deserves further attention adolescents perceptions of their food environment provide insights into features that can be manipulated to enable healthy choices

introduction health inequalities persist across the united kingdom underpinned by variations in life conditions that contribute towards the poorer health outcomes experienced methods study design a crosssectional survey of people attending hiv outpatient clinics in london uk setting and sampling participants were recruited from seven hiv clinics in london and classified according to their clinic attendance people with optimal attendance had attended all their hiv clinic appointments in the past year uk guidelines at the time of the study indicated that patients should be seen within 24 weeks of starting art and every 36 months for routine monitoring if on art and considered medically stable 33 we applied a simple algorithm that could be used by research staff in the seven clinics to recruit patients according to their recent attendance behaviour regardless of the complexity of their case regularity of their appointments people were classified as having suboptimal attendance if they had missed at least one hiv clinic appointment in the past year or had experienced a period of nonattendance for a year or more that had ended within the past year this is based on evidence that one missed visit in the first year of hiv care is associated with increased risk of mortality 16 people identifying as female or male who acquired hiv through heterosexual transmission were selected from the overall sample to be included in the following analysis data collection local research staff systematically approached clinic attendees in order to achieve a sample of at least 100 people with optimal attendance in the past year and 100 with suboptimal attendance written informed consent was obtained and no financial incentive was offered for participation the anonymous selfcompletion penandpaper questionnaire contained 80 questions and took 2030 min to complete questionnaire responses were linked to clinical data measures questions on date of birth ethnic group country of birth immigration status relationship status number of children housing employment education and hiv diagnosis were included participants were asked to report the importance of religion in their lives whether hiv affected their daytoday activities who they had told about their hiv whether engagement in hiv care is associated with a detectable viral load and poorer health outcomes 12 13 14 including increased mortality 15 16 17 18 a better understanding of the factors associated with engagement in hiv care and the impact of adverse experience and circumstance on clinic attendance is therefore essential studies from europe and the usa indicate that people who are male older white and men who have sex with men are less likely to disengage from hiv care 19 20 21 22 23 24 studies also indicate that those with more complex needs such as intravenous drug users and migrants are more likely to disengage from care 202224 stigma isolation poverty and adverse social circumstances are significant barriers to engaging in care and living well with hiv 25 26 27 28 29 and those at socioeconomic disadvantage are less likely to prioritise their hiv care 30 the reach project set out to understand patterns of hiv outpatient attendance among people with hiv to develop cost effective interventions to optimise engagement in care 31 we conducted a crosssectional survey of people attending hiv outpatient clinics in london uk our survey was developed to cover all components of the comb model a theoretical framework which proposes that behaviour is the outcome of an interaction between an individuals capability opportunity and motivation 3132 we found that those who had greater difficulties engaging with hiv services were younger had been diagnosed for longer were less likely to be homeowners or registered with a general practitioner and were more likely to have children to report neurocognitive impairment and poorer health and have clinicreported drug or alcohol dependency 31 given the reported differences in engagement between women and men and according to route of hiv transmission in this paper we concentrate on the subsample of women and men from reach with heterosexuallyacquired hiv the intervening period since our survey was fielded in 20142015 has seen important changes in our understanding of the virus that have impacted hiv care including new evidence that adherence to art means that hiv cannot be sexually transmitted to others we believe however that our use of these data to examine the social determinants of health for people living with hiv remains highly relevant here we focus on experiential and circumstantial factors to explore the potential impact of the wider social determinants of health on hiv clinic attendance explore the association between clinic attendance and current hiv treatment and health status and examine the reasons participants give for missing their appointments at the hiv clinic clinics collected data on art cd4 count viral load drug alcohol dependency and patient complexity according to the hars 3 category 39 data analysis only women and men who acquired hiv heterosexually were included in the analysis the chi squared test was used to examine differences between women and men with fishers exact test used when expected values in any cells were small binary logistic regression was used to analyse associations between predictor variables and clinic attendance and to test for an interaction with gender variables were selected for inclusion in multivariable logistic regression models if they were significantly associated with attendance in univariate analysis ethical approval ethical approval for the study was obtained from the national research ethics service committee london city road hampstead a more detailed description of the study methodology is provided elsewhere 31 results the overall sample included 983 individuals with 362 having acquired hiv heterosexually among these 356 participants 191 had attended all their appointments in the past year and the attendance of the remaining 165 had been suboptimal among those with suboptimal attendance 594 had missed ≥ 1 clinic appointment in the past year and 406 had a history of 1 year of nonattendance there was no difference by gender gender comparison women made up 702 of the sample there was no significant difference in attendance pattern by gender 476 of women and 434 of men had attended suboptimally in the past year the women were younger than the men with 540 aged 3145 years and 400 aged 45 years women were more likely to be of black african ethnicity and less likely to be of white or other ethnicity there were no significant differences by gender for region of birth or years in education they had enough money for their basic needs and their experience of intimate partner violence items on recreational drug use were included they were asked whether they missed appointments because of drinking alcohol taking drugs or to look after children or others and to tick all applicable items from a list of reasons for missed appointments each reason was rated on a 4point likert scale from never to often those on art were asked how many doses they had missed in the past week women were asked if they were currently pregnant had given birth in the past year or had been diagnosed during pregnancy items from the following scales were included in the questionnaire the patient health questionnaire 34 with reported symptoms rated as normal mild moderate and severe the strive internalised stigma scale 35 with stigma rated as low for 13 items ticked and high for 47 items ticked the dukeunc social support questionnaire 36 with low social support rated for a score of ≤ 12 and the beliefs about medicines questionnaire 3738 including the art necessity and art concerns subscales which ranged from 4 to 20 associations with suboptimal attendance we examined the association between variables relating to socioeconomic and hiv background current experience and circumstances and clinic attendance in unadjusted analyses the only significant differences between participants with suboptimal and optimal attendance were by current age and age at diagnosis with some indication of an effect of cd4 count at diagnosis and drug alcohol dependency compared to those aged 30 years at the time of the survey those aged 45 years were less likely to have suboptimal attendance but there was no significant difference for those aged 3145 years compared to participants aged 30 years at hiv diagnosis those diagnosed at older ages were less likely to have suboptimal attendance compared to those with a cd4 count 200 men were more likely than women to be diagnosed with hiv at an older age with 613 diagnosed aged 3145 years and 255 diagnosed at ≤ 30 years old and were more likely to have a cd4 count 200 cellsmm 3 at diagnosis we examined differences between women and men on all independent variables included in the subsequent analysis the only significant differences were that women were more likely to report that religion was very important to them and to have children and men were more likely to report that they had used recreational drugs in the past year only 20 of the women were pregnant at time of survey completion and 29 had given birth in the previous year more than one quarter of the women had been diagnosed with hiv during pregnancy the older age groups were less likely to have suboptimal attendance compared to those with british citizenship men with insecure immigration status were more likely to have suboptimal attendance we examined current health status treatment behaviour and beliefs for women and men we found that those with suboptimal attendance were more likely than those with optimal attendance to have a detectable viral load and complex healthcare needs they were less likely to be on art among those on art people with suboptimal attendance were more likely to have missed a treatment dose of art in the past week they were less likely to report strong belief in the necessity of art and were more likely to report concerns about art there were no significant interactions with gender on any of these variables reasons for missed appointments not wanting to think about being hiv positive was the top reason for ever missing appointments given by both those with suboptimal and optimal attendance in the past year simply forgetting was a key reason given by those with suboptimal attendance and feeling too tired and depressed or not having enough money were among the most common reasons that both groups gave for sometimes or often missing their cellsmm 3 at diagnosis participants with a cd4 count ≥ 350 cellsmm 3 at diagnosis were more likely to have suboptimal attendance and those with clinicreported drug and or alcohol dependency in the past year were also more likely to have suboptimal attendance we examined the same background current experience and circumstances variables to test for interactions with gender we found significant interactions for immigration status housing status and impact of hiv on daily activity associations between these variables and attendance are presented separately for women and men in table 3 among women there were no significant differences in attendance pattern by immigration housing or daily activity however among men those with suboptimal attendance were significantly less likely to have british or eu citizenship or permanent residency in the uk with lack of secure longterm immigration status reported by 256 of those with suboptimal attendance compared to 18 of those with optimal attendance those with suboptimal attendance were also more likely to report insecure housing and to report no effect of hiv on their daytoday activities we conducted multivariable binary logistic regression including variables significantly associated with attendance among men in the above analysis we did not conduct a multivariable analysis for women as we found no significant associations in the above analysis among men attendance was independently associated with age at diagnosis and immigration status compared to men in the 30 years and under age group referral to local nonclinical services within the community into holistic support for people with hiv with the aim of addressing such inequities we examined the influence of interpersonal factors on engagement in care our previous qualitative research found that partners can have a protective or destructive effect on engagement in care 31 but we did not find an association here with variables relating to partnerships faith or social support hiv however remains a highly stigmatised condition one fifth of our participants had not told anyone about their hiv status and about two thirds reported markers of internalised hiv stigma not wanting to think about being hiv positive was the most common reason given for missed appointments among both those with suboptimal and optimal attendance one fifth of those with suboptimal attendance in the past year had missed appointments because they did not want to be seen at the clinic it remains essential to tackle the causes of stigma and marginalisation among people with hiv one fifth of our participants had not attended appointments because they felt too depressed or overwhelmed while hiv per se may not be the cause of depression high levels of poor mental health have been found among people appointments while 308 of those with suboptimal attendance ever missed appointments because they had enough medication and 289 did so because they could not get time off work these reasons were lower down on the list for those with optimal attendance in the past year there were no significant differences between women and men on the reasons for missed appointments that are listed in table 5 among those with suboptimal attendance 71 had missed appointments because of drinking alcohol and 58 because of taking recreational drugs among those with optimal attendance this was reported by 23 and 13 respectively men were more likely to report recreational drug use and among men with suboptimal attendance 163 had missed appointments because of taking drugs and 209 had done so because of drinking alcohol half of the participants reported caring responsibilities and women were more likely to report such responsibilities among men and women with caring responsibilities 339 sometimes or often missed clinic appointments for this reason 511 of those with suboptimal attendance and 174 of those with optimal attendance in the past year there was no significant difference between women and men who reported caring responsibilities on missing appointments for this reason discussion our findings support previous work which shows that disengagement from hiv care among heterosexual women and men is more likely among those who are younger 19202324 those with suboptimal attendance in the past year were more likely to have a detectable viral load and complex healthcare needs and less likely to be on art among those on art suboptimal attendance was associated with missing doses of art less belief in the necessity of art and more concerns about taking art the top reason that participants gave for ever missing their appointments at the hiv clinic was related to stigma and not wanting to think about being hiv positive which was reported by two fifths of those with suboptimal attendance in the past year and one fifth of those who had attended all appointments precarious immigration and housing were associated with suboptimal attendance among men and immigration status remained significantly associated with clinic attendance in multivariate analysis for men it is also notable that about one fifth of our participants were living in insecure housing and or did not have enough money for their basic needs these findings highlight the importance of incorporating social prescribing which involves in the past year were more likely to have missed a dose in the past week they were more likely to be sceptical about the value of art and express greater concerns about art further work on managing these attitudes towards art is needed to realise the full benefit of universal treatment although we sought to recruit a representative sample of people living with hiv in london by including hiv clinics from across london this study is based on a convenience sample of people attending these clinics at the time of survey implementation and does not include those who were out of care at that time as the data were wholly collected in london it is possible that the factors associated with clinic attendance and reasons given for missed appointments could be different outside london however our findings from analysing the complete dataset were similar to those from analysis of uk chic data and are also congruent with data from the astra study which included study sites across the uk 51 this crosssectional survey cannot provide evidence of a causal link between the factors identified and hiv clinic attendance or assess the impact of unmeasured confounders on the analysis it is based on a convenience sample of people attending seven hiv clinics in london and their responses to a survey designed by the research team however the survey was developed from the comb model 3132 and wherever possible incorporated validated items our questionnaire was extensive and while we have selected the relevant items here to examine associations with the social determinants of health undertaking multiple hypothesis tests may run the risk of type i error while our multivariable analysis was subject to potential multicollinearity it indicated that further exploration of how immigration and housing status and daytoday activity contribute to hiv clinic attendance may be useful the power calculation for reach was based on a sample of one thousand participants and our subsample analysis here may not be sufficiently powered to detect significant differences between groups in view of the reduced sample size we combined participants who missed one or more appointments with those who did not attend for a year or more into one group and so were unable to explore any dose effect of missed appointments the findings may also reflect the changed perspectives of people who have returned to care our findings demonstrate the extent of the adverse experiential and circumstantial factors which affect people living with hiv and the association of these factors with engagement in hiv care they highlight the impact of stigma on hiv clinic attendance and the need to manage patients attitudes towards art in order to realise the individual and public health benefits of universal testing and treatment in the with hiv in the uk 27 of older and 21 of younger people with hiv reported depressive symptoms compared to just 8 of the older control group 40 and people with hiv are also twice as likely as the general population to report symptoms of depression and anxiety 41 high suicide rates are furthermore reported during the first year after diagnosis particularly among men 42 other studies have found that people with hiv in the uk experience poorer healthrelated quality of life than the general population 4344 and our study supports the call to add a fourth 90 to unaidss 909090 targets for global hiv control 45 90 diagnosis of hiv 90 treatment 90 viral suppression and 90 mental wellness 46 previous research has found that people who inject drugs are more likely to disengage from care 22 our sample excluded people who had acquired hiv from injecting drug use but clinicreported drug alcohol dependency was associated with suboptimal attendance among our participants men were more likely to have used recreational drugs and to report missing appointments at the clinic because of recreational drug use this reinforces the necessity of implementing measures to actively solicit drug use history systematically identify individuals at risk and provide mental health and addiction services in clinic 47 caring responsibilities were a key reason for missed clinic appointments women were much more likely to report such responsibilities than men and one third of participants with these responsibilities sometimes or often missed clinic appointments because of this among those with suboptimal attendance in the past year who had such responsibilities half reported missing their appointments for this reason our findings emphasise the need to address barriers to attendance such as childcare not having the money or time off work which have been discussed elsewhere 4849 the lack of association between background variables and attendance among women raises concerns that routinely collected clinic data do not help to signal potential difficulties for women and brings into question whether routinely collected data should be different or more inclusive as previously found 12 13 14 those with suboptimal attendance were more likely to have a detectable viral load and complex healthcare needs the survey was implemented before the era of universal testing and treatment and we found an association between not being on art and suboptimal attendance after treatment became a nationally commissioned service in the uk the proportion of newly diagnosed people on treatment within three months of diagnosis rose from 53 to 2014 to 78 in 2018 50 we may also be optimistic about the potential for universal testing and treatment to improve engagement in care among those on art people with suboptimal attendance availability of data researchers who are interested in accessing the reach survey data should contact the corresponding author with a description of their proposal and material code availability conflicts of interestcompeting interests the authors have no relevant financial or nonfinancial interests to disclose authors contributions fmb and cs were joint chief investigators of the study va s michie s morris ms chm ae vcd cs and fmb conceived the study and secured funding they were responsible for the planning and delivery of the study arh was responsible for study coordination data collection and analysis all authors contributed to the development of the study design and establishment of procedures arh led on preparing the manuscript all authors critically reviewed and approved the final version ethics approval

by more disadvantaged members of society 1 2 3 4 these adverse social cultural political economic commercial and environmental conditions or wider social determinants of health 5 are particularly pervasive among people living with hiv a national survey of people living with hiv in england and wales found that three quarters of black africans and half the people from other minority ethnicities did not always have enough money to meet their basic needs 6 research in the us has shown that people at socioeconomic disadvantage 7 and those living in poverty 8 are disproportionately affected by hiv and unaids continues to emphasise the impact of poverty and marginalisation on hiv globally 9 hiv is now a manageable longterm condition and successful treatment with antiretroviral therapy art leads to a life expectancy that is similar to the general population 10 art is also an effective means of hiv prevention as it stops transmission of the virus through the suppression of hiv viraemia to undetectable levels 11 however the individual and public health benefits of art can only be achieved if people with hiv are aware of their status and have sustained engagement with care and treatment poor a r howarth

the education system of switzerland is organized in regional units named cantons historically the cantons are old states which formed the swiss confederation as a nation in 1848 the cultural and religious differences between these former states are the reason why the competence for education and schooling remained in the cantons however since 2006 switzerland has had an article in the national constitution that gives the federal government the authority to coordinate the regional education systems this coordination concerns eg the structure of primary schools as well as the duration of the different school levels this project of harmonization of the swiss school system will be realized within the next couple of years so todays school systems are different in every canton correspondence concerning this article should be addressed to martin straumann email during the last decade almost every canton has reformed its school system canton solothurn has introduced schools with formal principals or school directors in a school district principals are responsible for administration the quality of education school development and school improvement this reform just started recently and the principals of the primary schools are still looking for the profile of their school some understand their role as managers and administrators others are more concerned with school development some are leading figures in their school and some others are more the former colleagues and so on parent involvement is a legal duty for every teacher principals are responsible for school culture and the quality of education when difficulties occur with parents that the teachers cannot deal with the principal supports his staff and tries to mediate or to solve the problem he calls parents into school to inform them about school matters the overall goal is to improve students records and to have fewer conflicts with parents with different views on learning and education in canton solothurn parent involvement is part of the quality concept of every school the quality system is based on the q2e system which means quality by evaluation and improvement module 5 of the quality system is about how the relationship between school and parents is designed questions posed by the evaluators are does a written policy about the cooperation of school and parents exist and has such a document entered into force the objective of the document is part of the quality concept of the school as well at the beginning of the reform the way to achieve an agreement between school and parents was quite different in some schools the strategy of cooperation is very participative parents are involved in discussing and developing the paper in some other schools the agreement is written by the principal discussed with the teachers and then discussed with or sometimes directly opened to the parents some other schools choose a third way they develop an agreement that they only present to parents causing difficulties when they do not exercise their duty in the domain of cooperation with the school an excerpt of a school agreement based on a partnership between school and parents is shown in figure 1 the school agreement is a commitment for both sides parents and teachers when problems occur the document is a good basis for mediation the school has the possibility to refer to the written standards that concern eg the behaviour of the children this year schools have to sign the agreements with parents or the representatives of parents these agreements are mostly written contracts about educational objectives and list the duties of parents students and teachers depending on the socioeconomic context of the school they have different agreements eg special paragraphs for immigrant parents research approaches and practice in switzerland literature about parent involvement exists in all germanspeaking countries and the issues discussed in the research literature are almost the same in germany austria and switzerland neuenschwander et al show in a representative study that parents have great influence on the performance of students the support students get at home and the participation of parents in school matters broadens the differences in the achievement between middleand upperclass parents and educationallydisadvantaged families lanfranchi analyses the effect of preschool socialisation in immigrant families he could prove positive effects when these children visit day care centers or nurseries an openminded educational style of parents and the intercultural knowledge of the teachers had a positive impact on learning outcomes in switzerland constitutional rights concerning education give priority to parents in the legislation of the canton we have three reasons why schools challenge this fact firstly school attendance is compulsory in switzerland parents are obliged to send children to the school in time they have to get enough sleep and must be adequately fed secondly primary schools now have the possibility to negotiate school agreements with parents the school defines the expectations about the behaviour of students finally school can interfere when teachers believe that education and educational support has a poor level in a family they can request the opinion of social authorities when they believe that the child is neglected nevertheless we notice in swiss primary schools that teachers have increasing problems with parents parents complain more often about examinations and decisions of school authority eg when children are removed from a class or when they do not manage to reach a higher school level these parents have high expectations mostly on special topics that are not yet treated in school even when the issue is dealt with later on the other hand there are families with low socioeconomic status very often these are working parents who have no time for school matters in such neighborhoods about 30 percent of the parents do not show up when the principal arranges meetings to inform about school matters in most swiss cantons it is possible to impose fines on parents that never show up at school for consultations or meetings to sum up at the moment the research interest is the practice of principals and teachers as well as the strategies they pursue and standards they have fixed about parent involvement in our research the opinions and the values of principals and teachers are important principals and teachers usually make external attributions when problems with students occur either there are reasons in the behaviour of the concerned student or they think that there are educational problems in the family bauer argues that difficulties in the cooperation between school and families can be explained by the double external attribution on both sides teachers attribute behavioural defects to the families and families attribute poor achievements of students only to the teachers so the reflection on the reasons of poor achievements and the consideration of both sides could be a good way of communication when we compare parent involvement in switzerland with the known forms of cooperation between schools und families we see a limited understanding of what parent involvement can be when we look at the six dimensions of cooperation and partnership of schools and families that epstein et al have elaborated we see that some of these dimensions are missing or are not included in explicit standards of parent involvement in swiss schools parenting is an issue discussed only when there are problems with students like violence drugs or pornography parenting is often delegated to social workers in the school or special institutions that include those families in education programs such as opstapje communication with parents written feedback letters to the families or newsletters of the school are usually not adapted to the language skills of families with low socioeconomic status or of immigrant families you can find all the technical terms of educational science with no explanation for those families third point is volunteering there are some schools that work with volunteers in the school mostly they are welcome to accompany a class for an excursion or help to prepare school events like student theatre and so on but there is little involvement of parents helping children in the classroom swiss teacher associations are afraid of deprofessionalisation the lack of concepts for volunteers in the classroom causes confusion in the roles learning support at home in switzerland children have a lot of homework to do the amount of homework increases from year to year parents are asked to check the homework and monitor the time pupils spend on it but there is no monitoring of how to learn and how a students working space should be organised at home these are ways that might help families with a lower socioeconomic status to give better support to the learning activities of their children at home these issues explain partially the gap between the way the lowerand upperclass regard success at school participation normally schools have a parents association which gives advice to the principal of the school an unwritten law says that only parents are welcome that have children in that school there is little direct communication among parents the school has no structures to strengthen the communication among parents therefore parents at the parents meetings frequently discuss the problems of their own children this might give them an advantage compared with families which are not present at the parents meetings last but not least collaborating with the community is a dimension that is little practiced by teachers communication with authorities in the community is often delegated to the school director to sum up most of the time parent involvement in switzerland is nothing but ritualized meetings where teachers either inform parents about students achievements or on special occasions where specific problems with a child are discussed educational issues are only discussed when there is an obvious problem with a single student or the class as a whole research question and sample the research group was first interested in the practice of school culture in primary schools school culture was defined by the social competence the values and beliefs of all teachers the staff and the principal of the school in addition the principal in primary schools forms and develops school culture and standards so we focus on the patterns of interpretations and the practice of principals in primary schools we have a qualitative research approach our focus of interest is the subjective opinions on parent involvement in primary schools we wanted to see whether the strategies in schools vary in relation to the socioeconomic status of the community of the school or whether the strategies vary in relation to the patterns of interpretation of the principal of the school that develops a specific school culture research questions are eg what are the patterns of interpretation of principals and what are the management styles related to parent involvement how can a school adapt the activities in parent involvement to the character of the families or to the structure of the community what is the division of labour between the principal and his teachers do we find a support structure and a homogeneous school culture and a practice of speaking to parents as partners the choice of the principals was conducted in a way to have a maximum of contrasts in the sample the procedure is called theoretical sampling one interview was excluded from the sample because the interviewer lives in the same community as the school concerned so the political activities in the communal authorities of the interviewer had a bias on the interview finally we organised seven interviews in a setting where the communication in the first step was very open and free at the end of the interviews we asked questions that had not been treated and we asked for a summary in the sense of drawing a balance for this reason we had prepared a guide for the interview with the important topics we would like to hear we transcribed the interviews literally into high german but we accepted dialect words and did not correct the word order common in the dialect the schools in our sample represent different settings schools in town and rural schools schools in the suburbs with middleclass populations and schools that are situated in segregated districts with 60 percent of families with a migration background finally we reconstructed eight cases of patterns of interpretation of school principals in germany the methodological approach for the interpretation of transcribed interviews is known as objective hermeneutik developed by professor ulrich oevermann with the help of this methodology you interpret a text by looking for the latent structure the latent structure is not only the summarised meaning of the text we try to look for the context of a practice and to work out the conditions that determine a professional socialisation process concerning work with parents so in a sequence analyses we interpret every sentence line by line and word by word the transcription of the interview is an image of the spoken dialect in a first phase of interpretation we worked out a specific case structure that describes the practice and the strategy of the principal concerned in the following text we present three different cases and we try to look at the effectiveness and the success of the strategies applied case studies we refer to three case studies that represent different patterns of interpretation of principals or school directors h the first case is a school director in the agglomeration the percentage of immigrant persons is about 62 percent during the last century the community was an industrial area the first generation of immigrants were workers called to do industrial work in these factories in the last decade many factories closed and changed to the service sector the neighborhood changed and became segregated the immigrants come to live in the community now because the rents for apartments are cheap h is the director of all the schools in the community he has four principals in four school campuses the school system consists of different kindergartens primary schools and also secondary schools teachers in the schools have a long tradition of dealing with immigrant families there are several associations and institutions in the community that organise the cultural life for some ethnic groups like italians spanish or tamils there are now children from more than 14 different nations in this school native speakers are a minority among the students in most classes this year the community opened up a centre for children and young people that combine rooms for lunch a daycare centre and childcare in the morning and after school and a leisure room for youngsters the mission of the school director is to bring public child care to the parents firstly the children and their parents should improve their german and secondly he hopes to get them connected to school issues he is trying to establish a close relationship between school and nonschool daycare so the new centre for nonschool daycare is at the end of a long journey with several projects on each school level which are now unified in the house for children and young people the school director organises information meetings for parents together with teachers translators and cultural mediators parents come together in smaller groups after a short overall presentation where the information is translated into their language teachers and cultural mediators work together in every group the teachers keep an attendance list every family which is not present at the meeting and did not give a good excuse gets a letter with a call for a personal meeting with the school director parents who do not respond to the letter are threatened with a fine when we take a look at the below text we see two dimensions firstly it is important that every foreign child learns german as soon as possible a daycare centre is an excellent place to learn the language and also to learn how to behave in our society in switzerland fiveyearold children start with kindergarten there is no outside school care where immigrant children could learn the language that is ridiculous you can laugh about it so in the time when they can improve their language we sleep therefore the idea was we build a daycare centre to reach out to everyone we cannot force them but we can tell the immigrant parents that it is important it is necessary to bring your child to the daycare centre secondly the intercultural competence of the school director is founded in his biography because his parents immigrated to switzerland he is familiar with the integration problems by personal experience then he was the head of a swiss school abroad where he had the same experience with his own children he appreciated the network of swiss families in a foreign country and he is convinced that social networks are important for integration moreover he was the head of a private boarding school he therefore has the competence to combine school and extracurricular activities i moved to a foreign country ten years ago and i taught at a swiss school the family was also with me my child went to preschool without speaking spanish he couldnt express himself verbally what was the problem he hit the others… in the manner that he defends his ideas h is quite dominant with his teachers in the secondary school a written agreement exists with the expectations and duties of students teachers and parents and when h starts the interview his statement on school culture is as follows so we have a concept that has existed now for actually three to four years but you cannot see it you cannot hear it the fact is that we really try to reach out to the parents quite early before school begins the school is familiar with the programs for immigrant children but the school culture is marked by the personal engagement of the school director in the school and in the community he visited almost every network of foreigners and he has excellent relations with the mosque in the community when he employs new teachers he prefers teachers with intercultural competences or with a migration background he instructs his teachers to distinguish between their middleclass life and the life of underprivileged families summarising h has a positive view of the world he believes that he can change social problems integrate migrants and avoid school absenteeism of parents or children personally he is very much involved and tries to convince parents and policymakers he personally designs and controls parent involvement in school and outside school in different networks of foreigners he is part of a committee that runs the youth club in the community s s is about 40 years old she was a teacher in a primary school for a long time s is engaged in many projects of school development three years ago she was engaged as a school director in a school district with four primary schools in four villages the villages are in the countryside there is a village with a majority of farmers and there is a village that is already near to the urban centre with middle class families in the village with the farmers social problems with parents hardly occur almost everybody is related to one another and problems are solved directly in the more urban village s encountered a severe problem with parents who complained about the school and the teachers s the start in that community was quite difficult its now three and a half years ago the school was the scum just like that the teachers are scum people in the community have talked in that manner they used very strong swearwords for the teachers in the school some parents treated teachers simply below the belt they attacked before i started there had been no structure in the school to address the difficulties we had young teachers after short a time they quit their job and there was nothing that has ever been fixed s brought some calm into that school and she started to build a structure to rebuild trust she organised a survey to get to know the needs of the parents the feedback was very positive there was much appreciation a new mayor was elected and this was the time she started to build a new school culture hearing teachers making nasty remarks about parents s interfered and started to work with them how should they communicate and deal with parents what are the needs and problems parents have what can we do when parents complain which person is contacted first and so on the teachers began to work with respect for parents today they have a normal situation parents know how to interact with the school in the last two years the parents and the teachers of the school have elaborated an agreement about the correct behaviour of children and the rights and obligations of parents in figure 1 we list the two sections about teachers and parents as teachers we • take our role model • develop our school as we educate ourselves regularly in the team • take responsibility for teaching we make it informative and varied the achievement of the curriculum is a priority • offer the children an environment that supports the best possible development • strengthen the confidence of the children in their own abilities • respect each child as an independent personality and meet it with kindness • ensure compliance with the rules and respond appropriately to violations • maintain good contact with parents and address problems in good time as parents we • take our role model • create good conditions for the healthy development of our child we ensure that the child has enough sleep a healthy diet and adequate clothing • see that our childs homework is done independently and conscientiously we send our child to school in time and to the class equipped with the necessary school materials • give our children the necessary support for school and actively support it throughout the school years this includes a space to work undisturbed at home the necessary material and adequate time to work and recreate • help our child to master the way to school alone and responsibly • support the school as we ask a child to take care of the school materials • participate actively in school life and read the letters from school carefully • attend class evenings otherwise we will inform ourselves about the topics discussed • when there are problems we contact the teacher early • we support school in its effort for a friendly and respectful relationships with each other for the effectiveness of that school the school agreement is a success the paper was worked out by parents and teachers regular meetings take place to speak about problems with parents when we consider the paper several dimensions of parent involvement are referred to health nutrition and sleep as preconditions learning conditions of the child at home and homework support by the parents papers and letters for parents communication and contact with the teachers when problems occur the school is creating a parent council that will discuss and advise the principle as a form of participation some dimensions are not mentioned like the volunteering of parents in the school or the support of the parents association in the community we dont know exactly the reason it may be that these issues were not discussed it may be that the principal is not in favour of volunteers in the class we dont know a strong reason could be the historically strong separation between school and families in switzerland parents associations that support schools normally place the emphasis on a clear role taken by teachers and parents and advise the principals not to have volunteers in the class who help with the children parents only volunteer when there are excursions or special events like a celebration or a school party s for me its important to react before a problem escalates the important thing is that we communicate with parents if you have questions we are always willing to answer questions we have open doors whether it is in the classroom or in the office with me come to me when something happened so things can be solved i guess we are good at responding in a very clear manner at any time so communication with parents has changed to a proper style on a low threshold they respond when a problem occurs she says and then we respond very well we inform all parents immediately we work with the classes with the team i look at how to deal with the problem and how we want to respond so we always try to resolve these issues immediately when there are educational problems s requests other resources social agencies parenting trainings or programs to prevent drugs etc s i think there we are of course smart enough that we usually look for help outside the school the teachers are not able to hold lessons in parent training the teacher advises the parents on school matters or learning issues when we deal with problems that could affect the education at home or could interfere with the education style of parents we take experts summarising s attaches great importance to communication between parents and school she prevents external attributions with mutual depreciation and she motivates the parents to express their needs she establishes a written standard of educational behaviour for all parties parents students teachers the principal and also the administration of the school when we look at the different forms we see that s has a wide range of different issues parenting home work a code of conduct learning conditions for the children the involvement of the parents in school we dont know what she thinks about volunteering or the relations with the community if we compare with the management style of h networking in the community is not important for s she argues that in these small villages everyone knows each other therefore social control is very high and families with migration background are rare a we analysed a third case of a principal of a school district in the countryside he is responsible for the management of three primary schools in three villages the socioeconomic status of these communities is rather high farmers and houseowners live in theses villages a is a former teacher as a teacher he was very committed he worked as a teacher trainer with students of the teacher training college he was member of a group of teachers that practice the pedagogy of céléstine freinet therefore he put a strong emphasis on independent learning on work in atelier groups and on printing the short stories that students wrote in the school the team of teachers has a great significance for a school life must be rich with many activities like sport events and celebrations when a speaks about parents he defends his teachers parents are partners of the school they are expected to criticise a teacher or the school when a teacher is a good teacher in the class a is in a fundamental opposition to the parents there is a teacher who does her work thoroughly well she has been here for 10 years she is accepted she does a good job some time ago i do not know why and when it happened a few people decided to attack this teacher and that is the way a story moves in the community and comes to the children right of course when parents say this will be your teacher now then you can imagine how they act right so at the school things have escalated it is very bad now a interprets his role as follows he is a principal who gives support to his teachers in all situations he looks upon his teachers as public persons of the community most of the time well known in many families but the public reputation of the teacher is not necessarily in accordance with his real performance as a teacher therefore the principal tries to mediate between parents and teacher but the reality is confusing and difficult to manage for example a teacher in a sport lesson had a discussion with students in the equipment room the students told their parents that the teacher had become violent the reaction of the parents was violent violence against children in the evening i got an email i looked at the email but read it in the morning and then i thought oh this is not good and i just called the two mothers that had complained and then she told me that she would be happy if we could discuss the problem and what happened the day before but the same time she went into the classroom of that teacher and there she said in front of all the students such teachers should be dismissed now thats too much right it is really incredible she did not tell me a tries to help and to understand the needs of the parents at the same time he pathologises the excessively protective behaviour of parents the external attribution is this student has problems at school because the parents behave in a certain manner he has to calm down the situation and to find a solution sometimes we see a role ambiguity between the role of teacher and the role of a principal that supports the teacher when parents complain he tries to follow the rules but sometimes he has to interfere directly we dont see a strategy that could deescalate the situation the practice of this principal is a practice with individual parents who cause difficulties in the school thats the reason why a is opposed to the written school agreements with all parents there is only a small number of parents who need meetings with the principal and in this situation he normally takes minutes with all the tasks for the teacher the student and the parents in the inner circle of the school a is the coach and the trainer for all teachers that do not know how to deal with parents he monitors meetings with parents and if he is not satisfied he organises a supervising meeting with the teacher involved and then you can see the teacher behaves as if she were on a navigation bridge yes i indeed do have a teacher who behaves like that i think i could put her on an a4 sheet of paper and for half an hour she will not move it was the extreme way the parents said nothing nothing more and so half an hour was gone and then she was ready with the program she was shocked herself and she told me yes the parents left quickly right and then i told her may i show you what youve done right yes but can you take it then yes yes then i stood there without moving and then she said no its impossible i said you criticised with the first sentence that you uttered the parents knew very well now im back at school but there was only the fear you were scared actually right yes she was totally scared summarising a is a principal who defends his teachers against the parents when something happens at school and parents call him he starts a process of mediation even before he speaks with the involved teacher when a child has difficulties at school he believes that the reason for the problem is the behaviour of the parents as a former teacher he is familiar with the educational problems of affluent parents because the school district with three villages in the countryside has only a small number of children he organises events and gives information about parenting once a year he organises a meeting for all parents of the three schools experts deal with educational problems last year a started a survey among parents and he found out that the great majority of parents is satisfied with the school services a invests a lot of time in the homepage of the school district communication about school life and school events is very important to him and corresponds to the needs of wellsituated parents in a community of the suburbs of the capital when parents complain about teachers he has a double strategy firstly he instructs the teachers on how to behave in a meeting with parents and secondly he focuses only on the family and looks for problems in that family in this situation his attitude is more like the attitude of a psychologist discussion we refer to three case studies of school directors or principals in a small canton of switzerland our project is at the beginning of a process that investigates communication between schools and families in different urban and rural settings the cases do not represent different types but we can see a big variation of strategies that are located in a dimension of conservative or progressive style of communication with parents we summarise the different influences we found on the practise of principals in a model in figure 2 the three cases studies represent different adaptations of principals to the social and socioeconomic structure of parents h is interested in having good cooperation with immigrants s tries to cooperate with parents that criticise teachers or the school we interviewed other principals eg in communities that had a population with a mixture of different socioeconomic levels they do not adapt their communication style but act like a middleclass person the social background of teachers is mostly a middleclass background teachers behave in that modus and ignore the fact that thirty percent of parents are immigrants and have poor language skills in german when we look at the potential of parent involvement and compare the practices of the three case studies with the six dimensions that epstein et al name we see a quite conservative trend legal duties like meetings to inform parents about school matters or individual meetings to discuss the transition to another school level take place the role of the principal is to assist teachers when difficulties appear and to coach new teachers how to act with parents volunteering of parents is limited to excursions or to assist in school celebrations then parents are welcome in a class to watch the group of children how they work or to watch their own child but in all cases parents are not allowed to assist the teacher in teaching matters we do not find evidence that learning at home is an issue in the communication in some papers we found indications about the time a child has to spend in relation to the class but monitoring of the learning process at home and the control of the working conditions of the child are not mentioned in the interviews possible forms of parent involvement the involvement of parents in school issues is still under discussion in many schools now parents representatives or councils are nominated but the roles of parents representatives are not clear yet in all cases they can give advice to the principal but at the same time they have no right to discuss teaching processes in a class in a council of parents the principal discusses school events excursions and special school weeks like summer camps etc when parents intervene they complain about discipline problems in a class the qualification for an employment as a principal or a school director varies between the cantons in canton solothurn a diploma as a teacher is not required so we can also find managers or executives of the administration as school directors in our case studies all three persons have a teaching diploma and a long experience as teachers school directors that are nominated can undergo further education at the teacher training college within this framework we can see a great variety of professional experiences that influence the communication style of a school director h was raised in a migrant family he is familiar with the vital problems of migrant families we can assume that his biography influences his professional career he was school director in a swiss school abroad and he was school director in a boarding school where he could manage the school life and the leisure time of the students we can see a strong pattern that consists in a belief that learning at home is not helpful and that a day school with educators who supervise the children doing their homework is the better way at the same time children learn the german language and the integration process for the student is easier parents at home who discuss whether they will return to their home countries can demotivate students the fulltime school is the better way to integrate immigrants when we have a look at the case study of s it is obvious that the influence of her continued studies in school development and her professional experience are important points when she still was a teacher she was already involved in school development processes based on these experiences a code of conduct for all teachers of the school is crucial to s she also tries to get an agreement with the parents in the case study of a we see a former teacher in a very small school who struggles to survive because there are less and less children in the community hence his strategy is influenced by public relation activities the image of the school has to be positive students with difficulties at school and parents that complain do no good to the image of a good school the role of a is characterised by his psychologicalising approach finally we can have a look at the interdependence of the management style of the principal and the school culture in the case studies of h and s we can see school directors who emphasise the school culture in the sense that they establish formal or nonformal standards how to relate to parents among their teachers and we see that the standards fit the school context and are influenced by the attitudes of the school director in the case study of a we see a school culture where every teacher has his own strategy and the principal has like a free back in soccer the role of a player who solves crucial situations at the last moment also we see three different ways written correspondence is handled the school of s was a pilot school for the canton that established a written standard in together with parents the parents and the teachers formulated their wishes and intentions in a written agreement and we see the school culture of h who is convinced that written agreements are of no use when you deal with families with poor language skills secondly written standards are dysfunctional for middle class parents who perform education in a good way they are indignant that a school director gives advice to them on how to educate children and in the third case study a opposes school agreements there is no need to have a homogeneous school practice a prefers individual agreements and measures that are adapted to the concrete situation treated with a parent outlook with its new education policy canton solothurn establishes partly independent schools with principals or school directors in a school district who develop a profile of the school and implement a quality management system parent involvement is an element of the quality management system of primary schools we see that the practice of principals varies in function of the socioeconomic setting of the school and the personal management style of the school director the practice of parent involvement of a school director is influenced by attitudes which are built in his biography and his professional experience depending on the assertiveness of the principal the practice of the principal forms the school culture and in some cases formal standards are established for example school agreements with parents parent involvement should help to develop a special profile of a school we see that parents are in many cases not involved or only slightly involved in the process we can say that the process of school improvement needs time to be established but we also see that in a small canton with 250000 inhabitants the parliament and the education department are the leading organs that support and instruct school innovations until now school directors have been more like executive managers that implement innovations which come down the hierarchy in a topdown approach school innovations normally have a strict timetable therefore there is little space for a school director to establish an individual profile of a school we can hope that the external evaluation of the schools with independent evaluation committees will judge the school improvement process of a primary school and will also judge the quality of the communication and the cooperation with parents in a next step we want to look at the attitudes and the practice of teachers teachers keep in touch with parents in a formal and informal way they are responsible for the information requirements and justify the decisions of the school when selections or promotions of students happen we would like to explore the interaction with the principal and the differences in the practice of parent involvement we want to introduce empirical results to teacher training the message could be there is no profit to a child with learning difficulties when teachers complain about the incompetence or absence of parents they have to look at the social situation and to adapt their practice to the needs of the individual family therefore they have to develop knowledge about the strategies of parent involvement they also have to match the specific demands of the school director and have to learn from each other in this way parent involvement becomes a part of the schools improvement process to supports students with difficulties at school

in a project of qualitative social research we analyse the interviews with eight principals of swiss primary schools we analyse the attitudes and the practice of parent involvement in these schools which depend on the socioeconomic status of the community the professional experience and the actual management style of the school director we found a great variety of practices that are based on different attitudes on how to interact with parents we can see a dichotomy of strategies one is the way how the principals deal with parents who relate to the school to enforce their individual interests in their own child or its success at school the other one concerns parents who obviously do not cooperate with the school patterns of best practice are analysed and will be used as a material to train student teachers the practice of the principal is not only determined by the parents and the social context of the school the biographical and the professional experience of the principal the management style which means the formation of the school culture and networking in the community represent an important part of the practice of a principal

introduction to examine changes of a population over time fertility is the most important factor in population dynamics it contributes for the change and structure of the population in subsaharan countries fertility rate is high compared to the rest of the world 1 2 3 in ethiopia the situation is similar ie there is high fertility and rapid population growth ratethe countrys population in 2013 was estimated to be more than 80 million 4 according to the 2011 ethiopian demographic and health survey the total fertility rate at national level was 48 children per woman 5 this value indicates that much effort should be made to attain the targets set in the national population policy of ethiopia by 2015 for high fertility rate the main reasons might be early age at first marriage desire for more children and extremely low contraceptive use there are some of the major reasons behind such high fertility rate 67 because agriculture is the major economic sector in ethiopia most families want to have large number of children this is because they are considered as an economic asset rather than liabilities for most of rural areasthe children assist their parents in farming activities ie the economic importance of children are over lifetime similar to many countries in subsaharan africa having many children is considered as an advantage and gift of god in a number of ethiopian rural communities 89 through years the ethiopian government developed several strategies to reduce fertility levels since 1993 the plan of the government is to reduce total fertility rate from the then 77 children per woman to 40 by 2015 therefore it is important to identify socioeconomic demographic and geographic factors which could contribute for the level of fertility in ethiopia 10 materials and methods data source the ethiopian demographic and health survey is conducted within five years of period this survey is administered at the household level for this study the 2011 ethiopian demographic and health survey was used the survey consist 624 selected enumeration areas complete household listing was carried out in each of the 624 eas for the survey 546 547 african health sciences vol 15 issue 2 june 2015 sample of 17817 households was selected to estimate at the national level all data of the survey were weighted therefore interviews were conducted with 9 096 1549 aged women and 6033 1559 aged men therefore the 2011 edhs sample was designed to provide estimates for the health and demographic variables of interest for ethiopia as a whole urban and rural area of ethiopia and 11 geographical areas 4511 variable of interest response variablesthe outcome of interest is the births in last five years this information is obtained by asking the mother how many live births she had in the past five years independent variablesthe independent predictor variables consisted of baseline socioeconomic demographic and geographic variables which were collected from each household the socioeconomic variables were the following main source of drinking water time taken to collect water toilet facilities main construction material of the rooms walls main construction material of the rooms roof and main construction material of the rooms floor and type of fuel for cooking geographic variables were region and type of place of residence and demographic variables were age of respondents religion literacy family size total children ever born and age of respondents at 1 st birth statistical methods for this study the linear mixed model was used this method first developed for applications in animal genetics and breading research 12 13 14 the linear mixed model consists of fixed and random effects a fixed effect refers to the levels of the factors used in the experiment the random effect is used if the levels in the study are randomly selected and the interest in the effect of the population of the levels of a factor or factors 15 therefore the general linear mixed model for the response can be written african health sciences vol 15 issue 2 june 2015 where is a vector of fixed effects is an vector of observed responses is an design matrix associated with β is a vector of independent random effects with a distribution is an design matrix associated with where is a vector of independent random variables with a n distribution is an vector of random errors from a n and and are mutually independent the random effects vectors are assumed to be independent and normally distributed with mean vector 0 and variance covariance g ie where g is a block diagonal with the ith block and the error vectors εi are assumed to be independent and normally distributed with mean vector 0 and variance covariance matrix ie for i 1 2 k here g and are and matrices respectively under the assumption of normality and independence for and the marginal distribution of the response is normal with mean xβ and variance covariance matrix where 1617 estimation of and the is done using either the analysis of variance method or the maximum likelihood and the restrictedresidual maximum likelihood methods under the assumption of normality and independence for and the methods are described in the next section further literature for linear mixed model can be found in different books 1314 16 17 18 19 20 21 22 23 24 result for this study the effect of socioeconomic demographic and geographic factors on fertility status of women was investigated to obtain the required result linear mixed model approach was used the result is presented in table 1 the null model likelihood ratio test for the analysis is given by chisquare value 2808 this is highly significant for this model indicating that the compound symmetry covariance matrix is preferred to the diagonal matrix of the ordinary least squares null model from the result it was observed that all socioeconomic demographic and geographic factors were found to have significant effect on the fertility status of the mother for the last five years except time to reach water source the results for the random effects that the effect of cluster was significant therefore the estimated value 006 was found to be significant the usual model error assumptions for these models were checked using the residual plots in figures 1 from the figures the first plot is of the predicted values against studentized residuals these plots show that the studentized residuals vary between 1 and 1 the next two plots are a histogram and qq plot of studentized residuals and intended to show the normality of the studentized residuals these plots show that the usual assumptions of the linear mixed model were not seriously violated by the data figure 1 plots of studentized residuals table 1 shows that fertility status of a woman is different among the eleven administrative regions as the result indicates the highest fertility is found in somali region followed by dire dawa administrative region compared to tigray region the lowest fertility rate was observed in addis ababa administrative region followed by harari benishangulgumuz amhara oromiya snnp gambela and afar regions compared to tigray region similarly women who live in rural area have 49 higher fertility compared to women who live in urban areas african health sciences vol 15 issue 2 june 2015 the association between fertility in the last five years and religion shows that muslim women have 17 higher fertility compared to women with traditional beliefs but women who are catholic have lowest fertility followed by orthodox and protestant compared to traditional religion on the other hand women who have no education have higher fertility followed by primary and secondary compared to women who attended higher education from the result it was found that main source of water and births in the last five years were found to have significant relation as the result indicates women who use tap water have lowest fertility followed by protected water compared to women who use unprotected water women who have no food to cook have more children compared to women who use woodcharcoal for cooking similarly women who used electricity for cooking have more children compared to women who use woodcharcoal for cooking regarding materials used for roof wall and floor from the result it was found that births in the last five years were found to have significant relation to material used for wall roof and floor this result is presented in table 1 furthermore from the result it were found that family size and births in the last five years found to have significant relationship therefore as family size in the household increases births for last five years decrease by 04 but as age of respondents at first sex increases births in the last five years increase by 15 in contrary for one year increase in the current age of respondent the birth in the last five years decreases by 21 discussion the most important challenge is how to manage with ageing and possible population declines in most countries in addition to this it is important to assist programmes to reduce the rate fertility in countries where population growth continues to be high therefore to maintain the fertility status of ethiopia it is important to increase age at first marriage this can be achieved by enhancing womens status through providing them with better employment and educational opportunities 2728 besides this it is important to expand family planning services and information communication and education to limit family size of the country because of this the government is implementing the population program so that fertility would decline over time at national level fertility has shown a declining trend but fertility is still high to some regions therefore from the result it was observed that there are clear regional differences in fertility levels and trends in ethiopia from the result it was observed that some of the regions like addis ababa have very low fertility which is below replacement level of fertility but other regions like oromiya somali and snnp regions have high total fertility rates for this high fertility there might be cultural and traditional barriers to effectively utilize modern birth control methods other factors could be low status of women and gender inequality including poor health service coverage for some regions it was difficult to implement programs that would contribute to fertility transition in each region besides regions high fertility was observed in rural areas than urban areas religion also has influence on the status of fertility since muslim respondents have more children as compared to others moreover women who are less educated have more kids based on the economic status of the woman women who have better facilities tend to have lower fertility this implies that in areas where traditional social and economic systems continue the level of fertility is still high therefore for essential change in fertility level it is important to breakdown the traditional social system in addition to this it is important to have transformation of the economy these changes have to be implemented from changes in the family system ie the persistence of agrarian economy that favours large family size these families maintained high fertility levels conclusion therefore from the result significant variation in fertility level was observed among rural and urban residents of ethiopia to reduce the gap of fertility between rural and urban population it is important to modernizedifferent factors these factors could be access to education media and providing employment opportunities in the modern economic sector besides this it is important to develop and maintain the access of family planning services

the most important elements to determine the rate of population growth is fertility fertility is the main element to affect the welfare of mother the survival of a child can be affected by high fertility and shorter birth intervals methods for this study the linear mixed model was used to determine factors affecting fertility status of women in ethiopia the 2011 ethiopian demographic and health survey data was used for this study results from the result materials used for roof wall and floor were found to have a significant relation to fertility level of women in the last five years moreover family size and births in the last five years were found to have a significant relationship conclusion significant variation in fertility level was observed among rural and urban residents of ethiopia to reduce the gap of fertility between rural and urban population it is important to modernize different factors these factors could be access to education media and providing employment opportunities in the modern economic sector besides this it is important to develop and maintain the access of family planning services

background most societies attach special importance to children and childhood allusions to the uniqueness and value of childhood abound in academic lay and political discourse yet social policies affecting children across a range of domains often fail to reflect the priority ascribed to children 1 2 3 in the field of health care policies on drug development regulation and funding routinely neglect issues unique to children in advanced and developing systems alike 45 in the realm of education mounting emphasis on adult economic attainment in early childhood policies arguably constrains pedagogies centered on caring relationships and geared toward meeting diverse childhood needs 6 despite progressive changes in sociocultural perceptions of children with disability in most advanced societies much of childhood disability policy and programming remains premised on narrowly delimited medical criteria for access 7 child welfare policies can induce greater focus on the protection of societal norms about ideal family structures and environments than on the protection of children themselves 89 social spending in a broad crosssection of advanced nations tilts heavily toward older populations and away from children 210 these diverse examples disclose a tension between tacit social values and explicit policy that warrants investigation a nuanced understanding of the moral foundations of childfocused policies is an important first step in this endeavor little clarity exists in popular political or scholarly spheres on the values that guide child health and social policymaking how do our societies value health gains in children when does a childs autonomy outweigh the interests of his family members how and in what ways should children participate in policy and program decisions that affect them the answers to these and allied questions rest on the foundational values that shape how we portray and involve children in our societies in this paper we review extant academic literature on the normative dimensions of child health and social policy to provide evidenceinformed foundations for the development and adjudication of childfocused health and social policies methods we conducted a qualitative systematic review of academic literature on the normative dimensions of health and social policymaking for children the search strategy followed a critical interpretive synthesis approach which balances the rigor and sensitivity to the quality of systematic review methodologies with the capacity for depth and breadth of inductive qualitative approaches 1112 a compass question guided our search of the literature what ethical and social values inform health and social policies for children based on concepts contained in our primary search question we developed a matrix of booleanlinked keywords and iteratively refined an optimal search strategy with guidance from a university librarian with expertise in electronic database search techniques between march and june of 2018 we searched the following databases refining search strategies for each platform to optimize yield ovid medline psychinfo embase web of science cinahl proquest and lexisnexis we developed a priori inclusion and exclusion criteria to guide article selection based on iterative discussions between study team members papers were excluded if they did not provide insight into the normative or values dimensions of social policy for children either with respect to the content of child health and social policies or the processes by which such policies are made to complement the systematic selection of relevant papers from online databases we employed an inductive qualitative approach to data collection purposive sampling of academic literature was conducted in an iterative fashion during the data analysis phase to fill emergent conceptual gaps this sampling stage was informed by the preexisting content knowledge of study team members and colleagues which was supplemented by snowball searches of reference lists from key publications this dual approach to the selection and refinement of relevant literature facilitated the reflexivity and ongoing interpretive synthesis at the heart of the cis approach 13 data analysis proceeded through four phases first we identified and categorically coded the major concepts and values in each included article second using constant comparative methods we worked interpretively across conceptual and normative categories to develop synthetic constructs that rendered each category in light of the whole body of evidence surveyed 14 third we sought to attend to points of tension and discordance within and among the constructs and to consider their meaning finally we built a synthesizing argument based on the insights from the interaction of these constructs out of which theoretical insights emerged we employed a social constructivist lens to frame juxtapose and interpret themes emerging from the diffuse literature on public policy for children 1516 political theory on the social construction of target populations served as a bridge between sociologies of childhood and public policy analysis 1718 our analysis of child health and social policies proceeded from the contention that the social construction of children as a target populationone often framed by vulnerabilityhas a strong influence on policy agendas and design and inversely that such policies embed constructed messages about children that influence societys perceptions of them and the social issues at hand results our database searches returned 14658 unique articles of which 342 met inclusion criteria upon review of titles and abstracts fulltext review yielded 72 relevant articles a purposive sampling of relevant literature complemented our electronic searches and was refined in light of the emergent results from data analysis adding an additional 51 original articles for a total of 123 articles our review of the literature exposes few explicit analyses of the normative foundations of child health and social policy formal attempts to name interrogate or prioritize select valueseither generally or in specific policy domainsare rare three central themes each encompassing a few key values emerge from the literature potential rights and risk the theme of potential captures discourse on childhood as a developmental state angled toward adulthood and the evolving capacity implied by this trajectory rights relate to ideas normative and legal about the human rights held by children which have gained prominence over recent decades risk incorporates ideas about vulnerability and the corollary need for protection that animate scholarship about children and childhood across a range of disciplines a set of established foundational concepts related to social policy for childrenwellbeing participation and best interests of the childcuts across and links these central themes we distinguish these concepts from the themes above to emphasize their use as fundamental tropes within and across the various studies in the literature that explore ideas related to childhood potential rights and risk they constitute the ideational goals toward which scholarship on social policy for children recurrently angles whereas the themes themselves surface the dynamic tensions inherent in pursuit of those goals finally an overarching theme of embeddingboth familial and societalemerges from the academic discourse in all policy domains examined which provides structural context for the expression and resolution of these tensions it gives form to the pervasive issue of a childs place in the family and in society at the heart of much social theory and applied analysis on children and childhood potential the idea of latent or unrealized potential inherent in children dominates in much of the literature allusions to childhood as a state of becoming cross disciplinary bounds and policy domains as do justifications for policy agenda setting development and implementation premised on the realization of childhood potential a number of distinct if overlapping subthemes surface recurrently notions of futurity and arguments for investment in children are inherent in both theoretical discourse about childhood and applied analyses of a range of childcentered policies 19 these arguments emphasize and often explicitly value childrens potential to contribute to society as eventual adultsespecially as return on investment in economic termsand leverage this idea as guidance for policy formulation 2021 critically this future orientation often eclipses valuing the present needs experiences and perspectives of children 2223 such constructs closely align with the core values and assumptions of economic liberalism wherein productive work and economic contribution epitomize social capital related to this are frequent equations of childhood with preparation childhood is routinely construed as a preparatory stage of life that framed as both an opportunity and a means to socialize the young into prevailing societal norms and expectations 24 varied policy domains invoke the idea of the childs potential in different ways both return on investment and health promotion have served as key normative frames for child health policy debate evidence suggests that these tropes have helped disaggregate children from other disadvantaged groups and produce the political consensus necessary to move policy initiatives on health coverage for children forward 25 childhood potential has also been invoked in health policy discourse to address national security concerns successive child health coverage expansions in the us relied heavily on policy frames such as early vulnerability human potential future economic contribution and in particular longterm national economic productivity and military strength 26 notions of return on investment also prevail in the scientific and policy literature on early childhood development early childhood development mounting knowledge about the impacts of early childhood environments and experiences on brain development and longrange cognitive outcomes has underwritten the development of policy arguments based on future potential and ultimate economic contribution 27 by contrast in the field of child welfare the available evidence on policy impact at the population level is comparatively thin so discourse focuses on extrapolating moral arguments from individual cases to broader child welfare policies moralistic frames predominate arguments based on desert rather than outcomes have often held sway 2829 rights rightsbased language figures prominently in the academic literature concerned with the moral dimensions of public policy for children rights have the broadest disciplinary reach mirroring the 20th century ascendance of human rights legislation and jurisprudence in national and international spheres of governance much of the literature draws on discourse and tenets from the united nations convention on the rights of the child which is the principal child rights covenant of modernity 30 the ratification of the crc dramatically increased the volume and changed the tenor of academic scholarship on childrens rights the construct of the competent child has emerged which is an image focused on the child as a rightsbearing individual one with legitimate needs and preferences the right to voice them and the right to participate in decisions about how to meet them notably while the discourse on potential focuses on the effects of policy rights discourse introduces issues of policy process the participatory rights of children and the inclusion of their voice in policy decisions impacting them are fundamental concerns this discourse strains traditional notionscommon in the child protection movement and couched in the rhetoric of riskof the child as a passive incomplete and ultimately incompetent vessel in need of protection and edification 31 the literature reveals important synergies between child rights and two paradigmatic normative concerns attached to policy formulation and adjudication for children wellbeing and best interests a parochial definition of wellbeing conceives it as the absence of abuse neglect exploitation a more expansive definition focuses minimally on need and optimally on inclusive holistic definitions of a high quality of life 3233 conceptions of child wellbeing in academic discourse have evolved from narrowly conceived ideas related to the protection of the most vulnerable in the 19th and early 20th centuries to expansive ideas about wellbeing couched in the universal rights of children 34 the justification for child wellbeing has evolved in tandem from one founded in charity to one premised on entitlement the broad acceptance achieved by the crc has tied notions of child wellbeing to achievement of their social cultural economic civil and political rights 35 and it has tempered culturally relativistic renderings of childrens purpose and wellbeing 36 a parallel narrative centered on participation emerges in the literature which sets in relief the role of rights in changing ideas about childrens wellbeing and best interests changing mores about children founded in changing models of the young child have influenced ideas about the legitimacy and necessity of involving children in policy decisions that affect them child rights are one of the principal drivers of changing societal perceptions 37 relatedly recent insights in the field of child development studies have contributed to major changes in conceptual models of the young child with corresponding implications for and impacts on ideas about involving children in policy decisionmaking scholars have identified three dominant models of the young childthe child as possession the child as subject and the child as qualified participantand have elaborated a new model of the child as social actor which is founded in novel theory and evidence from a diverse array of disciplines 38 crc principles and jurisprudence buttress this model united nations general comment no 7 elaborates an explicit accounting of a childs right to expression in the development of policies and services including through research and consultations 39 the upshot has been a progressive incorporation of ideas of autonomy and participation into ideas about childrens wellbeing and best interests in policy domains as diverse as predictive genetic testing sexuality and sexual health child welfare public health and research involving children and in forms as varied as a seat at the policy table proxy communication through identified advocates and the incorporation of research evidence on children in policymaking even so a number of tensions are inherent in the relationship between conceptions of childrens rights and their best interests the interface of child and parental rights remains a murky ethical and legal zone the values of child autonomy and participation can conflict with the legitimacy of parental discretion in decisions regarding children in the childs best interests child rights scholars offer a hierarchical taxonomy of intergenerational rights in response with parental rights as derivative from child rights and therefore functional in nature 40 this formulation recasts parental rights as prerogatives in the service of responsibilities insofar as they protect and advance the childs rights 41 allied issues relate to the substance and application of a childs right to participate what are the best ways to enact childrens participation in policy development what does participation look like in practical terms the literature reveals divergent views about the intent and form of legitimate child participation with identified problems ranging from tokenism to degrees of imbalance in power relations to issues of equity in opportunities for expression critics note that rightsthinking abstracted from social context induces myopia on structural barriers to rights execution some argue that the practical instantiation of rights implies degrees of autonomous capacity that many children lack due to sociopolitical constraints such as poverty ethnic or cultural marginalization familial mores or lack of political franchise in huntingtons words the dominant conception of rights is onesided in its emphasis on individualism rather than relationships 42 corrective attention to social embedding comes through most clearly and consistently in the public health literature scholarship on public health policy invokes twin imaginings of children as rightsbearing individuals and relational beings with attendant tensions between the two 43 one view affirms moral agency the other recognizes the embedded and contingent nature of childhood within family and societal institutions an exclusive focus on rights can divorce public health policies for children from engagement with the lived realities of childhood with corollary implications for equity and impact 44 an instructive example issues from the realm of childhood obesity policy some scholars prescribe programs with the intent for universal reach such as public education campaigns in deference to the ubiquity of the problem others contend that programs which emphasize health education above specific policy levers such as food taxes will tend to marginalize families and communities with less baseline capacity to act on educational prescriptions such as lowincome and rural groups 45 relatedly health care policy literature addressing difficult ethical issues about the value of life tests the limits of child rights in relation to their family and social context newborn and infant rights are a case in point inquiry into cultural intuitions about the value of newborn lifestudied through institutional policies and stakeholder perceptions attached to neonatal intensive carereveals an instance in which beliefs seem to shift from a defense of rights as unassailable entitlements to socially contingent ones 46 categorical distinction of the value of newborn life from other child life underscores the moral contingency attached to child health vague notions of personhood are leveraged to weigh the merits of acute medical intervention for the neonate 47 corollary considerations about the burdens imposed on other family members by newborn needs are incorporated into judgments about distributive justice within families in respect of both parents and siblings whether an acutely ill infant should live or die often rests on the results of such arithmetic such patterns of policy thought and clinical practice expose deeply embedded historical evolutionary and sociocultural factors that ground societal perceptions about the value of newborn and infant rights to life scholarly documentation of these and other instances of the relational character of child rights open critical windows into the landscape in which our social values about children move despite contentions the direction of movement is clear rights language has woven itself intimately into the fabric of academic and political discourse about public policy for children and it is certain to texture policy formulation and implementation into the future risk risk is a central theme linking social values to policies for children its expression varying by discipline and domain of social policy 48 innocence is a frequent precursor to notions of risk representations of the child as primitive and innocent abound in popular scholarly and political cultures with either positive and utopian or negative connotations 1 innocence relates closely to notions of vulnerability and protection as well as to the conception of childhood as a preparatory period of socialization discussed above allusions to vulnerability shape a common view of childhood as inherently risky vulnerability discourse is marked in the childhood development and welfare literatures insights from developmental science identify sensitive periods during which early experiences can have an outsized influence on developmental trajectories especially cognitive psychological and physiological patterns of behavior 4950 the childasvulnerable also prefigures but draws inspiration from theories and evidence on maternalchild bonding in developmental psychology 51 permanency is a closely related idea that has predominated in child welfare discourse and policymaking child welfare scholars and advocates theorize that stability in early childhood environments allows for bonding with a psychological parent that diminishes risk in early childhood and fosters improved developmental outcomes 52 the confluence of these perceived determinants of riskinnocence vulnerability and a need for relationship permanencyinduces an emphasis on protection and provision as natural domains for social policy touching on children protection from abuse and neglect has served as a hegemonic principle in social work and child welfare systems across disparate polities for much of the past century 48 themes about protection from risk relate closely to the concepts of childrens wellbeing and best interests the discourse linking these concepts to child protection issues from both the child welfare and public health fields with varying definitions as noted above wellbeing receives both narrow and expansive formulation its negative notion conceives wellbeing as freedom from abuse neglect and exploitation in positive terms it is measured by response to need and aimed at maximizing quality of life 32 critics have argued that the almost singular emphasis on a narrative of protection from risk in child welfare has excluded broader notions of child wellbeing which are attentive to structural determinants of health and human flourishing 29 they emphasize the socially and historically contingent nature of wellbeing one tied to family functioning and parental responsibility influenced by human rights paradigms and variably constrained by protection of the private sphere 33 from this standpoint the riskprotection nexus constrains the ambit of what child wellbeing could represent and how policy should seek to realize it the relationship between protection and best interests is more intimate still this connection emerges most clearly from the child health and welfare fields in which the concept of best interests of the child has served as a dominant moral and legal yardstick 53 the standard assimilates concepts related to protection from harm and promotion of welfare and it centers on an assessment of the balance between the benefits and risks of an intervention or policy 54 the health care field has long adjudicated clinical or research interventions in children by reference to bic a recurring theme in the academic discourse on best interests centers on their legitimate scope achieved by turns through the juxtaposition of individual family and population perspectives in the realm of research involving children a tension emerges between the protection of children as a uniquely vulnerable population and the promotion of aggregate child welfare through advancements in scientific knowledge 55 lags in childcentered health researchparticularly in the realm of drug and technology developmenthave challenged the definition of bic as protection of the individual child from researchrelated harm widening its scope to encompass the harms suffered by populations of children from constraints on scientific progress 56 bic is also a central standard in the ethics of clinical practice however again the locus of interests accounted forthose of child parent or familycomplicates the interpretation of bic a prime example relates to genetic testing in children 57 when genetic disease is not amenable to prevention or mitigation during childhood proper the bic standard has often dictated the deferral of such testing until such time as the child can make an informed decision about it 58 59 60 questions surrounding the handling of incidental results from whole genome sequencing and the rights of family members to knowledge of such results have challenged the traditional understanding of best interests 61 a tension is evident between notions of familyembeddedness and the evolving autonomy and capacity of children 6263 on the one hand the ascendance of rights paradigms has induced a conflict between paternalism and participation in the interpretation of a best interests standard some understand fidelity to best interests as fulfillment of the totality of crcenshrined rights with due emphasis placed on autonomy 62 others see the interests of a child as embedded in and dependent on the interests of the family unit and argue for the incorporation of parental and family interests in that standard 58 to wit the benefits that accrue to family members from the disclosure of incidental results about genetic disease in asymptomatic minors enter into the moral calculus governing the handling of genetic knowledge and weigh against corollary risks to the child debate on the legitimate bounds of a best interests standard also turn on different conceptions of risk again the ramifications of genetic testing provide a useful case study arguments to withhold incidental findings about genetic conditions center on worries about alterations to parentchild relationships the risk of sundered bonding from changed perceptions about ones child outweigh potential benefits from such knowledge 63 conversely those who argue for the disclosure of incidental results justify their position through reference to the medical risks of undetected conditions relatedly scholars and practitioners have defended the decision to grant parental requests for predictive genetic testing of their children through allusion to familial psychosocial risks related to uncertainty about a childs genetic inheritance the prevention or resolution of disabling parental anxiety counts in the tally of a childs best interests 61 child welfare scholarship and case law have also routinely employed bic as a means to measure the need for and justify interventions to enhance child protection the concept itself has roots in english feudal law and relates to the doctrine of parens patriae the king as father of his people initially employed to legitimate sovereign wardship over natural fools and idiots it was gradually expanded to include state duty toward the protection of children 54 the best interests standard has come to serve in most liberal democracies as a bulwark against historically unfettered parental possessory rights a childs best interests have become an elemental facet of legal decisionsand popular sensibilityregarding the protection and wellbeing of children in society the institutionalization of rights discourse culminating in the crc has underwritten this tendency the rights of the child imply specific corollary dutiesof the parent of societythat justify the curtailment of certain freedoms 64 signal debates in the child welfare literature issue from the intermingled interests of children the rights and duties of parents and the role of the state some scholars detect myopia in the hegemonic interpretation of best interests as child protection in social work and child welfare systems 65 protection from parental abuse and neglect dominates the prescribed hierarchy of child interests and leaves little room for more inclusive notions of wellbeing that are attentive to the social determination of health 66 as walsh notes focus on child abuse and the subsequent construction of child protection has contributed to the creation of neglected oppressions of age illness disability and poverty in the acceptance of those who are seen to be in need 29 in parallel there is a foundational struggle between participation and paternalism in child welfare services a complex dynamic exists where the states responsibility to safeguard children from harm meets its duty to promote their participatory rights this tension turns on the intrinsic vulnerability assigned to children and the consequent pull between competing views of the child as the powerless victim of the malice of adults and the potential unlocker of solutions 37 in the wake of a childs rights revolution social theorists have begun to detail portraits of children as active social agents rather than passive recipients of circumstance and to argue for social policy that empowers them to enact this agency 34 a survey of risk discourse across this broad range of disciplines and subjects yields a landscape of childhood marked by its vulnerability and populated by attempts to build in norms of protection protection from harmin the home environment in institutional contexts such as health care human subjects research and law in broader economic and political systemsis frequently justified and judged by reference to ideas about childrens wellbeing and best interests as with potential and rights risk is relational it is situated in family and societal contexts and calibrated against the interests of each discussion our review exhibits the prominence of three core themespotential rights and riskand established conceptswellbeing best interests and participationacross diverse academic disciplines and policy areas the boundaries of these themes are at times indistinct ideas about potential rights and risk move across disciplines and interact within them alternately reinforcing and challenging one another their relationship with wellbeing best interests and participation is also variable scholars invoke notions of wellbeing best interests and participation more explicitly in discourse on child rights and risk than in relation to arguments about childhood potential however they are not absent in the latter implicit ideas about wellbeing and best interests proceed from teleological views of the child wellbeing is equated with optimal development into adulthood and policies are seen to align with a childs best interests insofar as they promote this end notably the academic literature has tended to examine best interests and wellbeing in isolation from one another their interaction is little explored a view from above renders them as overlappingthough not transposableconcepts that derive from distinct historical and institutional trajectories wellbeing largely from public health and best interests from legal traditions in child welfare and human subjects research the potential to draw on conceptual synergies between the two is abundant but largely untapped the embedded nature of childhood is a foundational and unifying theme across diverse disciplines and subjects childhood is conditioned by layered structures of family community and society images of and debates about children are framed by recognition of this contingent state in particular conceptions of wellbeing and best interests of the child are routinely tied to the wellbeing and interests of the family and in certain instances to broader societal wellbeing dominant ideas about childhood potential couched in terms of future social and economic contribution blur the boundaries between individual and societal wellbeing in policy frames used to justify interventions in early childhood education and child health the framing and adjudication of risk in childhoodfor instance as evinced in policy debates on pediatric genetic testing and child welfareare closely allied to ideas about parentchild roles and responsibilities to one another and how these impact relational interests within families child rights discourse grapples with the foundational tension between the sanctity and contingency of personhood as capacities evolve and the contours of personhood solidify this tension is evident in the use of rights arguments in debates on a wide range of child health and social policy domains including research involving children genetic testing and public health interventions policy neglect much of the literature reviewed irrespective of policy domain describes situations of relative neglect with respect to robust public policy for children our analysis suggests that while the reasons for such neglect vary somewhat by political and cultural context reliable features emerge chief among them institutional and ideational factors consistent institutional constraints that surface across polities and policy worlds are the absence of political voice for children and the comparative lack of strong institutions designed to protect and advocate for children 232537 ideational challenges to public policy advances for children are often located in states of competition with other minority groups for political attention 17 on a number of social policy issues children are absorbed into negative social constructions that frame other groups to which their parents belong 2 the splintering of children into multiple subpopulations may dilute the effect of the positive societal associations attached to children per se despite recognition of the policy neglect attached to children insights into the need for more sophisticated policy arguments are rare in the existing literature rhetorical shifts our review also identifies shifts across time and place in the rhetoric used to justify public policy for children these shifts hint at the influence of historical and cultural context on the expression and impact of values on policy in a given jurisdiction or domain for instance us child policy rhetoric has shifted from arguments drawing on notions of rights obligations and compassion to economic arguments that leverage costbenefit calculus 67 this rhetorical shift has both political and sociocultural roots including declining religiosity the rising hegemony of empirical evidence in policymaking and fluctuating fiscal pressures 68 evidence suggests there has been a gradual overall rise in the use of economic reasoning to frame and justify child policy and a corollary decrease in moralistic reasoning 2 the speed and size of such changes vary by policy domain as discussed above moralistic arguments initially predominated in policy on education and poverty but gradually gave way to economic arguments by contrast us policymakers have long framed child health policies in utilitarian logic and couched their value in economic terms modern welfare states are at various points along a discursive trajectory from welfare to wellbeing as an ordering principle for childcentered social policy in most visions of the child as weak poor and needy have historically underwritten policy prescriptions in a few such visions give way to more holistic conceptions of wellbeing 1 in britain policies governing childrens services in a range of domains emphasize wellbeing as an objective variably incorporating notions of need deprivation rights quality of life and social standing in its definition and measurement 65 scotlands recent development of a national policy framework for children places wellbeing at its center 35 the socialdemocratic universalism long at work in most scandinavian countries has tended to induce a focus on need fulfillment rather than risk mitigation in social policy for children and families this has meant inclusive and positive definitions of child wellbeing at the core of social policies for children 6970 although rhetoric differs in tone and emphasis across jurisdictions there are broad trends evident our analysis captures the most prominent and impactful of these the increasing reliance on future potential often expressed in economic language is evident across the majority of liberal democracies mounting allusion to child rights and wellbeing as yardsticks of successful social policy is also broadly detectable and it has gained global traction in the form of international child rights covenants and broadly adopted social indicators 7172 however the relative concentration of literature on policies and populations in the global north precludes a truly global perspective on the relationship between values and child policies the vast majority of the worlds children live in political and cultural contexts where the impacts of child social policies have received little rigorous attention scholarly or otherwise crosscultural contestations of the values that ground public policy for children and the consequent means and ends of such policies are still poorly understood 73 limitations our analysis of the values dimensions of social policy for children is limited by language in two ways firstly we restricted our searches and analysis to english language literature as a result we may have captured a limited proportion of the existing cultural variance in values construction and emphasis visàvis children and childhood secondly the broad bounds of this work meant dealing with very different disciplinary languages the play of each theme discussed varies by policy domain depending on the tropes and accrued debates of the field abstracting from the specific context of such debate limits appreciation of the varied ways in which key issues are conceived and addressed finally our insights are constrained somewhat by the limited number of studies that explore the views and values of children themselves in the few studies that directly involve or report on child and youth perspectives emphasis on the a priori value of childhood experience predominates as compared to adult counterparts youth participants tend to accord less attention and import to instrumental justifications for child and family policiesfor instance child care as a means to adult economic productivity or education as a means to subsequent economic contributionand more to policies responsive to the intrinsic value of childhood 74 when solicited their policy preferences emphasize increasing child and youth voices in policy discourse reconceptualizing education as a means to more robust citizenship environmental protections and policies and programs to empower youth 75 the lack of literature that gives voice to child and youth perspectives on the values and goals that should shape public policies with direct bearing on them is a critical data availability statement all data generated or analysed during this study are included in this published article and its supplementary materials files gap in many fields of scholarship on children we hope our findings help motivate efforts to fill this gap conclusions the insights that emerge from the broad themes we identify suggest more coherence than fragmentation in the normative concerns attached to children and childhood weas academics as policymakers as citizens of a collectiverecursively frame and adjudicate policies for children in the light of a narrow band of moral presuppositions most societies paint children as potent vulnerable entitled and embedded it is the admixture of these elements in particular policy spheres across distinct places and times that determines the form of a given policy and societal reactions to it absent an understanding of these core values our capacity to learn from past policy failures and project future successes is fundamentally crippled foundational understanding of the moral language and dominant policy frames applied to children can enrich future analyses of existing and proposed social policies for children in a range of sociopolitical contexts potential applications are readily apparent better understanding of the ways in which societies value health gains in childrendoes their intrinsic value outweigh instrumental considerations are gains made now less valuable if they fail to promote longterm potentialcould help set system priorities for funding health technologies and services more nuanced evidence on modes and perceptions of child participation in social policy agendasetting and development could inform contextspecific criteria for engaging children and youth in political decisions that affect them subsequent work in this area will need to detail the degree and impact of variance in the values mix attached to children across sociocultural contexts supplementary materials the following are available online at 0678143s1 figure s1 research questions figure s2 literature sampling process and yield table s1 child policy values cis search strategy table s2 sample search strategy medline table s3 social construction of target populations table s4 relationship between policy domain and values all data generated or analysed during this study are included in this published article and its supplementary information files author contributions aed conceptualized the study led its design conducted data collection and analysis and undertook initial manuscript drafting ja assisted with the development of search strategies including inclusion and exclusion criteria and provided feedback on iterative drafts mg and wju reviewed the manuscript and provided detailed input on results interpretation all authors have read and agreed to the published version of the manuscript

background allusions to the uniqueness and value of childhood abound in academic lay and policy discourse however little clarity exists on the values that guide child health and social policymaking we review extant academic literature on the normative dimensions of child health and social policy to provide foundations for the development of childfocused public policies methods we conducted a critical interpretive synthesis of academic literature on the normative dimensions of child health and social policymaking we employed a social constructivist lens to interpret emergent themes political theory on the social construction of target populations served as a bridge between sociologies of childhood and public policy analysis results our database searches returned 14658 unique articles full text review yielded 72 relevant articles purposive sampling of relevant literature complemented our electronic searches adding 51 original articles for a total of 123 articles our analysis of the literature reveals three central themes potential rights and risk these themes retain relevance in diverse policy domains a core set of foundational concepts also cuts across disciplines wellbeing participation and best interests of the child inform debate on the moral and legal dimensions of a gamut of child social policies finally a metatheme of embedding encompasses the pervasive issue of a childs place in the family and in society which is at the heart of much social theory and applied analysis on children and childhood conclusions foundational understanding of the moral language and dominant policy frames applied to children can enrich analyses of social policies for children most societies paint children as potent vulnerable entitled and embedded it is the admixture of these elements in particular policy spheres across distinct places and times that often determines the form of a given policy and societal reactions to it subsequent work in this area will need to detail the degree and impact of variance in the values mix attached to children across sociocultural contexts and investigate tensions between what are and what ought to be the values that guide social policy development for children

introduction families represent not only environments wherein their members live but also whole complex social systems 12 thus according to the family systems theory perspective family functioning refers to processes and interactions in which the members of the system are involved to meet their needs make decisions define goals and establish rules for themselves and for the system as a whole levels of openness of communications and healthiness of interactions represent characterizing elements of familys ability to function adequately associated with positive outcomes at both individual and family levels 3 with specific reference to systems including adolescents mutual acceptance and open communications among family members can help them in managing stressors and negotiating adolescents individuation 4 as they allow children to talk with their parents about daily concerns activities issues and in turn parents being adequately supportive of them 56 moreover social cognitive theory assigns a central role to perceived efficacy in managing different aspects of daily relationships interactions and tasks within the system 78 specifically family collective efficacy is members beliefs in the capabilities of their family to work together to promote each others development and wellbeing maintain beneficial ties to extrafamilial systems and to exhibit resilience to adversity studies 59 showed that higher collective family efficacy associates with higher family satisfaction open communication effective parental monitoring and lower aggressive management of conflicts and communication problems such an efficacy plays a key role in managing demands and issues related to parenthood 7 representing a protective factor helping parents to get positive outcomes for their family system as a whole with reference to family relationships the most recent literature has deepened the understanding of the impact that social media can have on them with specific attention to particular family tasks challenges and phases of family life social media use can specifically be a central issue for families facing adolescence evolutionary tasks 10 11 12 which also refer to adolescents negotiation of autonomy and independence within the family system and to the significance of peer relationships 13 indeed given that nowadays adolescents spend significant amounts of time using social media with a variety of goals scholars often talk about generation m edia when referring to modern adolescents 1415 this seems to be an increasing trend according to the latest data from the we are social report 16 which states that in italy there are 4331 million internet users 34 million are active social media users 30 million do this through their mobile devices moreover 53 of italian new technology users believe that they offer more risks than opportunities while 54 state they prefer to use them if it is possible 16 thus it is evident that the information and communication technologies are profoundly changing the ways in which people behave and relate to each other 1718 and creating conflicting perceptions about their impact as they have become cultural practices embedded in everyday life relationships 310 19 20 21 22 23 24 25 26 27 their contribution to creating richer and more complex patterns of interactions 28 including to family life cannot be ignored 29 however whether the effects of these new forms of interactions on the functioning of family systems are positive or negative is still unclear even more when considering families with adolescents 30 thus with facebook and whatsapp being the most used social media in italy 16 also among relatives the present study aims at deepening the role that parents perceptions about the effects of social media on their family system can exert within the functionality of their family specifically referring to the relationship between collective family efficacy and open communications within family systems with adolescents perceptions about social media use within families with adolescents according to hertleins multitheoretical model 31 the ecological influences related to social media features the changes social media use brings with reference to family structure and the ones related to family processes are interconnected and interdependent thus due to the spread of new ways of communicating and to the consequences they can bring with reference to the functionality and habits of the family parents can have ambivalent perceptions about their impact on relationships and communications with their adolescent children consistently studies about families which include adolescents brought ambivalent results too ranging from higher social support 30 to lower family cohesion 31 and progressive isolation of family members within the same house 3233 indeed on the one hand icts use can provide positive results in terms of family cohesion adaptability and open communications 3 and can have a positive impact on family relationships too 34 by allowing family members to keep in touch make plans in realtime ensure childrens safety as they allow communications in emergency situations 35 strengthen family ties encourage parentchild interactions and promote and facilitate discussions 36 moreover icts and social media use could increasingly ensure what castells 37 defined as autonomy in security conditions as they help parents in communicating with their children at any time checking their movements in physical and online spaces 35 38 39 40 on the other hand the connectedness allowed by mobile devices and social media needs to be negotiated in times spaces and occasions where it is allowed and the chances to perpetually communicate need to be modulated 41 a risk arising from the lack of modulation and negotiation about social media and mobile devices use which could impact family relationships and dynamics seems related to the phubbing phenomenon ie ignoring someone in a social environment by paying attention to mobile devices instead 4243 altogether the arrangements needed to avoid these kinds of risks and modulating mobile devices use in times spaces and occasions could cause conflicts within families 353941 44 45 46 as parents who are more worried about social media impacts can exert a greater control over their childrens use 47 48 49 making adolescents get the perception of being hypercontrolled by their parents that in turn can increase the level of conflict and aggressive communications moreover as social media represents environments wherein different social norms and rules can be established and followed by adolescents out of their parents control this can make further risks arise if their use and its consequences is not adequately discussed among family members as therefore adolescents decisionmaking processes can be affected by those norms aim of the study it has been acknowledged that the perceived collective family efficacy refers to the perception about family members being able to handle daily social interactions challenges and communications within the system and helps in achieving positive family outcomes such as open communications 5 thus as the widespread itcs use within families represents a new challenge to be managed by parents through an active adaptation which can bring changes in family communications 3031 and habits beliefs and norms 29 the following hypothesis is suggested h parents perception of the impact of social media use on their family system mediates the relationship between their perceived collective family efficacy and the perceived openness of communications within the family system open communication has been chosen as a key outcome because it can be a particularly relevant issue in family systems which include adolescents 5152 materials and methods participants and procedures snowball sampling was used to recruit 227 italian parents with one or more teenage child who use facebook and whatsapp to communicate with them having at least one teenage child and communicating with she through smartphones and ict was the criterion to be a participant in the study the researchers paid attention to privacy and ethics and introduced the questionnaire with an explanation about confidentiality and anonymity issues conforming with the international applicable law at the end of this explanation every participant had to express hisher informed consent in case of a negative answer they could not take part in the study they received no compensation for participating in the study seventy percent were female 30 male 251 were born between 1943 and 1960 683 between 1961 and 1981 66 between 1982 and 1997 115 were from northern italy 84 from central italy and 775 from southern italy only 26 were from italian islands most of the participants were married or cohabiting while 159 were separated or divorced 88 unmarried and 31 widower about half the participants had a high school diploma while 26 a bachelors or masters degree and 79 a higher degree 141 had a secondary school diploma measures the questionnaire included a section about sociodemographic data and the following measures collective family efficacy the collective family efficacy scale was used it is compounded by 20 items on a 7point likert scale aimed at measuring the perceived operative capabilities of the family as a whole system such as managing daily routines achieving consensus in decision making and planning coping together with adversities promoting reciprocal commitment providing emotional support when needed enjoying the time together being interested in the holistic efficacy appraisal 5455 the total score was used family open communication a pool of 8 items was used to detect participants perceptions about the openness of their family communications respondents were asked to rate their level of agreement with each item on a 5point likert scale social media impact on family systems a pool of 9 items referring to both positive and negative impacts of social media on family systems was used to assess participants perceptions about it respondents were asked to rate their agreement with each item on a 5point likert scale as positive and negative impacts of social media use on family systems can be meant as two sides of the same coin the total score was used data analysis preliminary analyses as they had not been validated yet exploratory factor analyses with principal axis factoring and promax rotation were led to extract the factors of the family open communication and of the social media impact on family system scales for both scales sphericity was checked using bartletts test and adequacy of sampling using the keiser meyer olkin measure the emerged factor structures were further tested through confirmatory factor analyses run with structural equation modeling specifically for the social media impact on family system scale a twofactor structure as suggested by the efa and a hierarchical structure with the two factors loading on a higherorder latent dimension were tested to determine which one better fitted the data consistently with the theoretical model about positive and negative impacts of social media use on family system as two sides of the same coin for the family collective efficacy the factor structure that emerged from a previous study 8 was tested through cfa run with sem to evaluate the model fit for all the cfa different indices were observed 56 the chisquare test of model fit the comparative fit index the standardized root mean square residual for the cfi values equal to or greater than 090 e 095 reflect good or excellent fit indices respectively for the srmr values equal to or smaller than 006 e 008 reflect good or reasonable fit indices respectively 57 moreover when it came to testing which model better fitted the data for the social media impact on the family system scale the akaike information criterion and the bayesian information criterion were also used for both indices the lower the value the better the fit hypothesis testing the mediation hypothesis was tested through sem collective family efficacy was the independent variable openness of family communications was the dependent one the perception about social media impact on family systems was the mediator participants age and sex were modeled as covariates on all the variables in the model a dummy variable was created for participants sex before entering it in the model before testing the hypothesis the presence of outliers andor influential cases was checked using the leverage value and cooks d to test the absence of significant values in the data affecting the analyses 58 multicollinearity was tested through condition and tolerance indexes 59 common variance was controlled through harmans singlefactor test 60 given the interest in higherorder constructs a heterogeneous parceling was adopted 61 as it reproduces smaller but more reliable coefficients than the homogeneous one 62 and allows for creating parcels without generating a flawed measurement model because theoretically meaningful categories were included in the sem to evaluate the model fit the following indices of fit were observed 56 the chisquare test of model fit the cfi the srmr bootstrap estimation was used to test the significance of the results 6364 with 10000 samples and the biascorrected 95 ci was computed by determining the effects at the 25th and 975th percentiles the indirect effects are significant when there is no 0 in the ci results for the family open communication scale and for the social media impact on family system scale sphericity 974765 p 0001 social media impact on family system scale chisquare 756527 p 0001 and adequacy of sampling reported good values no item was deleted from the original pools due to too low loadings nor too high loadings on more than one factor all the items in the final versions of the scales had loadings above 03 in only one factor the cfa confirmed an adequate model fit for the family open communication scale chisquare 105100 p 0001 cfi 091 srmr 005 and for the family collective efficacy scale chisquare 789980 p 0001 cfi 094 srmr 002 for the social media impact on family system scale the hierarchical model chisquare 98878 p 0001 cfi 090 srmr 006 aic 5714096 bic 5816844 better fitted the data than the twofactor model chisquare 98878 p 0001 cfi 089 srmr 007 aic 5718096 bic 5827694 confirming positive and negative impacts of social media use as two sides of the same coin the descriptive statistics and the correlations for all the measures are in table 3 hypotheses testing since the leverage value was always lower than 009 and cooks d lowest and highest values were 0 and 036 there were no significant values in the data affecting the analyses as the variables in the model had tolerance indexes between 088 and 098 multicollinearity among them was not a problem 59 the hypothesized mediation model showed good fit indices chisquare 50280 p 0027 cfi 099 srmr 002 collective family efficacy emerged as a significant predictor of the openness of family communications b 0585 se 007 p 0001 biascorrected 95 ci 0410 0709 and of the perceptions about social media impact on family systems b 0204 se 0064 p 0001 biascorrected 95 ci 0067 0321 the latter was a significant predictor of the openness of family communications too b 0242 se 0056 p 0001 biascorrected 95 ci 0126 0342 the indirect effect of collective family efficacy on openness of family communications via the perceptions about social media impact on family systems was small yet significant b 0049 se 0019 p 001 biascorrected 95 ci 002 0098 supporting the hypothesis of partial mediation the unstandardized total effect was 0634 se 0066 p 0001 biascorrected 95 ci 0459 0747 participants sex emerged as a significant predictor only for the perceptions about social media impact on family systems b 0132 se 0105 p 0008 biascorrected 95 ci 0433 0022 participants age was significant only for the collective family efficacy b 0081 se 0072 p 005 biascorrected 95 ci 0004 0279 discussion the present study deepens the understanding of how social media can produce changes within family systems taking into consideration the role that parents perceptions about the impact of social media on family systems whether positive or negative can exert in the relationship between their perceived collective family efficacy and an open communication among family members specifically the leading hypothesis referred to the mediator role of these perceptions whether positive or negative in the abovementioned relationship the results confirm the hypothesis showing that parents perceptions represent a partial mediator of the relationship between their perceptions about collective family efficacy and openness of communications nevertheless the indirect effect of collective family efficacy on openness of family communications via parents perceptions about the impact of social media on family systems was small showing that all the direct effects in the model were still bigger it has already been widely acknowledged that social media and icts make human social interactions and relationships more complex however scientific results still showed conflicting results about whether such complexity can have a positive enriching role or rather than a negative detrimental one with reference to family interactions even more when the family system includes adolescent children 36 due to the evolutionary tasks they have to face up to which can impact on family relationships and interactions temporarily or permanently 10 11 12 13 these results provide further hints about social media role within family relationships and functioning indeed while it is well established that family collective efficacy can have a boosting role with reference to healthy interactions and open communications within the family system 510 what emerged here suggests that it is not only the real impact of social media on family systems 36 that matters but also how family members perceive it and how much they feel confident about their family managing daily challenges to achieve positive relationships healthy interactions and open communications indeed the results show that that being confident in ones family capabilities to handle daily tasks stress and challenges associates with a more positive perception about the impact social media can have on family system and the relationships within it as feeling able to manage family daily tasks and challenges could foster the feeling about being able to manage the adaptation to the increasing social media use among family members too this could make family members perceive at last these new technologies as opportunities for increased family cohesion adaptability interactions planning and open communications 33436 rather than as threats to positive family functioning and relationships in addition to family collective efficacy also such positive perception can further promote open communications among family members maybe because if social media are perceived as opportunities and useful tools they can offer further ways to maintain and improve relationships among family members when parents are aware of their familys ability to manage social mediarelated changes in family functioning and habits this can foster their perception about potentialities and new opportunities coming from social media use to keep in touch with their children most of all when they are adolescents and are facing up their individualization process if parents are able not to make their children feel they are invading their privacy or being oppressive and hypercontrolling and to discuss with them how social media should be used to reduce the risks social media can at last strengthen family ties promote and facilitate discussions and foster more secure conditions for adolescents to obtain greater autonomy from their parents and for parents to let them face up to these situations 35363839 indeed when used in a responsible and aware way social media can represent a resource and an educational added value within family relationships helping parents to exploit a new educational and participative space that could strengthen the relationships with their children this seems also consistent with previous results about how social media use can enhance the opportunities for a more open dialogue between parents and children allowing the latter to get closer to the language and lifestyles of the first ones and to share with them important sensitive andor educational discussion topics functional to their growth 36 thus social media may foster open communications among family members and a supportive family environment wherein adolescents can grow up and face up to their evolutionary tasks and subsequent stressful events getting positive outcomes 36 conclusions the study shows the relevance that parents positive perceptions about the impact of social media on social interactions and relationships within their family system can have in fostering a good family functioning and open communications among family members moreover with reference to the role that collective family efficacy exerts it also suggests that relying on family abilities to manage daily life tasks and face daily challenges could represent a strategy to promote the acknowledgment that challenges related to social media uses their consequences and the potential subsequent risks could be managed with adequate information and negotiation of the changes they bring in terms of family communications habits interactions and rituals among parents taking into consideration the results from this study an emergent issue seems related to the need to promote a wider acknowledgment that social media can be positively and functionally used among modern parents 36 showing them different ways in which social media can represent educational and participative spaces aimed at promoting a wider and more open communication between them and their children and a critical and responsible awareness for their children at the same time fostering at last their positive perceptions about social media impact on family systems indeed social media accessibility acceptability and accommodation require the redefinition of rules and roles producing new processes and dynamics within family systems 31 parents have to deal with if they want to get a positive perception about their use if adequately managed these processes can allow the creation of further spaces wherein the relational dynamics between parents and adolescent children can happen and be successfully managed consistently the aspects that emerged from this study invite to set up further studies aimed at deepening the meaning that social media tools can assume in the construction of transition spaces allowing the expression and mediation of the divergences and conflicts that can show up in families with adolescent children it is important to also acknowledge some limitations of this study first it takes into consideration only the parents perspective but a major comprehension of family relationships should take into consideration the childrens perspective also or even a dyadic one moreover the findings are based on selfreported data which can become distorted due to problems related to memory bias and response fatigue lastly another issue refers to the crosssectional design of the study thus the relationships described should be considered carefully and no causal inference is possible it would also be useful to extend the analyses to samples from other countries to verify whether and how the cultural and community 65 66 67 68 dimensions modify the perceptions about social media impact within family systems and their effect on family communications author contributions fp conceptualization methodology writing review and editing fg methodology and writing idn writing and review all authors read and approved the final manuscript funding this research received no external funding

communication through social media characterizes modern lifestyles and relationships including family interactions the present study aims at deepening the role that parents perceptions about social media effects on family systems can exert within their family functioning specifically referring to the relationship between collective family efficacy and open communications within family systems with adolescents a questionnaire to detect the openness of family communications the collective family efficacy and the perceptions about the impacts of social media on family systems was administered to 227 italian parents who had one or more teenage children and who use facebook and whatsapp to communicate with them from the results these perceptions emerge as a mediator in the relationship between the collective family efficacy and the openness of communications suggesting that it is not only the actual impact of social media on family systems that matters but also parents perceptions about it and how much they feel able to manage their and their childrens social media use without damaging their family relationships thus the need to foster parents positive perceptions about social medias potential impact on their family relationships emerges a strategy could be the promotion of knowledge on how to functionally use social media

children who live farther away as less filial however financial support from more distant children raises perceptions that these children are meeting expectations of filial piety in addition having more frequent contact with distant children strengthens perceptions of them as being filial results suggest that weak filial piety perceived by older parents of their more geographically distant children in rural chinaan area characterized by high rates of internal migrationis compensated by financial transfers and frequent communication as research shows that filial piety perceptions are important to the wellbeing of older adults in chinese populations threats to its decline due to forces of modernization and any adverse consequences may be overcome by forms of intergenerational solidarity that involve contributions of money and time by children to their older parents abstract citation id igad1043066 nonparental caregiver differences in locus of control and gpa of grandchildren and foster children maia mclin and danielle nadorff mississippi state university mississippi state mississippi united states there are approximately 5950690 children living with their grandparents with about half being raised without a parent present children raised by nonparental caregivers are at risk of worse academic performance and locus of control is shown to relate to childrens academic performance however differences between caregiver types and this relation are not well known the current study hypothesized that caregiver type would affect the strength of the association between loc and academic performance in children raised by grandparents versus foster parents participants m age 5566 yr 105 foster parents m age 3445 yr were recruited nationwide and surveyed via qualtrics panel service measures included an adapted academic locus of control scale from the child trends student survey and a question rating the degree to which the child receives mostly as and bs controlling for age and socioeconomic status of caregiver grandchildren had higher reported loc but did not differ in academic performance caregiver type was found to differentially affect the relation between loc and academic performance with a stronger association for foster children a significant group difference was found these results suggest that kincare may buffer the impact of loc on academic performance in children not raised by their parents for those raised in foster care it may be helpful to focus on increasing autonomy and sense of control regarding their grades abstract citation id igad1043067 older parents patterns of agreement and information sharing with adult children and their emotional outcomes noriko toyokawa southern oregon university ashland oregon united states the current study examined the effect of older parents pattern of agreementdisagreement with their adult childrens perceptions of their functional ability and their information disclosurenondisclosure to their adult children on their downloaded from by hochschule luzern user on 20 february 2024

the parentchild relationship is one of the longestlasting and closest relationships in human life because of its longlasting nature more studies focus on the longterm exchanges between parents and children few studies have examined the effects of daily interactions on relationship quality however such an understanding is crucial during public health emergencies when daily support amongst close family members is critical for life quality and even survival using data collected during the covid19 pandemic we examined the relationship between daily support and relationship quality among middleaged and older mothers and their adult children seventyseven dyads of mothers age range 4480 years mage 5378 sdage 957 and adult children age range 1854 years mage 2661 sdage 946 reported their daily exchanges with their childparent ie the support they had received from and provided to the other and daily relationship quality ie relationship satisfaction and trust each day for 14 consecutive days receiving support was positively associated with relationship satisfaction and trust on both day n and day n1 in mothers and it was positively associated with relationship satisfaction on day n and trust on both day n and day n1 in children offering support was positively associated with relationship satisfaction on day n but not day n1 for both mothers and children offering support was not associated with daily trust in either mothers or children the findings highlight the importance of daily support on relationship quality during a public health emergency

background secure affordable housing is fundamental to providing stability and security for individuals and families 1 in australia social housing is provided by government or community sector organisations to people on low incomes especially those at risk of homelessness or family violence due to limited housing stock social housing residents are prioritised according to need 2 residents may experience a range of stressors such as unemployment poor physical or mental health or disability which can impact their wellbeing 23 aboriginal and torres strait islander peoples living in social housing face additional challenges and stressors due to the impacts of colonisation and dislocation and their ongoing manifestations in racism and inequity 45 the complex and multiple needs of some aboriginal and torres strait islander peoples are evident in high rates of mental and physical health issues social exclusion trauma family breakdown psychological distress and personal safety fears 4 6 7 8 a body of literature exists on the wellbeing and needs of social housing tenants however little is known about the wellbeing needs and aspirations of aboriginal and torres strait islander peoples living in social housing freund et al 9 in an exploratory study of wellbeing needs of people living in social housing found that those who identified as aboriginal and torres strait islander had a higher number of wellbeing needs than those who were nonindigenous wellbeing for aboriginal and torres strait islander peoples can be described by the term social and emotional wellbeing in this context the term refers to multiple elements that are connected and in balance at the individual family and community levels to contribute to wellbeing 4610 while communities may differ in their interpretation of sewb gee et al 11 have identified seven common elements including connection to body mind and emotions family and kinship community culture country and spirituality and ancestors this sewb framework recognises the role of broader social determinants in shaping sewb such as income employment housing education and access to community resources 611 in addition to less recognised historical and political determinants the latter determinants refer to the degree to which individuals families and whole communitiescultural groups have been able to maintain connections to land culture community control and selfdetermination despite past and ongoing impacts of colonisation 11 the conceptualisation of self in this model views the self as inseparable 12 from and embedded within family and community 11 p 57 this understanding informs a framework to holistically understand the sewb of aboriginal and torres strait islander peoples who live in social housing identifying needs is important in planning and advocating for appropriate support services however it is not enough by itself needs can be thought of as changeable contingent on external conditions and sometimes requiring immediate relief whereas aspirations are aimed at selfdetermined positive life changes that are intrinsically motivated 13 aspirations provide insight into persistent desires for improving ones current situation 13 hart views aspirations as the kernels or precursors of many important capabilities which support human flourishing 14 p 336 understanding the aspirations of communities can inform social change policy action and investment 14 this study aims to • understand the social and emotional wellbeing strengths needs and aspirations of aboriginal and torres strait islander peoples living in aboriginal housing victoria social housing • assess the characteristics of respondents to determine the representativeness of the sample in comparison to the broader ahv population the findings of this study will inform the implementation of a novel wellbeing intervention by ahv 15 methods study design we conducted a survey of people living in social housing in three regions provided by ahv ahv is an aboriginal communitycontrolled organisation providing community housing to aboriginal and torres strait islander peoples living in victoria australia in addition to core tenancy management activities ahv provides a range of individual supports to assist a person in maintaining their tenancy along with individual and community support activities that contribute to wellbeing their vision is to provide appropriate affordable housing as a pathway to better lives and stronger communities 16 the crosssectional survey assessed social and emotional wellbeing strengths needs and aspirations and served as a tool for identifying people interested in participating in wellbeing support provided by ahv peer researchers conducted the survey between april and december 2021 among a voluntary response sample using a structured questionnaire the authors used linked administrative data related to tenancies to compare respondents with nonparticipants ethics the study adhered to principles of culturally safe and ethical approaches to research with aboriginal and torres strait islander communities 1718 aboriginal researchers were investigators on the research team and aboriginal advisory group members were involved with leading the project design the study responded to a community led initiative involved building the capabilities of local communities through the employment of peer researchers and utilised the knowledge of sewb as defined by aboriginal and torres strait islander peoples this approach reflects a decolonising research method with selfdetermination and empowerment integral to all aspects of the study including development and data collection 19 this survey was part of a larger study investigating the implementation of a coaching intervention that received ethics approval from the university of melbourne human ethics committee stem 1 on 9221 peer researchers assured participants that survey data were held by university researchers and were not available to ahv staff they also provided interested participants with a plain language statement explained the research and documented informed consent via the first survey question peer researchers provided a debriefing statement containing information about available support as some participants may be vulnerable to distress due to potential underlying mental health andor experiences of complex or intergenerational trauma 20 survey participants received a 40 voucher for participating in the survey survey the survey included domains of social and emotional wellbeing relevant to aboriginal and torres strait islander peoples initially the survey was used as part of a first 1000 days australia initiative to describe the aspirations and needs of aboriginal and torres strait islander families 21 we modified the survey to shift the focus from parenting to include additional aspects of sewb and trialed it with 22 aboriginal andor torres strait community members in the eastern region of melbourne we then shortened the survey to reduce the response burden and piloted it with five aboriginal and torres strait islander after making further amendments based on the pilot we finalised the survey the survey consisted of demographic information and questions in 12 domains as outlined in table 1 and took between 45 and 60 min to complete we drew survey items from established instruments modified instruments or instruments developed by researchers or through consultation with ahv or other key stakeholders we included only questions on psychological and emotional wellbeing from the mental health continuum short form tool 22 as questions relating to social wellbeing were not considered culturally appropriate by those reviewing the survey the aboriginal resilience and recovery questionnaire has been developed and is validated for use in the victorian aboriginal and torres strait islander population 2324 administrative data ahv routinely collects administrative data on all people who live in social housing in all ahv regions we linked administrative data to survey data via a unique identifier we used the administrative data for analyses as well as to compare the characteristics of our survey respondents with the broader ahv social housing population administrative data include information on gender household composition housing type and a range of data that are indicative of people experiencing difficulties in life including rent in arrears rent related maintenance charges and complaints eligibility peer researchers invited all aboriginal and torres strait islander peoples aged 16 years and over who were living in ahv social housing in three nominated regions to participate in the survey via the main tenancy holder ahv chose the three regions as a wellbeing program was being trialed in these regions recruitment and survey administration ahv employed five aboriginal and torres strait islander people and one non indigenous person including some who lived in ahv social housing as peer researchers from local communities to recruit people to the survey involving peers in recruitment was important in facilitating engagement with local communities and strengthening community capacity through skill development successful applicants underwent a oneweek training program in research ethics and consent confidentiality safety and survey conduct as well as ongoing supervision from a team leader peer researchers attempted phone contact with the main tenancy holder listed on the tenancy agreement in the three regions they made three attempts to contact all households they also asked the main tenancy holder if any other people aged 16 and over living at the property might like to participate in the survey peer researcher initially made face to face appointments with consenting participants to explain the survey and provide the participant with a laptop to selfadminister the survey after multiple lockdowns and social restrictions due to the covid19 pandemic prevented face to face visits most surveys were selfadministered via an sms link to a mobile phone version of the electronic survey peer researcher survey administration was available over the phone according to the preferences of the participant or the needs of those with low vision literacy access to internet or digital skills we collected survey data using qualtrics and exported data to stata for analysis by researchers at the university of melbourne analysis we analysed survey data in stata and used descriptive statistics to present the characteristics and sewb of participants we collapsed response options to several scales to simplify reporting for example we aggregated responses to items in the mental health continuum into the percentage who reported a feeling either 23 times a week almost everyday or everyday we also aggregated responses for the aboriginal resilience and recovery questionnaire selfdetermination strengthbased parenting aspirations and community attitudes questions and this is indicated in the results reporting on all responses to questions can be found in data supplementary file 2 we compared survey respondents with the full population of aboriginal and torres strait islander people living in ahv social housing using the administrative data to determine representativeness results response rate and respondent characteristics we attempted to contact the tenancy holder for each of the 410 ahv properties in the regions tenancy holders from 90 properties participated in the survey yielding an initial response rate of 22 with an additional 8 people housed in these properties recruited via the tenancy holder however only 255 of the 410 tenancy holders were eligible or able to be contacted by peer researchers with 23 main tenants ineligible due to nonindigenous status 49 main tenants having wrong or disconnected contact numbers and 85 not responding to any contact made by peer researchers the final response rate is therefore 35 of invited tenancy holders three respondents did not provide sufficient data beyond basic demographics and were excluded from the sample the final sample size for survey analysis was 95 respondents all survey respondents identified as aboriginal 1 most respondents had lived in their current properties for six years or more to summarise the sample was more likely to be female older single and living in shared housing compared to nonsurvey respondents importantly survey respondents and nonsurvey participants did not significantly vary in terms of the proportion experiencing rent in arrears tenancy related maintenance charges incurred complaints made against them and housing type connection to community culture family and country the survey included questions on personal community relationship and cultural strengths and resources and the results are presented in table 4 survey respondents exhibited a strong sense of identity with 80 indicating that they were proud to be aboriginal or torres strait islander and 77 indicating that being aboriginal or torres strait islander was an important part of who they are most respondents could identify their traditional country or homeland similarly 80 of respondents had knowledge of their mob or mobs almost all respondents had been involved in some sort of cultural or community ceremony or event in the last 12 months approximately a third of respondents indicated that they did not participate as often as they wanted in cultural and community celebrations and events due to a range of factors including affordability being too far away or a range of commitments preventing involvement family was a source of strength for most people with respondents indicating they had a family that loved them even when they muck up and felt safe with their family or their partner or people close to them either a lot or a fair bit when asked where they felt most comfortable respondents reported feeling most comfortable at home with their family or with other aboriginal and torres strait islander people some respondents expressed interest in family tracing services and in reunion services reflecting that 17 of people had been removed from their family andor placed under care of child protection services and 41 had relatives removed from family by the government most respondents felt content with their life felt able to make the right choice were able to deal with problems that occurred and could adapt to changes either a lot or a fair bit just over half felt in control of their lives either a lot or a fair bit most respondents who were parents demonstrated awareness of strengthbased parenting skills with 76 agreeing or strongly agreeing with knowing the things their kids were good at 82 being aware of their kids strengths 79 showing their kids how to use strengths in different situations and 79 giving kids many opportunities to use their strengths connection to body mind and emotions the survey explored respondents connection to mind body and emotions through questions regarding mental and physical health and the results are presented in table 5 fig 3 most respondents reported feeling happy interested in life and satisfied with life either a few times a week everyday or almost everyday in the past month most respondents also demonstrated psychological wellbeing by liking their personality managing their responsibilities having warm and trusting relationships feeling confident in expressing their own ideas and opinions having opportunities to grow and feeling that their life has a sense of direction or purpose at least a few times a week in the past month however 28 reported high or very high levels of psychological distress as measured by the kessler 5 eleven of respondents felt unsafe or afraid in the last 12 months with 8 threatened with physical harm 7 feeling controlled or put down and 2 subject to physical harm respondents rated their health out of a hundred on a visual analogue scale and the median was 70 26 of respondents reported having six or more health conditions confirmed by a healthcare provider s the most frequently cited health conditions were anxiety back problems asthma depression and problems with weight 61 of respondents noted problems with pain with 38 reporting chronic pain that is always there or keeps coming back most respondents indicated that they or someone in their house had a disability but awareness of the national disability insurance scheme was low and only 22 indicated that the person with a disability was receiving ndis support employment education and finances survey respondents were asked about social determinants of sewb through questions related to their employment status educational achievement and financial situation and the results are presented in tables 3 and6 almost half the survey respondents had completed either a year 12 or a certificate iii qualification or above 18 of respondents reported being in some sort of paid employment with 24 indicating they were unable to work and 18 indicating they were out of work and looking for work the main barriers to employment were ill health and disability followed by transport problems with insufficient skills and no job available both being cited by 7 of respondents less than half the respondents felt they had opportunities to develop skills in the community or further their education and just over half of the respondents felt they had opportunities to work in their life keep busy and stay involved either a lot or a fair bit almost half the respondents stated they did not have enough money to spend on everyday things most respondents had experienced problems paying bills in the last 12 months with 40 running out of money for food clothing or bills in the last two weeks the wider environment broader community resources and services the survey explored respondents feelings about the community and use of community facilities almost all respondents felt their local community was a place where all people are welcomed and valued irrespective of lgbtq status religion or spirituality gender and culture however only 35 of respondents felt the statement aboriginal and torres strait islander culture is valued in australia was often usually or always true approximately a quarter of respondents felt statements that aboriginal and torres strait islander peoples experience the same rights as other australians and do not experience racial discrimination were often usually or always true a third of respondents reported feeling unfairly treated at least sometimes with 24 being subjected to racial comments or jokes 10 being followed by security while shopping and 7 feeling they hadnt been trusted unfair treatment occurred in the public sphere by members of the public when applying for work social media and healthcare settings just over half the respondents agreed with the statement that services were culturally safe was often usually or always true respondents had difficulty accessing existing services such as social security services housing services hospitals and banks and financial institutions due to appointment availability access to services limited by no internet cost and poor customer service some respondents avoided situations because of past unfair treatment including going to public places or events contacting healthcare professionals contacting services such as police and lawyers applying for jobs and sporting or recreational activities respondents felt that a community place to feel culturally safe cultural events and activities access to culturally safe employment and training opportunities and access to services such as an aboriginal community controlled health organisation would be useful in dealing with feelings of being unfairly treated when asked specifically about a range of facilities and services that were important 70 of respondents indicated the importance of aboriginal services provided within mainstream services or aboriginal controlled service but indicated less availability with 55 and 56 respectively a gathering place was important to 53 of respondents education and training support such as subsidies and grants and homework assistance and tutoring were valued by survey respondents along with opportunities for children to participate in aboriginal and torres strait islander arts and language housing conditions as shown in table 7 most respondents indicated that their rental property felt like home and indicated that their house was at least adequate for their needs most households had a range of common appliances with 21 indicating their appliances were not in good working order only 40 of respondents had a computer and 46 had internet connection aspirations when asked their aspirations for the future most respondents indicated that improving their health and wellbeing and strengthening relationships with family and friends was moderately important important or very important discussion this paper presents the results of a survey conducted to understand the sewb needs and aspirations of aboriginal and torres strait islander peoples living in social housing in victoria australia this study is a first in addressing a gap in understanding the contribution of various domains and determinants to sewb in this population an important finding from the study was the identification of a set of strengths by respondents strengths the strong sense of identity connection to family and culture expressed by most survey respondents are key elements of sewb these strengths reflect the resilience of aboriginal and torres strait islander peoples to not only survive changing environments over many thousands of years but also the ongoing impacts of colonialism genocide and racism these strengths can be cultivated by addressing aspirations for enhanced family community and cultural connections opportunities for greater community and cultural engagement both for children through cultural learning experiences and more broadly through community events and safe places to meet such as gathering places were identified in the survey these domains can also inform strengthsbased approaches to improving sewb 15 in line with contemporary approaches in aboriginal and torres strait islander communities 2930 health burden coexisting with the strengths were a set of physical and mental health challenges the prevalence of health issues was frequently higher among respondents than in the general population of aboriginal and torres strait islander peoples and the general australian population for example a doctors diagnosis of asthma was higher among respondents than reported by the broader aboriginal and torres strait islander population in australia 31 smoking was reported by 41 of survey respondents which is similar to the broader aboriginal and torres strait islander population aged over 15 in australia 32 but higher than the 11 rate for all australians over 18 33 most households included a person with a disability which is more than the 36 of australian households 34 a study of south australian general population norms indicate a mean selfrated health score of 79 on the eq5d5 l instrument approximately 9 points higher than our survey group 35 norms for aboriginal and torres strait islander populations and the broader australian population are not available the prevalence of back pain among respondents is higher than in the broader aboriginal and torres strait islander population aged 2 years and older 31 these differences reflect the older age of study participants and the provision of social housing to support people experiencing ill health and disability the survey revealed high levels of depression and anxiety in aboriginal peoples living in social housing compared to the broader aboriginal and torres strait islander population with 13 and 17 respectively 32 the difference again reflects both the age range of participants and their prioritisation for social housing due to complex needs the rate of reported high or very high levels of psychological distress by survey respondents is comparable to the 31 of the broader aboriginal and torres strait islander population not living in remote locations aged over 18 31 but higher than the general australian population aged over 16 experiencing high or very high levels as measured with the k10 36 this analysis indicates that at least a quarter of aboriginal peoples living in social housing experience physical mental and emotional conditions at higher rates than the general australian population and at times higher than the broader aboriginal and torres strait islander population this is reflected in at least a third of respondents feeling only a little or not at all in control of their life being able to solve problems and make the right choices disrupted connections to mind and body can lead to poorer sewb 11 and hinder engagement in community cultural activities and broader social employment and training opportunities the aspiration most frequently reported by respondents to improve their health and wellbeing reflects the desire to address these disrupted connections addressing physical and mental health barriers to engagement in their local communities and broader society is not only a need but a priority of aboriginal peoples living in social housing social determinants additional challenges to sewb arise from social determinants year 12 or certificate iii qualification completion rates among respondents were less than the broader aboriginal and torres strait islander population aged 20 and over in australia 37 reflecting both the younger age range of participants and the complex needs of those living in social housing similarly the rate of paid employment among respondents was less than that of aboriginal and torres strait islander peoples in major cities and in inner regional areas 38 high rates of unemployment and inability to work are reflected in more respondents running out of money for food clothing or bills than the broader aboriginal and torres strait islander population 39 these disparities reflect barriers to employment including education level ill health disability financial stress and availability of transport many respondents faced difficulties in accessing services such as social security and health and engaging with employment and education due to past negative experiences the lack of respect for the culture or the rights of aboriginal and torres strait islander peoples felt by respondents along with reports of unfair treatment are significant deterrents to engaging with the broader community and essential services while persistent racism and inequity are not quickly or easily addressed in australia the need for culturally safe and appropriate pathways into health education employment and other key community supports are essential in enabling aboriginal peoples living in social housing to address their needs and realise their aspirations while most survey respondents held aspirations for greater engagement in education training and employment less than half the respondents felt there were opportunities to develop skills in the community or further their education to improve their employment prospects this may explain why more respondents aspire to improve their financial situation over education or employment as education and employment may not be seen as easily negotiable pathways to improving finances respondents identified the need for further support in the form of subsidies to make training and education more affordable for this population and tutoring to assist school children or coaching for adults strengths based approaches most aboriginal peoples living in social housing were happy interested and satisfied with life and have found ways to build identity and important connections to family and community that can enhance sewb despite high rates of health issues psychosocial and financial distress positive psychology has shown that distress and wellbeing can coexist 40 and resilience research has demonstrated people can grow and develop as a result of adversity 41 future quantitative research could explore through regression analysis the association between strengths and challenges and their respective contribution to wellbeing in this population this type of research could inform a move beyond deficit based approaches to strength based approaches to promoting wellbeing examining various strengthbased approaches in aboriginal and torres strait islander populations including those living in social housing will inform whether these approaches are appropriate and effective in improving sewb the evaluation of an ahv led coaching strengths based wellbeing intervention informed by the findings of this survey will be published once complete and contribute to understanding this approach 15 limitations the main limitation of the study is the low survey response rate among ahv tenancy holders this response rate is comparable to response rates in ahvs own renter satisfaction survey which returned response rates of between 17 and 27 in recent years 42 43 44 similar low response rates have been reported in research with social housing tenants internationally 45 46 47 the low survey response rate can also be understood in the context of being conducted through repeated and lengthy covid19 pandemic lockdowns which added to the stressors for aboriginal peoples living in social housing survey respondents were significantly older than nonsurvey participants as the survey was restricted to those 16 years and above despite the low response rate and the age difference the survey sample was found to be largely representative of the ahv tenancy population on several key dimensions related to tenancy stress therefore the study findings are likely to be generalisable to the broader population of people living in ahv social housing these findings are also likely to be indicative of common issues faced by aboriginal and torres strait islander peoples in other social housing settings however similar research examining the sewb of aboriginal and torres strait islander peoples in a range of other community and public housing settings in australia is needed to understand whether these findings are shared across the broader population selfselection bias may affect the results those with more time resources and experiencing fewer stressors are more likely to respond potentially presenting a more positive picture of social and emotional wellbeing than experienced by nonrespondents the greater proportion of survey respondents from single or single shared household types with fewer caring responsibilities or dependents supports this the surveys length and complexity may have also deterred some individuals from participating conclusions this study has begun to address a gap in understanding the sewb needs and aspirations of aboriginal peoples living in social housing in victoria australia strong connections to identity family and culture were found to coexist along with disrupted connections to mind body and community the strength of these connections along with challenges in accessing and engaging with employment education and community resources can influence sewb the study highlights the need and aspirations for culturally safe and appropriate pathways to services and community resources for aboriginal and torres strait islander peoples living in social housing to strengthen connections to body mind emotions and community targeted codesigned strengthsbased programs informed by research could play a role in supporting individuals and communities to enhance connections to key domains of sewb data availability all data generated or analysed during this study are included in this published article and its supplementary information files abbreviations supplementary material 1 supplementary material 2 author contributions ab contributed to the study development and drafted the initial manuscript which was based on the work of ga yp rr jn sb kh and lw who designed the study and compiled the grant submission th fm and ab completed the data analysis gg ds sd fm have all contributed to the design of the study all authors read and approved the final manuscript declarations competing interests the authors declare no competing interests

background little is known about the wellbeing and aspirations of aboriginal and torres strait islander peoples living in social housing aboriginal and torres strait islander peoples living in social housing face common social housing challenges of low income higher incidence of mental health issues and poorer health along with specific challenges due to the impacts of colonisation and its ongoing manifestations in racism and inequity a greater understanding of social and emotional wellbeing needs and aspirations is essential in informing the provision of appropriate support methods surveys of social and emotional wellbeing sewb were completed by 95 aboriginal people aged 16 years and older living in aboriginal housing victoria social housing in 2021 the survey addressed a range of domains reflecting social and emotional wellbeing as defined by aboriginal and torres strait islander peoplesmost respondents demonstrated a strong sense of identity and connection to family however 26 reported having 6 or more health conditions ill health and disability were reported to be employment barriers for almost a third of people 32 improving health and wellbeing 78 was the most cited aspiration experiences of racism and ill health influenced engagement with organisations and correspondingly education and employmentstrong connections to identity family and culture in aboriginal peoples living in social housing coexist along with disrupted connections to mind body and community culturally safe and appropriate pathways to community services and facilities can enhance these connections research aimed at evaluating the impact of strengthsbased interventions that focus on existing strong connections will be important in understanding whether this approach is effective in improving sewb in this population trial registration this trial was retrospectively registered with the isrctn register on the 12721 with the study idisrctn33665735

introduction though it is well known that mens penises come in many shapes and sizes larger penis size has been equated with a symbol of power fertility stamina masculinity and social status it is no surprise that researchers have found most men are unsatisfied with their penis size wishing it were larger others have found that many men seek penile augmentation surgery despite the fact that they have normal penis sizes using data from the body image survey lever et al reported on 25594 heterosexual men and 26437 heterosexual women on attitudes and perceptions of penis size they found even though 66 of men rated their penis size as average 46 of these same men desired a larger penis and 45 of all men desired a larger penis further less than one percent of men desired a smaller penis in addition lever et al also found mens penis size was significantly related to satisfaction with other body traits including ones face overall physical attractiveness and comfort in a swimsuit despite the fact that many men were unsatisfied with their penises lever et al reported that 84 of women were very satisfied with the size of their partners penis size and similar findings have been documented elsewhere while researchers have attempted to assess the average penis size for various groups of men there remains little research on how penis size effects an individuals sense of satisfaction self and other sociosexual outcomes research on the effectiveness of condoms to prevent hivsti transmission is vast and there is a large body of research highlighting the roles that both substance use and condom use skills can play in condom efficacy building from these findings some researchers have argued penis size too can impact correct and consistent condom use and hivsti transmission herbenick and reece have highlighted how there are only a limited range of condom sizes available with a majority of manufacturers producing condoms to fit an average penis researchers have suggested that experiences with the fit and feel of condoms and condom breakage and slippage reduce consistent use by some men as a result this has been hypothesized to inadvertently lead to greater incidence of hiv and stis with few exceptions there has been surprisingly little research among men who have sex with men assessing the association between penis size and socialsexual health drummond and filiault argued penis size may be of increased importance to some gay men due to the erotic nature of the body in many gay cultures and the double presence of the penis in a gay relationship or sexual encounter in addition they proposed that the importance of penis size may be exacerbated by the overall importance of the body in dominant gay male culture as such msm may be a particularly wellpositioned group compared with heterosexual men for such inquiry as they have had greater and more intimate exposure to other mens penises during the course of their lifetimes and thus have potentially had more opportunities to compare their penises to those of others as a result they may have a more accurate assessment of what average may be furthermore because us msm continue to comprise a disproportionate number of new hiv transmissions active hivaids cases and sti incidence and because penis size has been related to correct and consistent condom use msm may be a particularly vital group in which to closely assess the relationship between penis size and condom use in assessing the association between condom use and penis size among gay and bisexual men yet another layer to consider is the potential role that penis size may play in mens sexual positioning with their partners because of the value placed on larger penis size are men with larger penises more likely to assume the anal insertive role in contrast a larger penis size may make penetrative anal sex more difficult and uncomfortable in this case are men with larger penises less likely to assume the insertive role to our knowledge no researchers have investigated this though this connection may play a considerable role in condom use condom breakageslippage and the transmission of hiv and stis current study drawing from a diverse sample of msm these analyses sought to explore four questions first to what extent is perceived penis size associated with penis size satisfaction second understanding that condoms are often limited to a narrow range of available sizes to what extent is perceived penis size associated with condom use hiv and stis third to what extent is perceived penis size associated with mens sexual positioning finally to what extent is perceived penis size associated with psychosocial outcomes though the term sexual health encompasses a diverse range of physical spiritual social and psychological constructs as they relate to sexuality this analysis used the term sexual health in operationalizing its broad exploration the four aforementioned research questions certainly this analysis did not address all aspects of sexual health however its themes were intimately concerned with the associations between perceived penis size and a variety of healthrelated outcomes thus we believe our manuscript captures the spirit of sexual health method participants and procedure a crosssectional streetintercept method was adapted to survey 1065 gay and bisexual men at a series of gay lesbian and bisexual community events in new york city in the fall of 2006 through the sex and love study version 50 this approach to collecting data has been used in numerous studies including those focused on glb persons and has been shown to provide data that are comparable to those obtained from other more methodologically rigorous approaches such as timespace sampling at both twoday long community events the research team hosted a booth and a member of the research team actively approached each person who passed the booth potential participants were provided with information about the project and offered the opportunity to participate the response rate was high with 830 of those approached consenting the survey required 1520 minutes to complete andto promote confidentialityparticipants were handed the survey on a clipboard so that they could step away from others to complete the questionnaire privately upon completion participants deposited their own survey into a secure box at the booth as an incentive those who completed the survey were given a voucher for free admission to a movie survey data were entered into an spss database and checkedverified by project staff for accuracy table i reports characteristics of the sample the sample was diverse with ages ranging from 18 to 90 and 42 being persons of color most men identified as gay 94 as bisexual and the remainder as queer or straight most men were hiv negative 125 were hiv positive and 99 of men were never tested measures demographicsparticipants were asked to indicate their age sexual identity education and race and ethnicity response categories to race and ethnicity included african american asianpacific islander europeanwhite hispaniclatino and other specify men also indicated their hiv status perceived penis size and satisfactionin evaluating the association between perceived penis size and variables such as penis satisfaction lever et als operationalization of penis size was adapted men were asked do you consider your penis size to be with response categories below average average above average and way above average for this analysis men indicating above average and way above average were collapsed into a single category as to preserve statistical power and limit the use of degrees of freedom in χ 2 analyses men also indicated how often they lied to others about their penis size and how satisfied they were with their penis sexuality and sexual healthparticipants indicated if they had experienced a variety of stis ever in their lives and in the last year in addition men indicated if they had recently engaged in anal sex without condoms with nonmain sex partners separately for partners of the same hiv status and partners whose status was discordant response choices were dichotomous men also indicated the number of nonmain hiv seroconcordant and serodiscordant male partners they had sex with in the last 90 days finally men indicated their preferred sexual positioningrole this was trichotomized for the purposes of this analysis psychosocial well being and adjustmentpsychosocial well being and adjustment were operationalized using three scales the preventionpromotion scale was adapted from the original 18item measure to a 16item five point likert type scale the two excluded items were ones pertaining to school the preventionpromotion scale has two subscales the 8items that comprise the prevention aspects of the scale measured the extent individuals were focused on preventing negative events from happening in their lives α 75 the 8items that comprise the promotion aspects of the scale measured the extent individuals were focused on positive aspects of their future α 84 the gayrelated stigma scale is a 10item likerttype scale assessing stigma and negative consequences resulting from disclosure of ones sexual identity α 90 frost et al adapted the gayrelated stigma scale from the hiv stigma scale finally the gay life satisfaction scale was derived from an adapted version of the life satisfaction index this measure consisted of eight items five of which were positively worded and three items that were negatively phrased participants were instructed to respond to the items on a 4point likert scale and the negatively phrased items were reverse scored α 75 see appendix 1 analytic plan where appropriate chisquare and anova f tests were conducted to supplement chisquare tests and facilitate interpretation in cases involving two ordinal variables goodmankruskal gamma tests were performed as a posthoc for anova bonferroni tests were used for group comparisons as cell sizes were too small for traditional chisquare analyses fishers exact p tests were used to assess group differences in the prevalence of stis results perceived penis size in relation to penis satisfaction table i reports univariate characteristics of the sample in total 69 of men felt their penis was below average 539 felt their penis was average and 355 felt their penis was above average perceived penis size was positively related to penis size satisfaction such that 792 of men with below average penises wished their penis were larger compared to 405 of men with average penises and 147 of men with above average penises χ 2 138 p 001 γ 66 in addition perceived penis size was inversely related to lying about penis size such that 452 of men with below average penises had lied to others about their size compared to 386 of men with average penises and 301 of men with above average penises χ 2 999 p 01 γ 19 further lying about penis size was inversely related with size satisfaction such that 482 of men who wished their penis was bigger had lied to others about its size compared to 288 of men who did not wish their penis was bigger but had lied to others about its size χ 2 373 p 001 γ 39 perceived penis size in relation to condom use hiv and stis table ii reports bivariate associations between perceived penis size and sexually transmitted infections perceived penis size was not related to recent condom use neither with hiv seroconcordant nor hiv serodiscordant partners in addition perceived penis size was not significantly related to mens frequency of sex partners their hiv status or diagnoses of hepatitis b hepatitis c syphilis or crabsscabieslice it was however related to recent infectionsoutbreaks of viral skintoskin stis analgenital warts and analgenital herpes men with above average penises were significantly more likely than men with average and below average penises to report recent genital warts in addition men with above average penises were significantly more likely than men with average sized penises to report genital herpes fishers exact ps ≤ 05 finally men with above average penises were significantly more likely than men with average size penises to report having ever been infected with gonorrheachlamydiaurinary tract infection fishers exact p 001 perceived penis size and sexual positioning table iii reports the bivariate association between perceived penis size and mens sexual positioning perceived penis size was significantly related to sexual positioning men with below average penises were more likely to identify as a bottom men with average penises were more likely to identify as versatile and men with above average penises were more likely to identify as a top χ 2 197 p 001 γ 20 perceived penis size and psychosocial outcomes table iv reports on the bivariate association between perceived penis size and measures of sociopsychological well being on all three psychosocial outcomes men with below average penises fared significantly poorer than other men men with below average penises were significantly lower than men with average and above average penises on gay life satisfaction 953 p 001 men with below average penises were significantly lower than men with above average penises on life promotion 457 p 01 in addition men with below average penises were higher than men with average penises on gayrelated stigma 319 p 05 and higher than men with average and above average penises on life prevention 385 p 05 discussion historically the size of ones penis has been equated as symbol of power masculinity social status fertility and stamina to date the penis connection to masculinity and virility is continually perpetuated throughout popular media thus it is not surprising researchers have found many men are unsatisfied or feel shame about their penis size to that end a growing body of research has intimated a link between penis size and socialsexual health outcomes though there has been surprisingly little research with msm this analysis explored four research questions each assessing the connection between perceived penis size and sociosexual health outcomes though most of the men indicated their penis sizes were average many fell outside this norm either indicating a below average or above average perceived penis size further perceived penis size was inversely related to penis satisfaction and positively related to lying to others about the size of ones own penis these data provide further evidence of the real sociallyscripted cultural pressures msm may feel about their penis size comparing these results with a sample of heterosexual men from the body image survey fewer men in our sample classified their penises as below average or average meanwhile a larger portion of men from the sex and love study classified their penises as above average this is not to suggest msm may actually have larger penises than other men but rather this may be an indication that msm because of the intimate nature of exposure they have had with other mens penises via sexual encounters have a more accurate assessment of how their penis may contrast with other men and thus more positive feelings about its size nevertheless it is not surprising that far more men rated their penis size as above average compared to below average researchers who investigated similar effects about body image have attributed such a bias to positive illusions in contrast this might be an indication that as a result of increased focus on the body within mainstream gay cultures msm may feel pressured to inflate their estimates thus resulting in additional selfreporting of above average penis sizes in total these data highlight the need for a comprehensive assessment of the association between perceived penis size and satisfaction in a diverse sample of men that includes msm and heterosexuals in terms of sexual health outcomes findings were mixed perceived penis size was not related to frequency of partners hiv status or condom use in recent years condom manufactures have made concerted efforts to advertise a wider range of condom sizes this wider range of available sizes may be impacting condom use such that men who fall above or below the average condom size are more easily able to find condoms they believe will fit them this may be particularly salient for our sample of men from new york city where there exists a vast range of retail stores that sell a wide variety of condoms and are open around the clock future research might consider such an analysis among rural populations where access there may be reduced access to such a wide range of available condom sizes nevertheless this does not speak to the issue of condom slippage and breakage though our data did not capture experiences of condom slippage and breakage other researchers have suggested this may play a significant role in the transmission of stis particularly for men with above or below average penis sizes in the present analysis men with above average penises reported significantly higher incidence of viral skintoskin stis specifically hsv2 and hpv in essence although when compared with other men men with above average penises reported similar rates of condom use and statistically similar numbers of sex partners improper condom fit breakage or irritation may be exposing some men to skintoskin stis this is striking given that reported rates of condom use were consistent regardless of mens reported penis size further it is unsurprising that penis size was unrelated to nonskintoskin viral stis such as hepatitis b hepatitis c or hiv or pubic licescabies nevertheless these postulations may not adequately explain the increased incidence of some bacterial stis among men with above average penises and the nonsignificant association between syphilis and perceived penis size in all these data support previous research having associated penis size with sti transmission however more research is needed before definitive conclusions can be drawn perceived penis size also played a role in sexual positioning whereby men with smaller penises were more likely to identify as bottoms and men with above average penises were more likely to identify as tops the direction of this relationship further supports notions of the ingrained social value of having a large penis and the presumed masculine penetrative role these men are sociallyand sexuallyscripted to enact these data beg the question to what extent are men with below average penises being sociallysexuallyscripted into anal receptive roles does their having a smaller penis devalue these mens sexual potential sociallycoercing them into sexual roles they may not have otherwise assumed though our data cannot answer these questions it is striking that men with below average penises fared significantly worse on three measures of psychosocial adjustment certainly a variety of factors may also be playing a role in these associations but the strength and consistent direction of the relationships indicate a need to better understand the individuallevel consequences of living in a peniscentered size matters society as a word of caution several limitations should be addressed clearly these data do not generalize to all msm as this sample was limited to those who attended largescale glb events in new york city furthermore as these analyses drew from crosssectional data causality between variables should not be inferred nor do these analyses rule out the potential for confounding effects from other variables not assessed this sample does however give a very comprehensive picture about the types of individuals that attend large scale glb events and comprise a considerable portion of the gay bisexual and msm communities in new york city although efforts were taken to ensure confidentiality there was potential for biased responses due to social desirability in the reporting of sensitive information as with all social research these factors must be considered when evaluating the findings the survey instrument used for this analysis assessed a broad range of variables related to socialpsychological and sexual health such an instrument helps provide a general perspective about a variety of characteristics however it has its limitations consistent with the brief streetintercept survey method many of the questions on this survey were quantitative and closeended additional qualitative research is necessary to better capture the full range of experiences although a wide range of stis were assessed in this analysis gonorrhea chlamydia and urinary tract infections were captured using a single indicator our analysis found men with above average penises were more likely to report having been diagnosed with gonorrheachlamydiaurinary tract infections yet we are unable to disentangle which of the three if any might have been more common finally in an effort to increase response rates for questions on penis size men were not asked to report a numeric measurement but rather select from a nuanced range of values our use of a nonmetric scale to capture penis size reduces some precision however a numeric measure is still subject to selfreport biases as not all men have actually measured their penis and those who have may not use identical levels of precision though it may not be a topic well explored in academic literature perceptions of ones penis size were clearly and consistently associated with a variety of psychosocial and sexual health outcomes among the men sampled for this analysis these data highlight the need to provide comprehensive sexual health education that is inclusive of the varying physical and psychosocial needs that men with differing sized penises may require if indeed msm with above average penises are more likely to assume the anal insertive role then it is important for them to wear sizedtofit condoms and use sufficient amounts of lubricant as not to injure their partners nor increase their risk of hiv or sti transmission thus it is essential to improve access to sizedtofit condoms in contrast if msm who perceive themselves to have below average penises are more likely to assume the anal receptive role and to fare significantly worse on psychosocial measures then it is essential to develop health education programs that dualistically address the hiv sti and other health risks that accompany anal receptive sex and that also focus on improving psychosocial well being finally these data highlight the need to challenge the culturally ingrained notion that bigger is better as the social consequences of these messages may have lasting negative psychosocial and sexual health effects on the individuals receiving them table iv perceived penis size and sociopsychological well being the conditions of my life as a gaybi person are just as good as any one elses being gaybi is a difficult life experience i will be able to get all the important things i want in my life as a gaybi person my life as a gaybi person could be happier i am satisfied with my life as a gaybi person

larger penis size has been equated with a symbol of power stamina masculinity and social status yet there has been little research among men who have sex with men assessing the association between penis size and socialsexual health survey data from a diverse sample of 1065 men who have sex with men were used to explore the association between perceived penis size and a variety of psychosocial outcomes seven percent of men felt their penis was below average 539 average and 355 above average penis size was positively related to satisfaction with size and inversely related to lying about penis size all p 01 size was unrelated to condom use frequency of sex partners hiv status or recent diagnoses of hbv hcv gonorrheachlamydia urinary tract infections and syphilis men with above average penises were more likely to report hpv and hsv2 fishers exact p ≤ 05 men with below average penises were significantly more likely to identify as bottoms anal receptive and men with above average penises were significantly more likely to identify as tops anal insertive finally men with below average penises fared significantly worse than other men on three measures of psychosocial adjustment though most men felt their penis size was average many fell outside this norm the disproportionate number of viral skintoskin stis hsv2 and hpv suggest size may play a role in condom slippagebreakage further size played a significant role in sexual positioning and psychosocial adjustment these data highlight the need to better understand the real individuallevel consequences of living in a peniscentered society

target by 2020 90 of all individuals living with hiv should know their hiv status 90 of all individuals with diagnosed hiv infection should receive sustained antiretroviral therapy and 90 of all individuals receiving antiretroviral therapy should have viral suppression by 2030 the aids epidemic will no longer be a public health threat if these three targets are achieved 2 the key population are those who have a high risk of acquiring or transmitting hiv global studies have shown that key populations are 1322 times more likely to be infected with hiv than the general population 3 the key population includes female sex workers and men who have sex with men transgender 4 fsws and msmtg are 1314 times more likely to be infected with hiv than the general population 3 who recommended an integrated biological and behavioural surveillance survey to monitor hiv prevalence and risk behaviours among key populations in the late 1990s ibbs was started by the government of nepal as part of a response plan against an hivaids epidemic 5 hiv testing and counselling is the entry point for hiv care services in nepal and is provided free of cost to all htc is a critical intervention in achieving the first 90 that is people why dont key populations access hiv testing and counselling centres in nepal findings based on national surveillance survey rachana shrestha 1 sairu philip 2 hemant deepak shewade 3 bir rawal 4 keshab deuba 56 to cite shrestha r philip s shewade hd et al why dont key populations access hiv testing and counselling centres in nepal findings based on national surveillance survey bmj open 20177e017408 doi101136 bmjopen2017017408 ► prepublication history and additional material for this paper are available online to view these files please visit the journal online open access figure 1 study districts included in the integrated biological and behavioural surveillance survey 2012 nepal fsw female sex workers msmtg men who have sex with mentransgender living with hiv should know their hiv status though the first step is crucial in identifying people living with hiv the retention in care of plhiv in the second 90 and third 90 is equally necessary to maximise the treatment and prevention benefits of antiretroviral therapy 6 7 national consolidated guidelines for preventing and treating hiv in nepal had recommended various approaches for maximising hiv testing in facilityand communitybased settings 4 5 different surveillance surveys conducted in nepal found that the nonutilisation of htc was low around 50 in fsws and msmtg 8 there was a substantial decline in the proportion of fsws visiting htc in 2016 compared with 2012 as revealed by ibbs 2016 9 among fsws a decreasing trend in hiv prevalence was accompanied by an increasing trend in lack of comprehensive knowledge regarding hiv 9 10 the unaids target of 90 assessment of hiv status by 2020 might not be reached in nepal unless factors associated with nonutilisation of htc are identified and addressed 2 11 12 psychosocial variables like distressdepression were included only in the ibbs 2012 survey and were found to be high in the key population studied 10 13 14 different studies demonstrate that the psychosocial problems increase the likelihood of hivrelated risk behaviours among fsws and msmtg in nepal 15 16 studies conducted outside of nepal among key populations found that psychosocial and structural factors not only increase their risk behaviours but also lower the uptake of behavioural interventions 17 18 19 the identification of effects of psychosocial and structural factors in the uptake of htc would help us to improve existing challenges of reaching key populations in nepal however such evidence is very limited in nepal therefore using the ibbs 2012 data we aimed to determine the demographic behavioural psychosocial and structural risk factors associated with nonutilisation of htc in the last year by fsws and msmtg in nepal methods study design this study was a crosssectional study involving secondary data of fsws and msmtg collected from the ibbs survey of 2012 in nepal setting nepal with a population of 27 million is a lowincome beautiful landlocked country in southeast asia 20 htc in nepal in nepal htc is the entry point for hiv prevention and treatment services the primary aim of which is to identify people living with hiv and link them to treatment it is voluntary and provided free of cost health facilitators should maintain confidentiality and obtain informed consent during pretest and posttest counselling according to national guidelines key populations are expected to visit htc every 612 months 5 besides that communitybased interventions are also prioritised in which peer educators and outreach workers are mobilised in the community peer educators are volunteers who convey crucial information to key populations in informal and formal settings they also distribute condoms safe needlessyringes or make them aware about available treatment care and support services ibbs 2012 survey nepal the national centre for aids and std control nepal conducted two separate crosssectional ibbs surveys between september and november 2012 for fsws and msmtg respectively fsws were defined as women aged 16 years and above reporting to have been paid in cash or kind for sex with a male within the last 6 months msmtg were defined as men aged 16 years or above who have had sexual relations with another male in the 12 months preceding the survey 7 a survey among fsws was conducted in 22 terai highway districts and for msmtg in three districts of kathmandu valley figure 1 study population and sampling the fsws were recruited using twostage cluster sampling stage one was the selection of clusters and stage two was the random selection of an equal number of participants from each selected cluster to ensure a on may 9 2024 by guest protected by copyright bmj open first published as 101136bmjopen2017017408 on 28 december 2017 downloaded from open access selfweighted sample a cluster was defined as having at least 30 sex workers in that area those with fewer than 30 sex workers were merged with nearby locations to form a cluster to identify clusters mapping was performed with the support of local nongovernmental organisations to determine areas where sex work is common and noting the estimated number of possible survey participants in each area seventy clusters out of a total of 401 clusters were selected based on probability proportionate to size the msm were recruited using respondentdriven sampling 20 in three districts of kathmandu valley to begin with a total of eight msmtg were recruited as seeds those seeds were informed about survey protocols and procedures and were encouraged to randomly recruit other eligible individuals from their social networks to participate in the survey these initial seeds were provided with three coupons to pass to their peers who were eligible to participate in the survey detailed methodology and sampling strategies for ibbs surveys have been described previously 10 1315 data variables for the present study the ibbs survey included information on behavioural factors like uptake of interventions for hiv demographic behavioural psychosocial and structural variables 10 13 14 structural factors included environmental context conditions which were outside the control of the individual but which could influence hisher perceptions behaviour and health 21 psychosocial variables were assessed using the social support questionnaire short form and the centre for epidemiological studies depression scale respectively the cesd tool showed high reliability and validity in assessing depression in diverse groups such as plhiv women and msm with cronbachs α≥085 and comparative fit indices more than 090 22 the cesd is an extensively normed and validated tool 23 similarly the reliability and construct validity of the ssqs has been reported as high in different studies 24 25 a median score of 5 in thessqs scale was interpreted as dissatisfied with available social support cesd scores of 1621 and ≥22 were classified as distress and depression respectively we also assessed suicidality under psychosocialrelated variables prevalence of demographic behavioural psychosocial and structural factors is summarised in supplementary webonly tables 1 and 2 a selfreported visit to an htc facility in the past year by fsws and msmtg was chosen as the outcome variable the outcome variable was assessed by asking have you visited any htc centres in the last 12 months in addition to reasons above discussion on safe injecting behaviour was also one of the selfreported reasons among people who inject drugs for visiting htc the independent variables selected in this study have been described in online supplementary webonly box 1 analysis and statistics data analysis was done separately for fsws and msmtg data were analysed using stata categorical variables were described using frequency and proportions the unadjusted and adjusted analysis was performed separately for fsws and msmtg to assess the association of factors with the outcome variable all the rdsrelated descriptive outputs were adjusted to represent the structure of the study population which was based on information regarding who recruited whom and the relative size of the respondents network using the volzheckathorn estimator to assess the network size among msmtg the following question was asked how many other msmtg do you know who also know you well rdsadjusted values are presented in the supplementary material a convergence plot for outcome variables is also shown in the supplementary material adjustment for clustering of twostage cluster sampling was not required for fsw data as it was a selfweighted sample bivariate associations between each independent variable and nonutilisation of htc were calculated using a variance inflation factor after assessment for multicollinearity variables with a p value 02 in the bivariate analysis were included in the regression model adjusted prevalence ratios with 95 confidence intervals were calculated by fitting a poisson regression with robust variance estimates the variables included in the multivariate model for fsws were age group educational status condom use at last sex ever inject drugs ever participated in hiv awareness programme physical assault in last year forced sex in last year having dependents police detention in last 6 months stigma towards hiv and distressdepression the variables included in the apr for msmtg were age group condom use at last sex drinking alcohol ever participated in hiv awareness programme physical assault in last year forced sex in last year and discrimination in job and suicidal thought ever initially we used the logbinomial model to assess the association between independent and outcome variables of interest however the logbinomial model failed to converge to overcome the effects of failed convergence we used poisson regression with robust variance estimates as recommended by tyler et al 26 poisson regression with robust variance can be used as an alternative to logistic regression and also provides accurate estimates in the crosssectional study with a binary outcome of interest 27 we calculated the prevalence ratio because it was easier open access to interpret than the odds ratio we also assessed associations between outcome and independent variables via the poisson model using individualised rds weights ethical considerations ethics approval for the ibbs survey 2012 was given by the nepal health research council kathmandu nepal approval for the analysis of secondary data for this study was obtained in 2016 from the ethics advisory group the international unionagainst tuberculosis and lung disease paris france administrative approval was also received from ncasc and public health and environment research centre nepal waiver of informed consent was sought and approved by the ethics committee as this study involved analysis of secondary data results the ibbs survey 2012 included 610 fsws with a response rate of 889 the nonresponders were replaced by other randomly selected fsws of the same cluster the hiv prevalence was 1 among fsws the proportion of fsws in the age group 1619 was 139 the prevalence of nonutilisation of htc in last year was 54 among fsws more than half of fsws were married 24 of them were divorced or separated twothirds of fsws were literate the ibbs survey 2012 included 400 msmtg and we did not record nonresponse among msmtg because of the nature of the sampling technique that is study participants enrol the other possible participants in the study the hiv prevalence was 33 among msmtg the proportion of msmtg in the age group 1619 was 172 nonutilisation of htc in last year was 55 for msmtg the majority of msmtg were unmarried whereas very few of them were illiterate other characteristics of the fsws and msmtg are presented in online supplementary webonly tables 1 and 2 the factors associated with nonutilisation of htc in last year among fsws and msmtg are summarised in table 1 and table 2 respectively in the multivariable analysis the association between nonutilisation of htc and distressdepression remained significant fsws experiencing distress and depression were more likely not to use htc in the past year similarly fsws who were injecting drugs ever participated in hiv awareness programmes or had no dependents in the family were more likely not to use htc fsws who experienced forced sex in the last 12 months were also more likely not to use htc msmtg who were adolescents aged 1619 years and experienced physical assault were more likely not to use htc however msmtg who experienced forced sex were less likely not to use htc msmtg who did not use a condom during their last sex or participated in an hiv awareness programme were more likely not to use htc we also assessed the association between independent variables and outcome variable via a poisson model using individualised rds weights however not much variation was observed in the results of the weighted and unweighted analysis discussion in the ibbs 2012 survey in addition to individuallevel variables psychosocial and structural factors were added to the best of our knowledge this study is the first to explore the relation between psychosocial and structural factors with htc nonutilisation among fsws and msmtg in nepal the uptake of htc was low among msmtg in nepal which is consistent with the findings of studies conducted in assam and andra pradesh india zhejiang province china and bangkok thailand 28 29 30 31 our study also demonstrates a low level of uptake of htc among key population in nepal which is even lower among key population of manipur and nagaland in india 32 the current scenario suggests that the low uptake of htc among msmtg and fsws not only challenges timely identification and referring them for treatment to improve their health but also increases the risk of secondary transmission from hivinfected msmtg and fsws to their partners communitybased htc with different approaches that was found to be effective in increasing uptake of htc and linking people to hiv care among msmtg and fsws in other settings 33 needs to be evaluated in the context of nepal otherwise the 909090 targets prioritised to improve health and prevention of secondary hiv transmission will not be possible in nepal this study also found different risk factors for nonutilisation of htc in the last year among fsws and msmtg they were demographic late adolescents absence of dependent members behavioural injectable drug abuse and no condom use at last sex structural participation in hiv awareness programmes forced sex in last year physical assault in last year and psychosocial being distressed depressed psychosocial factors play an important role in health services utilisation 16 fsws who were distressed or had depression had a higher prevalence of nonutilisation of htc this could have resulted in disempowerment and resulted in not accessing htc services when needed 13 table 1 continued used alcohol and drugs to reduce stress and to help them cope with their work 17 34 a gambian study showed that women who experienced forced sex reported severe depression 35 a study conducted among fsws working outside of the capital city found a very high prevalence of depression and the experience of any form of violence was also common and associated with depression 36 currently there are no targeted programmes to address the mental health problems of fsws in nepal and the lack of laws that protect the rights of sex workers also exacerbates the experience of violence among them efforts to address violence and its consequences among fsws are essential in nepal otherwise it will be difficult to increase uptake of htc among them according to the ibbs survey of 2012 older msm tg were found to use condoms more often compared with younger msmtg similarly the median age of first sexual intercourse being 16 years and the fact that older adolescent msmtg did not significantly access htc are causes of concern 10 13 the risktaking behaviour in adolescents can compound their risk of acquiring hiv and therefore this group needs to be targeted in nepal the blanket approach to implementing 37 not visiting an htc facility was also associated with not using a condom during last sex among msmtg fsws who were injecting drugs were also less likely to use htc in the last 12 months our study findings are consistent with the study conducted among fsws in vietnam where unprotected sex and injecting drug use were associated with a lower likelihood of having a voluntary hiv test 38 the findings suggest that we are failing to reach those fsws who are at increased risk of hiv due to their dual risky behaviours such as unprotected sex or injecting drugs some factors affecting utilisation of htc by msmtg were different from those of fsws events like forced sex in the last year among fsw reduced the utilisation of htc among fsws among msmtg the experience of forced sex led to the utilisation of htc the difference might be due to the fact that msmtg are a more highly networked population than fsws 39 most of them are directly or indirectly associated with their community organisations which work for the rights of gender and sexuality minorities in nepal that may have resulted in msmtg seeking available services after experiencing sexual abuse participation in hiv awareness programmes by key populations has shown a decreasing trend over the open access years 10 13 participation as a risk factor for nonutilisation of htc for both fsws and msmtg is intriguing the activities which enlisted more participation were short duration events like condomaids day celebration compared with effective training methods like demonstration classes workshops and so on these aforementioned shortterm awareness activities might not affect the knowledge levels of fsws and msmtg about the importance of htc the other explanation for this could be the crosssectional nature of the data those who had visited htc in the last year might not have felt the need for attending hiv awareness programmes despite being limited by a crosssectional design the findings of this study bring out three significant policy implications first the intervention to address the burden of depression needs to be an integral part of programmes for fsws and msmtg at all levels second htc should be developed as an empowerment centre or training to improve the skills that help fsws and msmtg to tackle physical and sexual abuse third specific prevention programmes should be rolled out to reach adolescent fsws and msmtg and fsws who are practising dual risk behaviours such as inconsistent condom use or injecting drug use the htc centre should also consider the specific needs of adolescent fsws or msmtg our study adhered to strobe guidelines for conduct and reporting of the study 40 the findings are generalisable to fsws and msmtg of nepal as a standard sampling strategy was followed for the ibbs survey 10 1315 the present study had inherent limitations of analysing secondary data certain pertinent variables could not be included in the analysis due to missing data the limitations of the original survey like social desirability bias and recall bias due to the assessment of past exposures might have influenced the selfreported variables the crosssectional design may result in difficulties in ascertaining temporality between various factors studied and nonutilisation of htc conclusion to conclude psychosocial and structural factors are influencing the utilisation of hiv testing and counselling centres among fsws and msmtg in nepal in addition to focusing on these risk factors there is a need to improve htc to provide psychosocial support or to address the needs of specific adolescent fsws and msmtg or fsws who also inject drugs creative behaviour change and communication strategies or interventions to improve the skills to tackle physical and sexual abuse should be implemented to overcome the limitations of current programmes for key populations in nepal contributors rs sp hds and kd were involved in conception and design of the study all authors were involved in analysis and interpretation of data rs prepared the first draft and all authors were involved in critically reviewing the draft and approving the final draft for submission funding all the ibbs surveyrelated activities were funded by the global fund to fight aids tuberculosis and malaria this research received no specific grant from any funding agency in the public commercial or notforprofit sectors competing interests none declared provenance and peer review not commissioned externally peer reviewed data sharing statement data are available from the corresponding author and will be provided on request

objectives to assess the demographic behavioural psychosocial and structural factors associated with nonutilisation of hiv testing and counselling htc services by female sex workers fsws and men who have sex with mentransgender msmtg methods this study involved a crosssectional design we used the national surveillance survey data of 2012 which included 610 fsws and 400 msmtg recruited randomly from 22 and three districts of nepal respectively adjusted prevalence ratio apr and 95 confidence interval ci using modified poisson regression was used to assess and infer the association between outcome nonutilisation of htc in last year and independent variables results nonutilisation of htc in the last year was 54 for fsws and 55 for msmtg the significant factors for nonutilisation of htc among fsws were depression apr14 95 ci 11 to 16 injectable drug abuse ever apr14 95 ci 11 to 18 participation ever in hiv awareness programmes apr12 95 ci 10 to 14 experience of forced sex in previous year apr11 95 ci 10 to 13 and absence of dependents in the family apr11 95 ci 10 to 13 nonutilisation of htc among msmtg had significant association with age 1619 years apr14 95 ci 11 to 17 noncondom use apr12 95 ci 10 to 14 participation ever in hiv awareness programmes apr16 95 ci 13 to 20 physical assault in previous year apr18 95 ci 10 to 31 experience of forced sex in previous year apr05 95 ci 03 to 09 conclusion although limited by crosssectional design we found many programmatically relevant findings creative strategies should be envisaged for effective behavioural change communication to improve access to hiv testing psychosocial and structural interventions should be integrated with hiv prevention programmes to support key populations in accessing hiv testingglobally at the end of 2015 an estimated 367 million people were living with hiv of which 47 did not know their hiv status and hence were deprived of antiretroviral therapy and care 1 according to unaids 909090

introduction intimate partner violence is a major global health problem and human rights violation ipv consists of intentional and abusive attitudes in the form of physical sexual andor emotional offence and controlling behaviours within an intimate partnership 1 while ipv can take different forms maleperpetrated ipv is the most common form of violence against women 2 globally one in three everpartnered women reports experiencing some form of physical and or sexual violence in their lifetime with the strengths and limitations of this study open access who for the africa region recording the highest prevalence followed by the americas 3 the who multicountry study on vaw estimated that the prevalence of male ipv perpetration was 211 for physical violence only 117 for sexual violence only and 118 for both physical and sexual violence 4 reports from diverse social and cultural contexts have demonstrated that ipv perpetration begins early in the life course with most perpetrators reporting that they first engage in it during adolescence 5 ipv carries multiple wellestablished consequences for womens health and wellbeing with femicide being the most extreme form 6 7 ipv is associated with increased risk of sexually transmitted infections including hiv 8 9 severe depressive symptoms and substance use and abuse such as binge drinking 10 furthermore children born to women experiencing ipv are at higher risk of premature death poor health outcomes and emotional and behavioural problems later in life 11 experiencing ipv has been shown to affect women and girls social and economic empowerment 12 including decreased productivity at work loss of employment opportunities and other important social engagement 13 uganda has one of the highest burdens of ipv in the world and womens experiences of ipv have been the main focus of research on vaw in the country the 2014 ugandan demographic and health survey found that 47 of married women had experienced physical ipv in their lifetime with 29 reporting lifetime sexual ipv 14 slapping hitting and beating pregnant women were found to be common and have been shown to worsen during the course of pregnancy in northern uganda 15 16 furthermore the countrys hiv incidence has been found to correlate with the frequency and duration of exposure to ipv 17 while multiple intersecting factors drive male perpetration of vaw there is growing evidence linking ipv with food insecurity most often related to poverty 18 19 which is defined as a householdlevel economic and social condition of limited or uncertain access to adequate food 20 for example a crosssectional study in kampala slums found that extreme physical violence perpetration and experience of such violence was common among a convenience sample of young men and was found to correlate with reported hunger and alcohol consumption illicit drug use poor mental health status and parental neglect due to alcohol 21 in a report from south africa by gibbs et al economic indicators of food insecurity such as unemployment and low earnings in the past month were associated with ipv perpetration by men 22 a smallscale study from abidjan cote divoire revealed that women with severe forms of food insecurity were at higher risk of experiencing ipv 23 while studies from other regions such as nepal or the usa have established a significant relationship between food insecurity and both ipv perpetration and experiences among women few studies from subsaharan africa exist on this topic 24 25 according to the united nations food insecurity is increasing in uganda rising from 241 in 2006 to 41 in 2018 26 the ongoing covid19 crisis has contributed to this considerable increase in ugandan food insecurity and in line with predictions of the world bank and the world food programme is likely to continue to do so 27 28 likewise there is great concern that ipv is increasing across the world as a consequence of social isolation poverty and despair due to covid19related lockdowns social and financial hardships 29 male ipv perpetration against women is a complex multilevel social economic and structural problem one rooted in unequal gender norms and systems of power in most cultural settings a gendered order exists that favours stereotypically masculine mens dominance over women as well as over other more marginalised masculinities that do not live up to the norms of being a real man 30 ipv can thus be viewed both as a symptom of and a tool to achieve this type of hegemonic masculinity and power 31 being unable to provide food for ones self or household could be interpreted as failing to meet stereotypical masculine norms thereby forcing men to use alternative strategies to demonstrate their manhood 19 mental health issues which occur when concerns about food availability are accompanied by poor coping mechanisms such as alcohol consumption can further lead to ipv as demonstrated by hatcher et al in periurban south africa 19 furthermore the concept of patriarchal risk 32 can help to theoretically explain the cultural and societal dependence of women on male family members for food and protection and traditional gender roles are closely linked to all dimensions of food insecurity access availability stability and utilisation although women tend to have less control over the household budget they are often held responsible for feeding the family and blamed if they fail to provide food on the table leading to different harmful coping strategies such as transactional sex which in turn increases their risk of hiv 33 given the increasing reports of food insecurity in uganda 26 and the lack of existing literature in lowincome andmiddle income subsaharan african settings it is important to investigate the potential link between food insecurity and maleperpetrated ipv in the country the primary aims for the present study were to determine the prevalence of lifetime male ipv perpetration among a representative sample of males in two ugandan districts and to assess its association with food insecurity the secondary aim was to determine whether the strength of the association between food insecurity and male ipv perpetration is affected by sociodemographic factors and health risk behaviours in the urban semiurban and rural populations under study in central uganda the evidence gained through this study can help inform programmes and policies to prevent and better respond to ipv in uganda and beyond something that likely will be needed more than ever as we enter into the postpandemic era methods study design data were collected between may 2018 and july 2019 as part of a crosssectional baseline survey of a longitudinal open populationlevel cohort established by the africa medical and behavioural sciences organization to conduct population health surveillance in the wakiso and hoima districts of uganda in brief the ambso phs aims to generate evidencebased data in order to inform policy on the health status of the population through periodic monitoring of disease trends and determinants of health the cohort includes males and females aged 1380 years in the study communities and collects yearly data on sociodemographic factors violence including ipv noncommunicable diseases communicable diseases food and nutrition immunisation of children health risks and mental health the current study uses the baseline data with a focus on mens lifetime perpetration of ipv in the study communities study communities with a population of nearly 2 million wakiso district lies in the central region of uganda and surrounds parts of the capital kampala hoima district located in the bunyoro region of midwestern uganda has a smaller population of roughly 570 000 individuals the selection of these two districts was purposeful based on their common and diverse characteristics wakiso has a high migrant worker population and is known to be a hot spot for sex workers and men who have sex with men the discovery of oil in hoima and increasing mining activities attract migrant workers sex workers and fisher folkspopulations known to have high risk of hiv 34 each district was stratified into urban semiurban and rural areas residents in all urban and semiurban areas and those in a randomly selected rural community were included in the baseline survey study population and sampling the study population comprised of males aged 1380 years in the study communities a lower age limit of 13 years was considered because of the high prevalence of early sexual debut in uganda 35 this study sample was defined as males who reported ever having a sexual relationship in each study community the sampling frame included all households in each household all males aged 1380 years were considered potential participants data from the ugandan population census suggested that the total populations of male inhabitants in wakiso and hoima districts were 949 035 and 287 906 respectively 36 in determining the sample size the study population males aged 1380 years was estimated to be 65 of the total male population in each district that is 621 617 and 188 578 in wakiso and hoima respectively the ugandan dhs 40 estimate of male ipv perpetration 35 and the study population were entered into epin info statcalc tool to estimate the study sample a minimum sample of n738 was needed to estimate the association between food insecurity and ipv perpetration with 80 power at the α005 level to be eligible participants had to be able and willing to respond to the survey questions and to provide informed consent the full survey sample consisted of n2014 male participants who were recruited into the ambso phs cohort males who reported not ever having been in a sexual union and those who abstained from responding to questions on male ipv perpetration were excluded even though the individual response rate was 804 the final analysis sample was near double the estimated sample of n738 participants needed to estimate the association this 804 response rate is similar to that of a multicountry survey on male ipv perpetration in asia 4 a sensitivity analysis comparing the characteristics of those who responded to the ipv questions and those who did not respond is included in online supplemental appendix 1 the sensitivity analysis revealed that in comparison with those who responded to the ipv questions nonrespondents were more likely to be young christian and of lower educational level there was no significant difference in food insecurity among nonrespondents and respondents any observed differences did not affect the findings as the final sample was more than double the minimum estimated sample needed to establish an association procedures data were collected in the baseline using a structured questionnaire covering 10 domains sociodemographics first sex experience family planning practice marital status and practices food supply and food security ipv hiv testing services hiv care and treatment services prostate cancer and behaviour risk trained data collectors of the same sex as participants collected the data via open access facetoface interviews using tools translated into local languages in addition to these survey questions the phs collected 10 ml of venous blood samples that were used to determine the hiv and syphilis status of participants and aliquots stored for other future studies hiv status was determined following the ugandan ministry of health rapid test algorithm 37 and the rapid plasma regain serological test was used to determine syphilis status of the participants dependent variables the dependent variable was adapted from the who multicountry study on vaw 3 and defined as lifetime selfreported perpetration of physical andor sexual violence against an intimate partner following the approach used by fulu et al 4 the outcome was grouped into four independent and unordered categories no perpetration of physical andor sexual violence physical ipv perpetration only sexual ipv perpetration only and both physical and sexual ipv perpetration the no ipv perpetration category was used as the reference group referring to males reporting to never have perpetrated physical andor sexual violence against their intimate sexual partner the physical violence only category consisted of males reporting to have perpetrated one or more forms of physical violence but who had never used any sexual violence sexual violence only was coded using the same approach but referring to one or more forms of sexual violence males who reported to having perpetrated both physical and sexual violence in their lifetime were grouped into the physical and sexual violence category lifetime estimates were used in this study in order to capture all selfreports of ipv perpetration independent variables food insecurity the main independent variable was pastyear food insecurity assessed using an adapted version of the food insecurity experience scale questions 38 in which six selected items were used to evaluate the household food situation during the preceding 12 months in line with international definitions 39 negative responses to assessment questions such as no never only 1 or 2 months were coded as 0 while positive or affirmative responses such as yes always almost every month some months but not every month were coded as 1 all codes were summed to obtain a total score of up to 6 for food insecurity with higher scores indicating the extent of food insecurity as adapted from international approaches 39 participants were categorised into the following categories no food insecurity low food insecurity and high food insecurity due to the small proportion reporting high food insecurity low food insecurity and high food insecurity were merged during the modelling procedures in line with previous studies 19 that is comparing food insecurity against food security in line with previous studies sociodemographic and health risk behaviours other important independent variables included sociodemographic indicators such as study district age education level marital status religion and having living children health risk behaviours included number of lifetime sexual partners pastyear condom use use of illicit drugs alcohol consumption and male circumcision the choice of health risk behaviours was based on previous studies indicating number of sexual partners as well as condom use 40 41 42 and male circumcision 42 as risk factors for ipv statistical analysis we first conducted descriptive analyses to explore the distribution of variables and to identify outliers the analysis in this report was not weighted missing values for covariates were replaced using multiple imputation assuming random missingness pearsons χ 2 test and fishers exact test were used to compare proportions with α set at 5 next we performed bivariate multinomial logistic regression to determine the crude relative risk open access ratios and 95 cis of ipv perpetration in relation to the independent variables we followed the approach used by fulu et al 4 and used no ipv perpetration as the base outcome against which all other outcomes were compared assuming that the association of food insecurity is different for each typology of violence this type of regression produces rrrs which are the exponentiated coefficients of the regression and explain the relative effect of the independent variable on the outcomes using one of the outcomes as a base outcome a full model was built to explain the associated factors to ipv perpetration in relation to both food insecurity health risk behaviours and sociodemographic background the full model included all the variables from the bivariate analysis irrespective of significance levels that are theoretically known to be associated with ipv perpetration variables for the final adjusted model were selected through backward elimination using a maximum likelihood ratio test all analyses were conducted using stata v16 while microsoft office excel was used to design figures patient and public involvement the study team worked hand in hand with community health workers local community leaders and a communityresearch advisory structure to develop and clarify a common understanding of the aims of the populationbased survey the design and operational aspects as well as how results will be disseminated as part of this patient and public involvement effort a consensus was reached with the advisory committee on a plan to increase general public awareness of the study and health issues that were deemed areas of phs focus results sample characteristics table 3 shows the characteristics of the study participants the mean age of respondents was 34 years food insecurity was found to affect one in four men with 207 and 36 categorised as low versus high food insecurity respectively about onethird and 50 of men reported having had multiple sex partners and used alcohol in the past year respectively and approximately 6 tested positive for hiv prevalence of lifetime ipv perpetration open access figure 2 shows the prevalence of selfreported ipv perpetration across different age groups as can be seen the prevalence of physical violence only and both physical and sexual violence was highest among those aged 2534 years old compared with the other age groups with perpetration of sexual violence only being most commonly reported by young men and less common after age 34 years factors associated with ipv perpetration bivariate analysis in bivariate analysis foodinsecure participants had an rrr of 271 to have perpetrated both physical and sexual violence but no significantly higher risk to have perpetrated physical versus sexual violence only respectively compared with the youngest age group 1324 years young adult participants had an rrr of 259 for perpetrating physical violence only and 264 for both physical and sexual violence and the rrr for those aged 35 years was 216 for physical violence being married was associated with a lower relative risk of having perpetrated sexual violence only having living children and reporting no condom use were associated with perpetration of physical violence only reported use of illicit drugs during the preceding year was associated with perpetration of physical violence only and both physical and sexual violence there was no association between education level with ipv perpetration multivariable analysis table 6 illustrates the adjusted rrr for ipv perpetration in relation to food insecurity controlling open access for sociodemographic factors and health risk behaviours food insecurity remained significantly associated with selfreported perpetration of both physical and sexual violence in terms of independent health risk factors having two or more lifetime sexual partners also remained associated with perpetration of physical violence only and both physical and sexual violence any alcohol consumption remained associated with all typologies of ipv perpetration under study and illicit drug use remained associated with physical violence and both physical and sexual violence in terms of sociodemographics having living children remained associated with perpetration of physical violence only while being married appeared to be protective against perpetration of sexual violence only age and religion were not associated with any ipv perpetration in the adjusted model discussion the current study set out to explore the prevalence of lifetime male ipv perpetration and its association with food insecurity as well as sociodemographics and health risk behaviours in two ugandan districts we found that one in four men reported ever perpetrating any form of physical andor sexual violence against their intimate partners and 53 reported perpetrating both physical and sexual ipv pastyear food insecurity was associated with male perpetration of both physical and sexual violence after adjusting for age group religion number of lifetime sexual partners marital status having living children alcohol use and illicit drug use the prevalence of lifetime perpetration of ipv reported by this study is lower than that of other studies conducted in the region 19 43 44 obtaining accurate data on the true burden of vaw is a global concern due to underreporting 45 it is likely that community awareness about laws and litigations in place to prevent vaw may undermine truthful responses to ipv survey questions nonetheless a fair proportion of men in our survey did admit to ipv perpetration in these new demographic surveillance sites and first round of the assessments it is possible that the communities have not yet built sufficient trust with the survey teams to report very sensitive information and potential illegal behaviours comparing the prevalence estimates of this study with data from previous studies is therefore difficult mainly due to the existence of limited research in a subsaharan african context and the nonstandardised ways in which surveys have assessed male ipv perpetration for instance although the 2006 ugandan dhs 14 found that 40 of males perpetrated ipv this finding was solely based on reports of physical violence without taking into account sexual ipv perpetration another largescale study that focused on pastyear perpetration in the rakai district of uganda indicated a prevalence of 104 for physical violence and 31 for sexual violence 42 in the present study 193 of men reported ever slapping or pushing their intimate partners an estimate that is similar to other countries including ghana 43 and vietnam 46 but lower than those obtained by the international men and gender equality study in the democratic republic of congo and rwanda 44 in this prepandemic assessment one in four men reported to be food insecure and food insecurity was associated with almost three times the relative risk of having perpetrated both physical and sexual ipv our findings are consistent with results of a recent study from a periurban setting of south africa in which food insecurity doubled the odds of males perpetration of ipv 19 the open access results from our study align with findings from nepal 25 and the usa 24 that food insecurity was more common among married women who had experienced physical violence from their intimate sexual partners however the causal relationships are uncertain the world food programme expects the number of people who are food insecure to increase dramatically as a consequence of covid19related mobility restrictions and poverty potentially driving another 135 million people worldwide onto the brink of starvation similarly the un population fund warns of increases in ipv as a consequence of social isolation hopelessness and financial hardship 29 thus the prepandemic estimates presented in this study are expected to worsen and should serve as an important warning indicator for urgent mitigation efforts previous research indicates that the association between food insecurity and ipv perpetration may be driven by mental health problems such as anxiety and depression that arise from concerns about food availability related to poverty and unemployment 19 which are also expected to increase as a result of the current pandemic the influence of conservative gender norms is important whereby the inability of men to provide for their partners and households affects their perceived masculinity and contributes to their use of violence 47 a qualitative study in bangladesh found that inadequate food portions offered to men may trigger retaliatory acts of violence against their wives and that men could withhold resources used to acquire food as a form of power 48 corroborated by previous research the present study also found that men who had consumed alcohol in the past year and who have multiple lifetime sexual partners were at significantly higher risk of perpetrating ipv 4 49 50 the use of illicit drugs though assumed to be underreported was also found to be associated with ipv perpetration after adjusting for confounding in line with previous research 51 the association between food insecurity and ipv perpetration may thus be influenced and mediated by multiple factors previously examined for example through structural equation models including poor mental health gender attitudes multiple partnerships controlling behaviours and alcohol consumption 19 22 furthermore we found that the prevalence of ipv perpetration varied by age group with reports of sexual and physical ipv being more common among young adult males compared with older men while in the adjusted models being 35 years and older appears to confer a protective effect against perpetraton of ipv these findings are in line with previous studies from the usa 50 52 for young men it is possible that a relative lack of relationship experiences masculineidentity seeking and vulnerability to peer influence 50 52 increase their tendency to perpetrate violence 53 these findings have implications for the design of future preventive interventions for different subpopulations especially men in the younger age groups our findings highlight the need for early prevention of ipv that targets young men and the necessity open access to investigate and respond to food insecurity within the framework of ipv prevention even though a temporal association between ipv and food insecurity is yet to be established the findings of this study should serve as an alert to more initiatives to address ipv particularly in light of an expected dramatic increase in both ipv and food insecurity reports as a consequence of the covid19 pandemic 29 existing ipv preventive interventions in uganda such as the sasa communitybased programme 54 and the program p initiative 55 may provide concrete guidelines for efforts to engage more men in ipv preventive programmes the sasa and program p interventions also use comprehensive strategies and should be strengthened with considerations for advocacy to include for food security measures as part of the packages to respond to ipv there is an urgent need to adapt contextrelevant interventions to address food insecurity especially during the current pandemic with severe increases in both ipv and food insecurity warning and reports worldwide this is of particular importance in subsaharan africa where a huge surge in poverty rates and food insecurity is expected 56 57 thus our study suggests that ipv may become an even larger public health issue in uganda and beyond in the near future potential interventions to reduce poverty and food insecurity could include efforts to boost agricultural food production such as shortterm provision of seeds and tools to rehabilitate farming and facilitate the acquisition of credits for small businesses conditional cash transfers to women household heads to enable purchase of necessities and pay for health expenses implementation of school fee waivers and school feeding programmes and the provision of food vouchers to enable purchase of food in local markets and the emergency distribution of food 58 structural interventions to address ipv should be advocated for including more discussion on gender norms and harmful masculinities in schools and communities putting in place systems to prevent male violence perpetration encouraging women to report incidences of ipv accompanied with a strengthening of legislation training and monitoring of the police force and justice departments in ipvrelated issues and set up support and counselling centres for women who experience ipv 59 limitations this study is one of the first to investigate lifetime perpetration of different forms of physical and sexual violence among both younger and older men and to examine their association with food insecurity and male ipv perpetration in a populationbased representative cohort in rural urban and semiurban uganda given the selfreported nature of the data on a sensitive topic like ipv underreporting of physical and sexual ipv as well as recall bias is possible some participants may have considered the questions to be too private andor shameful to talk about and some may have feared legal implications or found it challenging to respond honestly in light of this potential social desirability bias the true rate of ipv perpetration is likely higher than reported in this first round of the assessments in the future exposure to and increased population trust in the data collectors in this reoccurring populationbased survey may further improve the confidence in selfreporting ipv perpetration even though the minimum sample needed for this study was attained a fairly high proportion of men did not respond to the ipv questions in the survey the sensitivity analysis revealed however that this had no significant effect on the findings data on poverty indicators such as income levels and employment status were unfortunately lacking at individual level but it can be assumed that food insecurity is a reflection of income level and the availability and access to livelihood resources finally due to the crosssectional nature of the data coupled with the measurement of food insecurity as past year and ipv as lifetime we were unable to establish a temporal association between food insecurity and ipv perpetration even though multivariate analysis was performed in this study the likelihood of residual confounding still remains conclusions although likely an underestimation the reported prevalence of male ipv perpetration in these ugandan communities was still sizeablein particular among young men and must be addressed by enhanced ipv preventive strategies and programming in schools and communities food insecurity was associated with both physical and sexual ipv suggesting the need for integrated approaches to address vaw poverty and food insecurity considering the impact of covid19 lockdowns and multiple reports on increased ipv as well as expected huge increases in poverty rates and food insecurity throughout uganda the need for preventive interventions is even greater than before longitudinal surveys are needed to investigate the temporal relationships and drivers of food insecurity in uganda and beyond and to determine its impact on different forms of violence twitter george awungafac awungafacg competing interests none declared patient consent for publication not required ethics approval the ambso phs cohort study received ethical approval from the clarke international university ethics committee as the local institutional review board of record and clearance from the ugandan council of science and technology clearance was obtained from both districts to conduct the study all participants provided a written informed consent assent before participating in the study with the exception of emancipated minors who gave their own written or oral assent in addition to written parentalguardian consent was obtained data were collected by a study team trained and certified in human subject protection and good clinical practice interviews were conducted in private unique identification codes were used in all computerised data and the lists that linked participants names to the codes were accessible only to senior project staffs in passwordprotected computers participants who tested positive for hiv infection and syphilis were linked to specialised care while those who needed other health support services were referred to health facilities of their choice provenance and peer review not commissioned externally peer reviewed data availability statement data are available upon reasonable request the data for this study are strictly not available to the public a reasonable request for the data can be done by contacting sm supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

household food insecurity and its association with selfreported male perpetration of intimate partner violence a survey of two districts in central and western uganda

introduction smoking and alcohol consumption are the two most relevant contributing factors that cause death all over the world 1 adolescence is the most frequent period for trying these substances and children who start substance use at this early stage have a greater chance of continuing these habits later which may lead to severe physical and mental health consequences adolescence is the life period when involvement in risktaking has longterm effects on a youths later health 2 this is because during this critical transition phase of adolescence rapid physical emotional cognitive and social development allows adolescents to develop a range of health risk behaviors on the other hand this period may be the most optimal and appropriate time for laying the foundations for health promotion in adulthood thus the importance of existing and further prevention and intervention targeting adolescent alcohol and tobaccorelated factors remains a challenge previous studies have shown the complexity and multilayered background of substance use and highlighted the interrelationship between individual psychological and social factors 3 therefore a key to successful interventions and actions is a clear understanding of the development predictors and indicators of health risk behaviors although traditional health risk behaviors such as substance use are slowly declining in the 21st century these tendencies are not as prevalent in hungary and eastern europe compared to western countries 4 the prevalence rates of smoking and alcohol use differ from highest to lowest in eastern europe southern europe western europe and northern europe results from the health behaviour of schoolaged children study 5 and the european school survey project on alcohol and other drugs 6 showed substance use in hungary appeared to be one of the most frequent health risk behaviors in eastern europe especially adolescents alcohol consumption is one of the highest health risks in europe and while boys drink more alcohol than girls the rate of smoking among girls is higher than that of boys in addition to smoking and drinking still having a considerable occurrence in eastern europe they are closely connected to adolescents mental wellbeing and quality of life 7 therefore we need to further explore and strengthen protective factors to support this declining tendency including at the individual school and social levels furthermore it would also be necessary to map differences in correlates of experimentation and regular use several individuallevel protective factors may be identified in terms of adolescent smoking and drinking such as selfesteem selfcontrol coping and resilience selfesteem is defined as an individuals overall evaluation of their worth or value as a person and is often linked to feelings of confidence and selfrespect 8 individuals with low selfesteem may be at higher risk of engaging in smoking and drinking as a way to cope with negative emotions or to fit in with social groups 910 in relation to substance use selfesteem was found to mediate the relationship between selfcontrol and selfefficacy therefore it may be an asset in prevention 11 indeed due to coping skills training in a substance abuse prevention program for adolescents selfesteem was significantly improved as compared with a control group 12 however associations between measures of selfesteem and smoking or drinking are not consistent adolescent smoking is not necessarily related to selfesteem in adolescents 13 and sometimes people with higher selfesteem are more likely to be current drinkers 9 this further emphasizes the importance of understanding the role of selfesteem in substance use selfcontrol has been defined as an individuals ability to regulate their thoughts emotions and behaviors in order to achieve a desired goal 14 individuals with low selfcontrol tend to be more impulsive and they may lack the ability to delay gratification which makes them more susceptible to engaging in smoking and drinking 1516 the selfcontrol theory 17 suggests that when people experience stress or stressors their ability to selfregulate their behaviors is diminished and as a result the likelihood of smoking and drinking increases consequently those with weaker reflective processes and stronger impulsive drives may be at higher risk of engaging in smoking and drinking 1819 coping refers to the conscious use of cognitive affective or behavioral efforts to manage or reduce the negative emotions or stress people experience in response to challenging situations 20 the tension reduction theory posits that alcohol and tobacco are consumed to achieve tension reduction 2122 thus substance use may often serve as a way of coping with stress 23 research results suggest that particularly proactive coping which is a type of problemfocused coping can play a role in reducing stress by assessing future goals and setting the stage to achieve them successfully 24 in this way it prepares an individual for potential future stressors resilience refers to an individuals ability to adapt and recover from adversity or stress 25 resilience plays a role in smoking and drinking as it supports personal resistance and flexibility helps adaptation in the face of stressors and decreases the possibility of substance use 26 resilience may buffer the effects of stress on health behaviors so that resilient youth are better able to cope with stress and negative emotions may be less likely to engage in substance use and report better mental health 27 at the school level some important protective factors can also be found since children spend a lot of time in school the school domain serves as a tool for secondary socialization where children learn new behaviors and build connections with teachers and peers while earlier studies focused mostly on negative experiences such as problems with school achievement or adjustment in relation to substance use 28 recent studies have concentrated more on school climate referring to interpersonal relationships norms and values social interactions the school environment and both negative and positive experiences 29 a positive school climate may act as an effective protective factor against dropout bullying aggressive and violent behavior 30 and substance use among adolescents 31 school engagement or school attachment may particularly serve as a protective factor against problem behaviors 32 among the social protective factors social relationships can significantly contribute to positive youth development 33 family especially may provide protection against adolescent substance use such as smoking and drinking 34 familial protection can be explained partly by parental control and monitoring and partly by the good quality of the parentadolescent relationship which provides social support for children however not all types of social support can act as a protection while family support usually decreases the likelihood of substance use 35 support from friends and peers appears to be risk factors for smoking and alcohol consumption 36 finally several variables of quality of life may provide mental health protection against substance use such as general or psychological wellbeing and satisfaction with life life satisfaction as a global assessment of a persons quality of life reflects a positive attitude towards ones life overall 37 an earlier study revealed that cigarette smoking regular alcohol use binge drinking and illicit drug and steroid use were all significantly associated with reduced life satisfaction in addition this was also the case in terms of the first use of cigarettes and alcohol 38 an association between psychological wellbeing and substance abuse among south african adolescents was also concluded 39 data from the 20172018 health behaviours in schoolaged children study showed that adolescents mental wellbeing was closely connected to substance use and their level of social support 7 based on the literature we aimed to examine the role of potential protective factors in adolescent smoking and drinking at multiple levels psychological factors at the individual level school attachment factors at the school level social support variables at the social level and measures of quality of life at the level of mental health first descriptive statistics and sex differences in substance use and protective factors were examined in this case we hypothesized a lack of sex differences in substance use or a slightly higher incidence rate among girls particularly in smoking 6 subsequently we calculated correlation coefficients for the scales assuming strong interrelationships between them then using logistic regression analyses we determined their contribution to differences in the odds of adolescents smoking and drinking we assumed that each of the potential protective factors might be a significant predictor of smoking and drinking particularly in terms of current use finally in multivariate analyses we determined the most significant predictors of smoking and drinking materials and methods participants and procedure our study involved 276 students the sample included adolescents from grade 5 to grade 12 representing the age range of 1118 years only five children declined to participate in the survey which resulted in a response rate of 98 data collection was based on convenience sampling in budapest and villages in its metropolitan area according to the students selfassessed financial situation 14 belong to the lower class 65 to the lowermiddle class 482 to the middle class 373 to the uppermiddle class and 65 to the upper class in terms of family background 622 of the participants live with both parents 164 live with one parent and a foster parent 135 live with their mother only 4 live with their father only and 4 live with other guardians the ethical approval was granted by the ethics committee of the doctoral school of education university of szeged hungary participation in the study was voluntary and anonymous and parental informed consent was obtained in all cases the data collection occurred in the school year 20212022 using a selfadministered paper and pencil questionnaire the questionnaire took approximately 2530 min to complete the researchers with the help of teachers made an effort to administer the survey during early school lessons thus the childrens cognitive load was acceptable and fatigue effects did not affect the results measurements beyond sociodemographic data the questionnaire contained measurements on substance use and its potential protective factors in terms of smoking and alcohol both lifetime and threemonth prevalence rates were obtained we asked the following questions have you ever drunk alcoholsmoked cigarettes and did you smokedrink alcohol in the past three months responses were applied in these analyses in a dichotomous format the hungarianvalidated version 41 of the rosenberg selfesteem scale 8 was applied to measure the students global selfworth the respondents were asked to rate their level of agreement with the statements on a 4point likerttype scale the questionnaire contains 10 items 5 positive statements and 5 negative statements higher scores mean greater selfesteem the reliability of the scale was found to be adequate as a measure of selfcontrol we used the selfregulation scale developed by luszczynska et al 42 the questionnaire examines attentional control in cases where individuals pursue their goals despite barriers and setbacks the scale includes 7 items and respondents are asked to rate on a 4point likerttype scale how they feel each statement is typical of them higher scores indicate higher levels of selfregulation the scale was reliable with a cronbachs alpha of 085 with the current sample the proactive coping scale as part of the proactive coping inventory was used as a measurement of coping developed by greenglass et al 43 the inventory consists of 7 subscales of which we used one that contains 14 items we have chosen this scale because it measures the proactive coping strategies that are relevant to our research the statements in the questionnaire summarize responses and reactions to specific life situations and ask respondents to indicate on a 4point likert scale how they experience the situation the hungarianvalidated version was adapted by almássy et al 44 higher scores indicate a greater tendency to use this type of coping the scale shows adequate reliability with the current sample resilience was measured using the hungarianvalidated version 45 of the 10item connordavidson resilience scale 46 which measures an individuals psychological resistance the items are taken from the original 25item connordavidson resilience scale students are asked to decide on a 5point likerttype scale how true the provided statements are for them where 0 is not true at all and 4 is absolutely true higher scores show more resilience the scale shows adequate reliability with the current sample for schoolrelated resources we used the hungarian school attachment questionnaire 47 the 20 items of the questionnaire can be grouped into five factors general attitudes towards school attitudes towards peers attitudes towards teachers attitudes towards school subjects and attitudes towards the school environment respondents are asked to rate on a 4point likerttype scale how they feel each statement is typical of them higher scores indicate greater attachment the subscales were reliable with the following cronbach alphas attitude towards school attitude towards peers attitude towards teachers attitude towards school subjects and attitude towards the school environment these values are quite similar to those in the original study 47 the students social support was explored by using the multidimensional scale of perceived social support 48 the hungarianvalidated version 49 the questionnaire contains three subscales family friends and significant others in the 10item questionnaire students are asked to indicate how strongly they agree with each statement on a 5point likerttype scale higher scores suggest more social support these subscales were reliable with the following cronbach alphas family support friend support and significant others support in terms of psychological wellbeing we used the epoch adolescent psychological wellbeing questionnaire 50 which assesses five aspects of wellbeing that together support a higher level of wellbeing the hungarianvalidated version was used which was developed by láng 51 responses for the 20item 5point likert scale varied from almost never to almost always higher scores indicate a greater level of psychological wellbeing the scale was reliable with a cronbach alpha of 090 the 5item version of the who wellbeing questionnaire 52 was used to measure general wellbeing the hungarianvalidated version 53 the questionnaire includes five statements about the respondents feelings over the past two weeks responses were measured on a 4point likerttype scale higher scores reflect a greater level of wellbeing the reliability coefficient was α 070 with this sample finally the hungarianvalidated version 54 of the satisfaction with life scale 37 was used to measure the level of life satisfaction as a general measure of subjective wellbeing the students indicated how strongly they agreed with each of the five items and responses ranged from 1 strongly disagree to 7 strongly agree the final scale had a range of 535 where a higher score indicated a greater level of life satisfaction although the scale was originally developed for adults it is now widely used in adolescent populations as well the scale was reliable with a cronbachs alpha of 081 with the current sample data analysis the analyses were completed using the ibm statistics 25 software package first before executing statistical analyses the rate of missing data was taken into account those who did not submit questionnaires were removed from the database as we checked the nonparticipating children did not differ from the overall sample on key characteristics in a small number of cases a wholly random instance of missing data occurred ie a single item was absent these data gaps are random and lack an identifiable pattern in these cases we replaced the missing values with 999 although we cannot find a certain criterion about the acceptable rate of missing data it is suggested that a missing rate of 5 or less is inconsequential 55 thus we did not need to apply any other imputation method spss treated these values as missing values on this basis the available case analysis method was employed ie each variables entire data set was analyzed if the number of items in the variable has changed as an outcome this is indicated when the results are reported first descriptive statistics were used to detect group differences subsequently we calculated correlation coefficients for bivariate associations for the scales then we implemented bivariate logistic regression analyses at the 95 probability level to determine the effect of each independent variable on increasing or reducing the odds of substance use an odds ratio 10 indicates that there is a positive association between the factors of interest and the baseline odds while a value 10 indicates the opposite a maximum pvalue of 005 was used to define statistical significance and 95 confidence intervals were also calculated for this reason finally multivariate logistic regression was used to determine the most relevant contributors results table 1 shows descriptive statistics for substance use variables by sex frequencies show that 223 of the students have smoked in their lifetime and 156 have smoked in the last three months while 564 of students have drunk alcohol in their lifetime and 507 have drunk alcohol in the last three months there were no sex differences in the prevalence data table 2 presents descriptive statistics for the scales by sex using ttests for significance boys scored significantly higher than girls on the scales of life satisfaction t 197 p 005 and general wellbeing t 322 p 0001 furthermore girls showed significantly higher scores on one dimension of school attachment namely the general attitude towards school t 260 p 001 table 3 presents descriptive statistics for the scales as independent variables by current substance user status using ttests for significance for smoking we found that there were significant differences between the two groups in most variables smokers reported lower levels of selfesteem t 343 p 0001 selfcontrol t 310 p 001 and family support t 418 p 0001 among schoolrelated protective factors attachment to the school environment t 219 p 005 attachment to peers t 236 p 005 and attachment to teachers t 206 p 005 proved to be lower among smokers than nonsmokers all dimensions of quality of life showed higher scores in smokers than nonsmokers for drinking we found similar results regarding quality of life measures among the individuallevel factors in addition to selfesteem and selfcontrol lower scores on resilience were also reported by those who drank alcohol t 236 p 005 and they received less social support from significant others t 222 p 005 in addition all types of attachment to school showed lower scores among those who consumed alcohol during the past 3 months we calculated correlation coefficients for bivariate relationships between the applied scales in addition to all the significant correlations we should highlight some important and strong relationships selfcontrol was strongly correlated with resilience r 067 p 0001 and social support from the family r 062 p 0001 family support was also significantly associated with proactive coping r 053 p 0001 and resilience r 059 p 0001 as well as life satisfaction r 068 p 0001 general wellbeing r 066 p 0001 and psychological wellbeing r 089 p 0001 tables 5 and6 show the results of simple binary logistic regression analyses for smoking and drinking age elevated the risk of experimentation with both smoking and drinking in the case of having ever smoked we found that selfcontrol selfesteem and resilience reduced the chance of trying out smoking for school attachment the oddsreducing effect is observed for all dimensions of this variable including attachment to school school subjects school environment peers and teachers this was also the case in terms of quality of life factors regarding social support family support and support from significant others reduced the odds of smoking in connection with alcohol experimentation we found that individual factors such as selfcontrol selfesteem and resilience had an oddsreducing effect in terms of school attachment and quality of life factors the results were similar to smoking except for attachment to peers which had a nonsignificant or in terms of social support similar to smoking family support and support from significant others reduced the chances of trying alcohol subsequently we explored which factors have an oddsincreasing or oddsreducing effect on current substance use similar to the lifetime prevalence of smoking quality of life factors social support from family and significant others and selfcontrol and selfesteem were significant predictors here among individual factors resilience did not increase the odds of current smoking among schoolrelated factors only attachment to the school environment and peers were significant predictors the odds ratios characterizing the relationship between each independent variable and the dependent variable are derived from logistic regression analyses performed separately a reference category or odds ratio ci confidence interval p 005 p 001 p 0001 for alcohol consumption significant oddsreducing effects were observed for all dimensions of school attachment and quality of life factors in addition we found similar results to having ever drunk alcohol including selfesteem selfcontrol resilience and social support from family and significant others finally table 7 presents the results of the multivariate logistic regression analysis the goodness of fit was significant in all cases age and selfcontrol proved significant predictors of both smoking and drinking in terms of having ever smoked certain social support variables were significant protective factors family support and support from significant others regarding having ever drunk alcohol in addition to selfcontrol attachment to the school environment was a protective factor however friend support acted as a risk factor current smoking was related to attachment to school subjects attachment to the school environment was again a predictor of current alcohol use similar to having ever drunk alcohol friend support was a risk factor discussion the purpose of this study was to examine a set of potential protective factors at multiple levels for smoking and drinking in a sample of hungarian adolescents according to european and worldwide international research despite a decreasing tendency of traditional substance use among adolescents such as smoking and alcohol use it is still a great concern particularly in eastern european nations including hungary 4 5 6 thus identifying preventive factors may help reduce the occurrence of these health risk behaviors we approached the concept of protection from the perspective of teenage mental wellbeing since adolescent mental health was found to be an important public health priority 714 we also used multiple levels of potential protection our findings supported the first hypothesis there were no statistically significant sex differences in adolescents substance use however girls reported slightly higher rates for the threemonth prevalence of smoking and drinking 6 likewise there were only a few sex differences in adolescents levels of protection calculating the odds of independent variables selfcontrol seemed to play a universal protective role against substance use while age was a general risk factor in addition certain other potential protective factors might also contribute to prevention while friend support acts as a risk factor for alcohol use 36 the initial step in our research was to look into the occurrence of substance use and differences between the two sexes among adolescents previous research on smoking and alcohol use in the eastern european region confirmed that both lifetime and threemonth prevalence rates are higher than those in the western european region 4 5 6 indeed around 50 of the teenagers had already tried and used alcohol during the previous three months prior studies varied in their sex differences for these outcomes 5610 we discovered no differences in either lifetime prevalence or threemonth prevalence between boys and girls this finding confirms previous research results showing that sex disparities in substance use appear to be decreasing 4 5 6 furthermore girls reported a slightly greater occurrence among the protective variables only a few of them showed sex differences girls scored lower on the life satisfaction and general wellbeing scales this study validates prior research results showing girls perceptions of the world during adolescence differ from boys adolescent girls may be more sensitive and perceive their world in a different way from numerous viewpoints than adolescent boys and these perceptions may be more complex and in many cases more negative this represents girls increased sensitivity at this age but it may also result in a higher risk of behavioral and emotional problems 56 the disappearing sex difference or the slightly higher rate of girls substance use compared to boys may also reflect this situation we also compared levels of protective factors by substance use based on the current prevalence of smoking and alcohol use we found differences in various domains between substance users and nonusers for both types of substance use consumers among the sampled adolescents scored lower particularly on the following scales wellbeing selfesteem selfcontrol and social support from family these findings support prior research findings that there is a close connection between substance use and certain intrapersonal traits such as selfesteem and selfcontrol 9 10 11 12 16 wellbeing 739 and family support 35 substance use may deplete personal resources or lower levels of these resources may be a risk factor for substance use through a selfmedication strategy differences in areas of school attachment also showed their importance in teenage substance use and confirmed prior research findings 28 31 32 33 those who were disengaged from school were more vulnerable to being engaged in substance abuse activities while youth who avoided using substances reported better degrees of school attachment this finding can point to the protective role of school attachment adolescents with positive attitudes toward their school are more involved with school their teachers peers and academics and they are more likely to engage in healthy behaviors our findings suggest that school attachment is particularly relevant in the case of alcohol use a similar picture can be seen in the results of bivariate logistic regression analyses regarding adolescents selfcontrol and selfesteem their wellbeing and social support from family and significant others these results confirm prior findings that selfesteem and selfcontrol can have a riskreducing effect on substance use these protective factors together with other personal resources such as selfefficacy selfimage and effective selfmonitoring and planning can protect against negative health impacts 2122 resilience has been identified as a clear protective factor for the lifetime prevalence of both types of substance use and the threemonth prevalence of alcohol use namely adolescents with greater resilience are more likely to say no to the temptations of substance use especially in the initiation stage this validates prior results showing that resilient adolescents are better at adapting to stressful situations since their resilience may prevent them from engaging in experimentation and regular use of substances 2627 from the results it seems that proactive coping cannot serve as a protective factor further research is needed to identify more effective coping strategies against adolescent substance use personal resources together with wellbeing variables are important protective factors suggesting that a welladapted and mentally wellbalanced teenager is able to resist health risk behaviors 3638 at the interpersonal level social support from the family and significant others together with a successful school attachment also provides protection for adolescents 2831323435 parental emotional support as well as the parents guarding behavior or joint programs together as a family are all relevant aspects of family support 34 furthermore the adolescents commitment to their school as well as the quality of their social interactions with teachers and their acceptance of the schools learning environment can also prevent them from adopting health risks and problem behaviors 283132 not surprisingly age was identified as a risk factor in all cases while sex did not play a role as multivariate analysis suggests selfcontrol is a universal protective factor against adolescent substance use on the other hand age is a universal risk factor while friend support elevates the risk of alcohol use 3638 peer pressure is a strong determinant of drinking since it is a social activity usually shared with friends interestingly attachment to peers in school that is learning together with them was not a risk factor while the role of close friends might differ from this connection 57 social support from family and significant others provides protection against smoking while school attachment seems to be a more important protective factor against drinking while using a complex model of protective factors at different levels is the strength of our paper we should also mention some limitations these are the crosssectional design of our study and the nonrepresentative sampling which may restrict the generalizability of the findings due to the relatively small sample size we should consider this sample as a first step in a larger study in addition the reliability of certain scales proved relatively low we did not want to skip them due to their relevance but this needs further adaptation all in all we justified a set of relevant protective factors at multiple levels which can be target points in a schools health education program and school curriculum conclusions overall the results of this study highlight some important protective factors against adolescent substance use therefore they will be valuable for teachers school psychologists social and health professionals and anyone living or working with teenagers we believe that integrating wellbeing and related domains into systemic prevention particularly in school settings is essential there is also a need to develop interventions involving families we really think that a complex prevention program can be the most effective in reducing risk behaviors promoting preventive health behaviors and ultimately strengthening mental wellbeing among adolescents based on our results such interventions should be based on improving youths selfcontrol helping develop school attachment offering examples for youth on how to socialize with peers without using substances and building a social network between school and families however before the development of practical interventions a solid theoretical framework should be considered positive psychology seems plausible for developing a curriculum to foster adolescents wellbeing since it applies a strength model instead of concentrating on pathology and problem behavior 58 as a positive psychological framework perma is suitable for a school environment providing a strong basis for adopting a positive mindset in both teachers and children 59 in a study of australian high school students a schoolbased mental health program combining acceptance and commitment therapy and positive psychology was introduced 60 using a randomized controlled trial increased wellbeing and reduced anxiety levels could be measured as a result of an 8hour workshop series in addition to concrete psychological training however tools of positive education would also be favorable eg strengthening school communities forming friendly school environments and democratizing teacherstudent relationships data availability statement the datasets generated during andor analysed during the current study are available from the corresponding author on reasonable request informed consent statement informed consent was obtained from all subjects involved in the study

adolescence is the most critical life stage for experimentation with substance use however this is also the most suitable period for strengthening protective factors and thus promoting adult physical and mental health since smoking and drinking still appear among the most frequent types of substance abuse in europe this study aims to examine the role of potential protective factors at multiple levels for adolescent smoking and drinking psychological factors at the individual level aspects of school attachment at the school level social support variables at the social level and measures of quality of life at the level of mental health this crosssectional survey involved a sample of adolescents aged 1118 years n 276 in budapest and villages in its metropolitan area hungary in addition to descriptive statistics logistic regression analyses were used to detect odds for potential protective factors there were no sex differences in adolescents substance use selfcontrol seems to be a universal and most determining protective factor against substance use while other potential protective factors selfesteem resilience social support from family or significant others school attachment and mental wellbeing may also contribute to prevention however age and friend support acted as risk factors findings suggest that a complex approach to prevention should receive consideration

introduction dementia and its impact on the individual caregivers and healthcare system have been the subjects of growing interest worldwide 12 of particular concerns are the considerable personal and socioeconomic consequences related to the extent and duration of dementiarelated disability cost of care and loss of productivity of those with dementia and their caregivers clearly providing appropriate effective and efficient services to the increasing numbers of individuals with dementia is a critical healthcare priority early detection and timely diagnosis are paramount providing individuals with access to appropriate interventions and support services the value of a comprehensive cognitive and functional assessment and the importance of educating patients and families about expectations and disease progression have been documented 3 4 5 and guidelines for the diagnosis and management of people with dementia in primary care settings are available for formal care providers 6 unfortunately underreporting of dementia diagnosis and delayed referrals for dementiarelated services are common 7 9 populationbased screening studies have found that a significant number of individuals with dementia are unknown to their family doctor 1011 and that 2050 of dementia cases are routinely recognised and documented in primary care settings 12 13 14 those who care for a family member with dementia are confronted with heavy psychological and physical burdens 15 family caregivers usually lack knowledge of available services and rely on health professionals for information 16 obstacles that delay diagnosis may have serious consequences including delayed access to treatment and services not receiving critical disease management education and information and the inability to plan ahead and make important decisions 17 with the increasing incidence of dementia with advancing age the rising prevalence of dementia is of particular concern for rural and remote regions of canada which comprise a greater number of older individuals 18 rural settings pose particular healthcare and service delivery challenges necessitating long travel distances to access formal services in urban areas 19 20 21 limited services and underservicing of specialneeds groups such as older adults have been identified as areas of concern for rural remote and northern canadian communities 1822 providing quality care for individuals with dementia can only be accomplished when the context complexity of care provision and care providers needs are understood this paper describes formal and informal caregivers perceptions of the challenges and needs associated with providing services care and support for individuals with dementia living in rural and remote regions in the province of saskatchewan canada methods the work reported here was part of a larger research program focused on improving the care of persons with dementia living in rural and remote areas 2324 this research represents a component of a broader process evaluation designed to inform the initial and ongoing development of a communitybased participatory program in rural dementia care which included the development of the rural and remote memory clinic 23 a mixedmethods exploratory design comprising four approaches was used to examine informal and formal caregivers needs thematic analysis of consultation meetings with healthcare providers telephone and mail questionnaires completed by healthcare providers thematic analysis of referral letters to the rrmc and examination of family caregiver satisfaction with care prior to the initial rrmc visit setting saskatchewan covers an area of 651 036 km 2 and has a population of approximately 1 million health care including telehealth is delivered by 13 regional health authorities rha population densities range from 01 to 92 25 the three most northern rhas comprise 44 of saskatchewans land mass and have 33 of the population 25 thematic analysis of consultation meetings with rural healthcare providers prior to rrmc implementation research team members travelled to 13 saskatchewan communities in eight different rhas that had a telehealth site operated by the provincial network and to two sites operated by first nations bands 23 meetings were held with a variety of healthcare providers and others employed by healthcare facilities or working in the community the purpose of the meetings was to discuss development of the rrmc and perceived needs related to providing dementia care in a pa5rticular community a research assistant captured discussions verbatim into notes that were then transcribed into a typed record analysis the record was thematically analysed using a general inductive approach 26 thematic analysis a qualitative data analysis method was used for identifying analysing and reporting patterns within the data thematic analysis does not derive from nor is tied to a particular epistemological or theoretical position 27 the record was read and reread multiple times by two authors independently key ideas and multiple meanings were considered and text segments containing meaning units were identified recurrent themes were indexed and categorised text segments relevant to each category were noted and compared to developing themes the authors met to discuss and compare the themes and text segments and findings were verified by consensus and convergence telephone and mail questionnaires a crosssectional sample of rural care providers was surveyed regarding their comfort and confidence in providing dementia care and their continuing education needs sample a convenience sample of healthcare providers who attended the consultation meetings was invited to complete a followup questionnaire consultation meeting participants interested in being contacted for additional studies provided their name and contact information which were entered into a database of the 109 nonphysician participants in the database 35 were excluded because they were not healthcare providers eg senior administrators and clerical staff and of the 51 physicians in the database nine were deemed ineligible for participation eg no longer practising illness could not commit to an interview questionnaires initially a telephone interview guide was developed for all participants subsequently a mail questionnaire was developed for nonphysician healthcare providers because of administration feasibility issues including inability to leave messages and participants not being available for a phone call the two approaches used similar closed and openended questions tailored for the two groups but differing with respect to administration modes the survey questionnaire and telephone interview guide were examined for face and content validity by research team members and were pilot tested with healthcare providers physician interviews were conducted by a physician research staff conducted an initial 28 telephone interviews and the remaining 34 healthcare provider participants received a mail questionnaire response rate thirtythree physicians completed the telephone interviews and 28 care providers in management or administration positions and 33 direct care providers completed the telephone or mail questionnaire analysis descriptive statistics were used to analyse respondents comfort and confidence with dementia care service provision and continuing education needs thematic analysis of referral letters to the rural and remote memory clinic to better understand patterns of needs of rural family physicians rrmc referral letters were examined two hundred and fifty consecutive referral letters from 91 discrete physicians representing the 13 rhas over a 5 year period were independently descriptively and thematically analysed by two authors each author summarised the content of the referrals grouping content by similarity and themes were developed the authors then met to review the similarities patterns and consistency of the themes and consensus was reached regarding the final themes family caregiver satisfaction the last approach involved examining informal caregivers satisfaction with care received prior to the initial rrmc visit as part of the rrmc clinic day assessment a family member or other accompanying caregiver completes a baseline questionnaire four specific questions from the baseline questionnaire were examined what is the nature of the problem that has caused the most concern who decided to seek help for this problem are you satisfied up to now with care received for this problem and specify why you have not been satisfied up to now with care received for this problem all responses from caregivers who completed the questions were descriptively and thematically analysed by two authors as described previously ethics approval the research was approved by the behavioral research ethics committee university of saskatchewan results thematic analysis of consultation meetings with rural healthcare providers those who attended the community consultation meetings indicated there was a need for improved referral management and consultation services for individuals with memory problems and support services for family members broadranging specific service needs were identified including increased access to physicians specialists and rehabilitation professionals and longterm care and respite facilities and day programs the need for increased services is best represented by the following two quotes theres nothing for seniors no facility theres nothing here no services for elderly the resultant impact of lack of services on the family and increased family burden was also described often families are the longterm care in addition the need for improved services and better coordination of services were identified as priorities additional themes were related to trying to provide services in remote and rural areas in particular in areas with high proportions of aboriginal populations examples of travel and travel burden related needs included having to obtain government authority for healthcarerelated travel lack of government or personal funds for travel to healthcare facilities having to deal with buses that travel to urban centers only on certain days and cutbacks in taxi services the need for translation services and more culturally appropriate assessment tools for nonenglish speaking individuals and their families were also identified last the broad theme of educational needs was evident and three subcategories were identified across the communities management of difficult client cases recognising memory problems and increased continuing education opportunities telephone and mail questionnaires physician respondents the majority of physician respondents indicated their practice was rural and 35 indicated their practice was remote the median number of patients with dementia seen per month was six the range was wide and dependent on whether the physician had responsibility for longterm residents the median number of new dementia cases diagnosed in the past year was three a large majority of physicians reported using a standardised mental status test with 90 of these respondents using the minimental state exam thirtytwo percent of respondents reported using published clinical guidelines to diagnose dementia about half of the physicians reported being fairly comfortable with diagnosis and management of patients with dementia while 10 reported being extremely comfortable thirtyfive percent indicated being extremely comfortable with explaining the diagnosis and prognosis of alzheimers disease and other dementias to patients and their families and 39 reported being fairly comfortable with respect to dealing with drivers license issues 19 reported being very comfortable and 32 reported being fairly comfortable a majority of physicians reported that they would like more access to continuing education opportunities on the topic of dementia particularly diagnosis and initiating treatment workshops were the preferred format and 29 indicated it was extremely important for continuing education opportunities to be offered locally almost half of physicians reported support services available to persons with dementia and their caregivers in their community to be adequate sixtyfive percent of the physician respondents indicated that more care facilities and programs would enhance currently available services about onethird indicated that additional healthcare professional services such as support services and counselling physical therapy occupational therapy weekend nursing services geriatrician expertise and psychology were needed nonphysician healthcare provider respondents of the 61 nonphysician respondents 475 were in management or administration positions and 508 were involved in direct patient or client care more than half indicated that their practice was rural 49 indicated their practice was remote and some endorsed both rural and remote onequarter of the respondents reported being uncomfortable in their ability to recognise the signs and symptoms of ad and other related dementias 38 were neutral and 36 reported being fairly or extremely comfortable similar findings were reported for comfort and confidence in providing support and guidance to individuals with dementia or their families with 31 being fairly comfortable and 14 extremely comfortable ninetyone percent of respondents reported wanting more continuing education on the topic of dementia with preferred formats being workshops and telehealth and 80 indicated that it was extremely important that educational opportunities be offered locally in contrast to the physician respondents less than onefifth indicated that support services available to persons with dementia and their caregivers in their community were adequate and the following were identified as needs healthcare facilities and services such as respite home care day programs longterm care facilities and programs for early stage patients family support services including support groups social work and volunteer psychogeriatric nursing services staff training and other early diagnosis and treatment public education and a team approach to care thematic analysis of referral letters to the rural and remote memory clinic of the 250 referral letters analysed 157 included either a stated diagnosis of dementia or evidence that the physician suspected a dementia as indicated by a mmse score a functional assessment questionnaire score or a notation that the patient was taking a medication for dementia there was wide variation in the extent and sometimes the quality of information provided referrals ranged from a oneline statement such as please see this patient for assessment to a lengthy family and medical history with complete clinical workup fiftythree percent of the referral letters were general requests for assessment evaluation or consultation and 25 were requests for management a small proportion of these management referral letters were a specific request primarily for medication and medical treatment consultation needs as identified through the referral letters were categorised into the following four broad themes representative quotes that highlight the needs are provided confirmation of diagnosis or treatment confirmation of diagnosis or medical treatment was being sought in about 25 of referrals in some cases referrals reflected the need for an opinion about what was causing the patients problems in other cases the family physician had made the diagnosis and indicated the treatment option under consideration and needs included a second opinion to validate a dementia diagnosis the specific type of dementia diagnosis or confirmation regarding the proposed medications i am not sure of the diagnosis and would be grateful for your involvement i would appreciate it if you would kindly assess her and advise if she is a candidate for aricept request for further management suggestions in some cases a specific dementia diagnosis had been made by the family physician and pharmaceutical treatment initiated prior to referral needs in these instances were related to receiving information about additional treatments that could be implemented to manage the patient overall or to manage specific impairments such as behavioral symptoms these referrals were typically related to nonresponse to treatment worsening of symptoms or disease progression she was tried on aricept as well as exelon with a poor response mmse has been declining over the last few months i would appreciate your evaluation of this patient in this regard is there anything further that can be done for him your assistance with further management would be appreciated patient or family request as described previously in some instances a dementia diagnosis had been made and treatment had been initiated by the referring physician however rather than reflecting worsening of symptoms or disease progression the referral reflected a need to respond to a patients or family members specific request for additional assessment and in particular a referral to the rrmc his wife is very interested in other treatment options for his alzheimers disease mmse is 1430 i started reminyl 4 mg bid and increased it to 8 mg already daughter wants assessment progressive dementia on aricept patient requested referral consultation regarding difficult cases the last category of need included requests for assistance with managing complex patient cases issues causing case complexity leading to the referral were typically related to disease progression development of new symptoms or worsening of symptoms she presented with primary progressive aphasia and now has developed cognitive problems tried a course of aricept her children think it is making her worse family caregiver satisfaction not surprisingly memory problems caused the most concern for family caregivers followed by agitation or confusion language or comprehension problems and concentration or thinking problems other problems identified as causing the most concern were behavioral symptoms such as emotional changes personality changes lack of motivation or energy and hallucinations family caregivers also reported health issues balance mobility and gait difficulties and difficulties with activities of daily living or instrumental activities of daily living as the problems causing the most concern in response to the question who decided to seek help for this problem 539 of the caregivers reported they had initiated seeking help for the problem the remaining responses indicated the referrals were initiated by the patient and family physician only two indicated that other healthcare professionals prompted the referral thirtyone percent of informal caregivers expressed not being satisfied with the care received prior to the rrmc assessment four themes related to lack of satisfaction with care prior to the rrmc visit were extracted and representative quotes are included perceived lack of care inadequate care or inappropriate care informal caregivers often indicated they felt the care provided prior to the rrmc assessment was not appropriate or sufficient patients receiving a medication that seemed to be ineffective healthcare professionals not adequately addressing specific patient problems and informal caregivers needing to find information themselves were often reported because writing another prescription isnt the answer doctors specialists they didnt seem to agree they keep changing medications he was given pills but there was no followup ive had to get my own information and have asked the doctor to act on it there really was no care particularly dealing with his memory family physician or other healthcare professional minimised the problem informal caregivers noted problems experienced by the patient were often dismissed by healthcare professionals informal caregivers reported being told there was no cause for concern or that the problems their loved one was experiencing were considered normal ageing bs doctor doesnt seem to recognise this as a problem drs and mental health specialists did not take the problem seriously wait times or amount of time to diagnosis many caregivers commented negatively on the wait time to get appointments with healthcare professionals to have diagnostic testing completed and to get answers to their questions in addition to access issues caregivers reported having multiple appointments without getting the information they needed or having an understanding of what was causing their loved ones identified problems these multiple visits added to the amount of time to receive a diagnosis we have been seeking help for over a year long wait lists difficulty getting any tests done lack of diagnosis informal caregivers reported frustration with not receiving a name for the problem the patient was experiencing or for the behaviors the patient was exhibiting difficulties and delays were experienced in getting a specific diagnosis and informal caregivers felt things werent being done or being done quickly enough to determine what was wrong with the patient i have not had an answer as to why m has not been well what has caused his not feeling well and memory loss discussion the multipronged approach used to examine areas of need for rural and remote dementia care in saskatchewan canada incorporated a broad continuum of care contexts and included formal and informal caregivers perspectives not surprisingly for both physicians and family caregivers the primary reason for referral was suspected memory problems however the motivation and rationale for referral differed in some cases physicians were responding to family members requests for further evaluation informal caregivers reported they were often the ones who initiated the referral suggesting that even when primary care medical management is perceived as appropriate family members may feel the need to ensure the best care avenues are being pursued for their loved one in other cases a specific dementia diagnosis had been made and the physician had already initiated pharmaceutical treatment prior to referral this finding suggests primary care physicians may be seeking confirmation of their diagnosis or may need assistance when dealing with difficult aspects of care such as assessment of driving competence or medication prescription about twothirds of physicians who participated in the telephone interviews indicated being fairly or extremely comfortable with the diagnosis and management of patients with dementia and about half reported being fairly or very comfortable dealing with drivers license issues these findings are similar to those reported in other jurisdictions for example 64 of uk general practitioners described themselves somewhat or very confident about their ability to diagnose dementia and 32 felt somewhat or very confident about communicating management 28 the main difficulties identified by these practitioners included talking to patients about the diagnosis responding to behavior changes and coordinating support services 28 responding to behavior changes was also identified in the analyses of physician referral letters the differences between needs identified through the referral letter and the telephone interview responses may be a reflection of the data collection methods or the context of care provision it is possible that physicians may be more open or detailed in a telephone interview being conducted by another physician rather than in a written referral document requesting specialist services as well the referral letters were linked to specific patients whereas in the interviews physicians were asked about their comfort and confidence in diagnosis and management of dementia in general the degree of overlap in samples between the physician referral letter and telephone survey components is not known but is likely very small this may account for differences in responses found between the two methods the rural or remote practice setting is unique and highlights the complexity richness and challenges of therapeutic boundaries rural settings are highly interdependent and interconnected uncertainty and lack of agreement within and among rural health professions regarding the appropriate course of action that should be taken when problems arise have been reported in the literature 29 this uncertainty is often exacerbated by the intertwined health professionalpatient relationships in rural settings for example the patient may be the healthcare providers mechanic minister or postal carrier 30 familiarity between healthcare providers and their clients is often a prerequisite to developing trusting relationships and is often unavoidable in the rural context 3132 whether or not and to what extent close personal relationships or the relative intimacy of rural or remote life played a role in the different findings could not be determined and should be further explored both informal and formal caregivers identified a need for increased and improved services for people with dementia living in rural and remote areas although the number of respondents indicating that services were adequate differed between physicians and other healthcare professionals both groups identified the need for healthcare facilities and care programs informal caregiver needs were more aligned with nonphysician care providers with respect to the need for improved access to physicians specialists and healthcare professionals who can provide additional care services such as physiotherapists and occupational therapists it is possible that the physician participants interpreted the question about support services differently from the other healthcare providers however the findings may be a reflection of the amount of time primary care physicians versus other healthcare providers are able to spend with patients and their family due to the nature of the healthcare system and the context of providing medical care in rural and remote areas uneven distribution of physicians nurses medical specialists healthcare professionals and other care providers and a payment system that does not reflect the time needed for assessment are real issues in providing services particularly in rural and remote areas as well physicians have a different role in caring for patients and families this could have resulted in the different perspectives regarding adequacy of supports nonphysician healthcare providers may be more closely involved in postdiagnostic support for patients and families and may be more aware of the challenges of accessing supports and the consequences when the supports are not available the lack of diagnosis and long wait times for services identified by the informal caregivers have been found to be common concerns in previous studies 3334 speechly et al reported that it took almost two years to contact a healthcare professional and roughly 27 years from first symptom onset to receiving a diagnosis 33 the mean time from first contact with a healthcare professional to arrival at a memory assessment service was reported to be almost three years in a uk study 34 clearly these types of delays can cause much frustration and anxiety for patients and their family members the direct quotes from family caregivers highlighting a lack of satisfaction with care received prior to the rrmc visits are very telling although these quotations may appear harsh at first glance it is important to keep in mind that the quotes are a reflection of the frustration experienced by informal caregivers in accessing adequate services and answers to their questions in particular when human resources and facilities are stretched beyond their limits in rural and remote areas another difference between physicians and other healthcare providers was related to continuing education needs physician respondents did not view local access to continuing education as a priority whereas nonphysician respondents indicated a stronger preference for opportunities offered locally physicians may be more easily able to access educational opportunities offered at a distance or may have more access to or may be more comfortable with webbased learning compared to other healthcare providers physicians are likely to have more professional autonomy to take the time away from clinical practice for travel as well as greater resources for travel and continuing education opportunities in general access to continuing education can affect job satisfaction 35 and influence the retention of health professionals in rural areas 36 in light of the findings continuing education opportunities targeting the specific needs of those involved in providing dementia care in rural and remote settings are recommended in addition general access issues and service delivery shortages need to be addressed funding programs should be established for nonphysician formal caregivers and programs that advance rural and remote healthcare professional recruitment and retention strategies similar to those targeted to saskatchewan physicians formal care providers reported a desire for more information about dementia assessment management and family support strategies as reported by others the nonphysician healthcare providers reported feeling uncomfortable in their ability to identify signs and symptoms of ad and other related dementias 37 38 39 40 highlighting the need for further education using acceptable and feasible strategies areas of need as indicated by referral letters also included management and family support strategies as well as differential diagnosis confirmation of diagnosis and consultation regarding complex cases these identified areas provide a focus for developing continuing education programs and strategies for healthcare professionals caring for people with dementia living in rural and remote areas with the advances in webbased technology both for personal use and for healthcare delivery it is possible to structure continuing education using nontraditional teaching strategies the canadian consensus guidelines propose that most patients and families can be assessed and managed by a primary care physician 41 yet only half of the physician respondents reported they were fairly comfortable with diagnosis and management some studies suggest up to 50 of dementia cases are not diagnosed by primary care physicians and that primary care physicians do not consistently apply recommended assessment procedures 12 13 14 others have reported the number of accurately identified cases to be high 4 and studies suggest primary care physicians can make a dementia diagnosis with reasonable accuracy if specifically prompted 42 in a paper describing what general practitioners want from specialist services in managing people with dementia williams reported the following to be important receiving confirmation of diagnosis and prognosis for both the general practitioners and family assistance with the special needs of young dementia patients helping caregivers accept the diagnosis assistance with driving cessation recommendations and assistance with symptomatic treatment and planning care 43 thematic analysis findings of referral letters align with many needs identified by williams 43 however it is not clear whether the needs reflected in the findings represent feelings of inadequate training in dementia care lack of confidence in managing people with dementia concern over the implications of a dementia diagnosis for patient and family whether primary care physicians feel the diagnostic task and disclosure of the dementia diagnosis belongs to specialists or other contextual factors further research is warranted and is underway conclusions this study focused on understanding formal and informal caregivers perspectives of the challenges issues and needs in providing care for people with dementia living in rural and remote regions of saskatchewan canada informal and formal care providers needs were similar to those previously reported increased availability and types of services care facilities and programs increased access to primary care providers specialists and rehabilitation professionals to address wait times for diagnosis and management and continuing education related to recognising signs and symptoms of ad and other dementias and the diagnosis and management of people with dementia nonphysician care providers were more aligned with informal caregiver regarding the need for improved access to additional healthcare professionals and dementia care services referral letters indicated primary care physicians sought confirmation of their diagnosis and assistance with difficult aspects of care although preferred modes of delivery differed both physicians and other healthcare providers indicated a need for more continuing education focused on dementia assessment management and family support strategies those directly involved in dementia care policy makers and governments are challenged to develop innovative health service delivery models that meet the diverse needs of formal and informal care providers and address human and other resource shortages within the unique context of rural and remote care

rural and remote dementia care challenges and needs perspectives of formal and informal care providers residing in saskatchewan canada

chinese adults cognitively demanding volunteering or both types in addition the results of ancovas revealed that the retirees engaging in cognitively demanding volunteering had better cognitive functioning than those who did not volunteer at all while the retirees engaging in instrumental volunteering exhibited more depressive symptoms compared with those who engaged in cognitively demanding volunteering and those who did not volunteer at all these results remained significant even after controlling for sex education socioeconomic status and perceived health our findings suggest that cognitively demanding volunteering activities should be promoted to maintain the psychological and cognitive wellbeing of retired persons session 3285 abstract citation id igad1041066 longterm paid care workforce shortage burnout training turnover whats next chair ann rhodes discussant anne martinmatthews although the longterm care workforce has struggled historically with staff satisfaction safety and retention the pandemic triggered increased turnover and higher levels of staff burnout as a result many residential care organizations are using agency staff at unprecedented levels given that continuity of care is central to highquality personcentered care and the workforce should have access to a physically and psychologically safe environment it is imperative that the gerontological research and practical community understand the changing conditions experienced by this workforce in crisis and offers solutions at the workplace industry and policy levels in this symposium authors explore different facets of paid longterm care workforce to stimulate thought and discussion one paper contrasts the wellbeing of the workforce to that of the residents during covid19 a second paper presents workforce management capabilities and strategies and posits essential questions for the capacity of management and leadership needs of the workforce two papers highlight the struggles that are presented as paid longterm care relies increasingly on contract shortterm workers paper three discusses how the use of the contract workforce does not support the provision of personcentered care for conditions like dementia paper four uses payrollbased journal data to delve into short and longterm use of contract workforce and discusses the nature of contract staffing and considers how contract staffing may be disruptive to both the direct care worker and the nursing home environment the discussant will draw out the policy and practice implications arising from the papers this is a collaborative symposium between the aging workforce and paid caregiving interest groups

wellbeing and to examine whether social participation and civic activity can buffer works negative effects random sampling survey was conducted in 2019 on people living in the tokyo and hyogo prefectures the response rate was 430 n 1063 aged 5074 analyses of covariance were conducted on wellbeing depression anxiety loneliness and life satisfaction we found that work has negative effects on anxiety and life satisfaction with civic activity moderating the negative effect on life satisfaction gender differences were observed regarding anxiety and loneliness women showed higher anxiety and men showed higher loneliness regarding age difference people in their late 60s exhibited the lowest depression and those in their late 50s higher anxiety it is argued that japans third agers live in more difficult work circumstances than ever before and it is thus necessary to explore agefriendly labor conditions for older adults

background in denmark and germany the richest ten percent of people have a six times higher income than the poorest ten percent in the united kingdom and the united states the richest have ten to fourteen times higher incomes than the poorest 1 income inequalities bring inequalities in housing conditions neighbourhoods in which people live circumstances at work and number of material goods with which people can surround themselves 2 these inequalities also bring inequalities in risks of disease and premature mortality 3 particularly because these socioeconomic inequalities have such profound implications for daily life excesses in such distributive processes have raised heated scientific ethical and political discussions about whether the conditions in which people from lower socioeconomic groups live should be considered unfair 45 given this environmental background it is striking to see that only so few examined whether a general perception of unfairness is particularly common in people who are allocated the smallest shares of resources 6 furthermore only few have examined whether this perceived unfairness relates to subsequent poor health outcomes 67 most research in the field addressed injustice and perceived unfairness in the work situation only 8 9 10 11 or only used one item to measure perceived general unfairness 67 or did not examine perceived unfairness regarding its contribution to socioeconomic inequalities in health 7 using sevenyear prospective cohort data from the dutch smile study among 55 years olds and older we set out to examine the contribution of perceived unfairness to the higher risks of physical and mental dysfunction in men and women with a lower socioeconomic position methods study population the dutch smile study is a prospective cohort study which started in november 2002 as a joint project of maastricht university and the eindhoven corporation of primary health care centers 12 part of the data collection concerns people 55 years old and older they received annual questionnaires in may medical diagnoses and deaths were registered via the computerised general practitioners registers in may 2003 9557 persons of 55 years or older were sent a questionnaire of whom 4745 responded of the respondents in 2003 1539 also responded on questionnaires in 2008 and 2010 after exclusion of the persons with missing scores on the relevant variables the final sample comprised 1282 participants 633 women mean age 65 sd 7 participants were followed up for seven years the study is approved by the medical ethical committee of the maastricht academic hospital measures healthrelated functioning healthrelated functioning was measured by two summary scales of the sf36 mental and physical functioning 13 this sf36 scale which was included in the questionnaires of may 2003may 2008may and 2010 has thirtysix items on health pain healthrelated functioning and psychosocial factors the questions can be clustered into eight subscales which can be further recoded into two components ie mental and physical functioning 14 as per the sf36 guideline persons that had more than 50 missing scores in a subscale were considered missing persons with less than 50 missing scores on a subscale were assigned the mean score of the other items functional change between 2003 and 2008 on the one hand and 2010 on the other hand was dichotomised functional decline was defined by having a change score that was more than 1 standard deviation below the average change socioeconomic status in 2003 monthly household income was measured and subsequently individualised taking into account the number of people living from that income 15 the highest attained level of education was also asked for looking at both the participants and his or her partners educational level participants were able to choose between eight different options from primary school to academic education income and education were correlated but income had somewhat more missing values and probably is less reliable than education both income and education were therefore standardised and the mean of both standardised scores was used to indicate socioeconomic status this score was categorized into three categories based on tertiles low intermediate and high level of socioeconomic status perceived unfairness the perception of unfairness was assessed in may 2008 by nine items these items asked for how often people felt treated unfairly in contrast to previous research 6 7 8 9 10 11 our questions refer to more general unfairness perceptions at work but also beyond work the nine items were how many times you have had the feeling that a you are being treated unfairly of unjustly b important information is being withheld from you c noone is there to listen when you have problems d noone is there to offer actual help when you have problems e you are being criticized wrongly f you are not being valued for all your work g other people are treated better or fairer than you h the legislation in the netherlands is disadvantaging you i your efforts get too little reward people could indicate whether they had this experience always often sometimes rarely or never the mean across the nine items was computed missing scores on less than half of the scale were imputed with the mean of the other items for that person cases with more than 50 missing scores were considered missing participants were subsequently classified in three categories bases on tertiles low intermediate and high perceived unfairness the cutoffs indicate relatively low levels of perceived unfairness covariates age and sex were measured in 2003 and were included in all the analyses as covariates statistical analysis depending upon whether variables were categorical or continuous chi 2 tests or ftests were used to examine whether there were significant differences between socioeconomic groups in age sex perceived unfairness mental and physical functioning in 2003 and their decline between 2003 and 2010 multiple logistic regression models were estimated to examine how socioeconomic position and perceived unfairness scores were related to physical and mental decline between 2003 and 2010 these analyses were controlled for age sex and physical and mental functioning in 2003 respectively several sensitivity analyses were performed to check the robustness of the findings firstly sensitivity analyses were done to exclude a potential bias from the possibility that the responses to the perceived unfairness questionnaire in 2008 had been affected by prior functional decline therefore the logistic regression analyses were controlled for healthrelated functioning in 2008 perceived unfairness was then related to functional decline between 2008 and 2010 secondly as the categorisation of socioeconomic position and perceived unfairness into three categories might have been too crude and the cutoffs too arbitrary 16 we reran all logistic regression analyses but with the continuous forms of the socioeconomic and perceived unfairness variables thirdly as also dichotomisation of the outcome variable might have been too crude and too arbitrary 16 we also ran linear regression analyses but with the original continuous forms of longitudinal change in mental and physical function socioeconomic position and perceived unfairness results persons with a high socioeconomic position reported less perceived unfairness than persons with a low socioeconomic position furthermore persons with a high socioeconomic position more often were men more often were somewhat younger had better scores on physical functioning at the start and less often experienced a substantial decline in mental functioning than their counterparts with a lower socioeconomic position there were no significant socioeconomic differences regarding baseline mental functioning and the decline in physical functioning multiplicative interactions of age and sex with socioeconomic position and perceived unfairness and of socioeconomic position with perceived unfairness did not show a consistent pattern of age or sexspecficity of our findings hence no interactions were modeled in the subsequent analyses table 2 shows that perceptions of unfairness were related to both physical and mental decline between 2003 and 2010 although the latter only when perceived unfairness was introduced as a continuous score persons reporting much perceived unfairness had a 175 116262 and 148 higher odds of physical and mental decline respectively low socioeconomic position was related to mental decline but not physical decline persons with a low socioeconomic position had a 182 higher odds of decline in mental functioning than persons with a high socioeconomic position when both were controlled for each other both odds ratios decreased but not substantially for example above odds ratio of mental decline for low socioeconomic position decreased from 182 to 176 and remained statistically significant when only the change between 2008 and 2010 is considered a similar pattern of results is found although perceived unfairness appears to lose its statistical significance when related to physical decline and when controlled for socioeconomic position when all variables are introduced as continuous measures a similar pattern is found although now the only nonsignificant finding is that of the association between low socioeconomic position and physical decline regression coefficients for both socioeconomic position and perceived unfairness decreased only little when simultaneously controlled both foremost have independent effects on healthrelated decline discussion addressing general perceptions of unfairness both in work and beyond work we found that middleaged and older persons with a low socioeconomic position more often reported such perceptions than persons with a high socioeconomic position both socioeconomic position and perceived unfairness were related to healthrelated decline in mental functioning in the sevenyear followup interval perceived unfairness was also related to healthrelated decline in physical functioning but low socioeconomic position was not when socioeconomic position and perceived unfairness were simultaneously controlled odds ratios for both determinants decreased only very little hence despite their association perceived unfairness and low socioeconomic position foremost had independent associations with the outcomes unfairness at least the perception thereof is an important predictor of functional decline the question rises whether it is the subjective perception in itself that matters for health or whether there is something unfair about the environments in which these perceptions of unfairness are rooted despite perceived unfairness being more common in lower socioeconomic status groups a the socioeconomic continuous score is a standardised score with mean 0 and standard deviation 1 higher scores indicate worse socioeconomic status b perceived unfairness continuous score ranges from 0 to 4 c model 1socioeconomic position and perceived unfairness not simultaneously adjusted d model 2 socioeconomic position and perceived unfairness simultaneously adjusted only a small part of the odds ratio for perceived unfairness was explained by our measure of socioeconomic position this indicates the possibility of residual confounding by socioeconomic factors maybe more specific unfair situations would have provided more insight into the environmental roots of the perceptions of unfairness for example effortreward imbalance at work and at home might prove one of the more specific routes through which unfair environments influence perceptions of unfairness and ultimately individual healthrelated functioning 1718 similarly unfairness perceptions might also be fuelled by the unfairness of restricted opportunities for upward social mobility 19 living in toxic areas 20 or being stigmatised and discriminated 21 in short more research is needed to find out whether in order to improve public health it is more effective to have persons change their frustrating perceptions or to have the fundamental environmental unfairness and injustice diminished methodological issues first nonresponse at baseline is substantial as is the attrition between 2003 and 2010 nonrespondents and those who left the cohort were more often of a low socioeconomic position more often reported perceived unfairness and more often reported poor functioning this pattern might have contributed to an underestimation of the strength of the associations in the current report of the 1282 participants 36 had their sf36 data imputed as per the sf36 guideline most of whom with only one item missing the simple personal mean imputation remains a viable and appropriate approach using the sf36 22 furthermore some might have died prior to baseline and others have died during followup mortality as an extreme form of functional decline might also have resulted in underestimated associations in our report however both perceived unfairness and socioeconomic position were not related to the risk of mortality between 2008 and the end of 2010 second our study relied solely on selfreports which may have led to information bias in our perceived unfairness and functioning measures individuals with a general tendency toward complaining may overreport perceived unfairness and mental or physical dysfunction this may have led to an overestimation of the association between perceived unfairness and healthrelated functioning however we used longitudinal data and controlled for functioning at baseline in 2003 next to excluding reversed causation we assume that this will have also eliminated bias due to excessive complaining more research is needed regarding how differential item functioning might additionally have affected our findings 23 third in the absence of validated cutoffs the cutoffs used in the logistic regression analyses might have been too crude and too arbitrary 16 for the sf36 outcome we defined decline as reporting a decline that at least is one standard deviation more than the mean decline using two standard deviations would have left two few decliners the findings of the sensitivity analyses using the original continuous variables confirm the general pattern of findings conclusion our findings suggest that the general perception of unfairness at work and beyond work might have substantial implications for both physical and mental functional decline in middle and older age although in our cohort perceived unfairness is more common in low socioeconomic positions both have foremost independent effects on functional decline however rather than addressing and changing individual perceptions of unfairness more research is needed to find out whether environments can be defined as unfair and whether such environments can be effectively tackled in an attempt to truly improve public health competing interests the authors declare that they have no competing interests

background people in lower socioeconomic positions report worse healthrelated functioning only few examined whether perceptions of unfairness are particularly common in these people and whether this perceived unfairness relates to their subsequent poor health outcomes we thus set out to examine the contribution of perceived unfairness to the higher risks of physical and mental dysfunction in men and women with a lower socioeconomic position methods sevenyear prospective cohort data from the dutch smile study among 1282 persons 55 years old and older were used physical and mental healthrelated functioning was measured with the sf36 socioeconomic status with income and education and the perception of unfairness with an extended new measure asking for such perceptions in both work and nonwork domains results perceived unfairness was more common in lower socioeconomic positions such perpection was related to both physical odds ratio 157 95 confidence interval 117211 and mental 147 107203 decline while low socioeconomic position was only related to mental decline 133 106167 when socioeconomic position and perceived unfairness were simultaneously controlled odds ratios for both determinants decreased only very little socioeconomic position and perceived unfairness were for the largest part independently related to longitudinal healthrelated decline conclusions the general perception of unfairness at work and beyond work might have implications for functional decline in middle and older age we recommend thatrather than addressing and changing individual perceptions of unfairnessmore research is needed to find out whether specific environments can be defined as unfair and whether such environments can be effectively tackled in an attempt to truly improve public health

theoretical framework as well as our emphasis on strengths offers a novel approach towards understanding the complex factors that influence stress and resilience in vulnerable families toxic stress in childhood in an effort to understand how stress impacts development over time researchers have proposed a conceptual taxonomy consisting of three types of stress response in early childhood in a toxic stress response persistent elevation of a childs stress response system results in a complex release of glucocorticoids catecholamines and inflammatory cytokines that disrupt development of the brain and neuroendocrine immune metabolic and cardiovascular systems a toxic stress response is consequently associated with impaired health and developmental outcomes throughout the lifespan including obesity growth delay and impaired cognitive skills in childhood and depression alcoholism diabetes and cardiovascular disease in adulthood given the vast array of consequences associated with a toxic stress response in early childhood prevention of toxic stress is critical for promoting health and reducing health disparities in vulnerable families preventing toxic stress among vulnerable families in environments of adversity caregivers can play a crucial role in toxic stress prevention evidence from human and animal models demonstrates that positive caregiving characteristics and a secure maternalchild relationship can help protect children against a toxic stress response the presence of a supportive caregiver has also been identified as an essential component for the development of resilience or the ability to thrive despite the presence of adversity however providing this protection can be tremendously challenging for caregivers who are vulnerable due to poverty young age or ethnic minority status vulnerable caregivers particularly mothers are faced with a multitude of unique stressors that occur on individual community and societal levels for example impoverished or young mothers may experience vulnerability due to a lack of tangible or personal resources while ethnic minority mothers may experience structural racism or interpersonal discrimination mothers who experienced toxic stress during their own childhoods may also be poorly equipped to manage stressful situations as adults the result is a paradoxical situation in which vulnerable mothers are charged with the dual responsibility of managing their own poorly regulated stress response systems while also protecting their children from the effects of exposure to multiple stressors thus in order to support vulnerable mothers to protect their children from a toxic stress response we must first understand the complexity of their environmental stressors and the strengths that promote effective coping while childhood trauma or adversity may occur within any demographic or social class socially and economically marginalized families are at an increased risk for adverse experiences and thus may significantly benefit from toxic stress prevention and intervention efforts guided by bronfenbrenners bioecological model we will review the current health sciences literature on vulnerable mothers stressors and strengths identify gaps in knowledge requiring further investigation and develop a research agenda that will guide future investigations of factors that impact caregiving in families at risk for toxic stress according to bronfenbrenners bioecological model an individuals development is influenced by ones surrounding environment bronfenbrenners model consists of four interconnected structures surrounding the individual the microsystem mesosystem exosystem and macrosystem the microsystem situated most closely to the individual is theorized to have the most direct influence on development in each following layer of the model the influence of each system becomes less direct bronfenbrenner ceci 1994rosa tudge 2013 in this scoping study the use of the model serves three primary purposes to guide the selection and classification of studies for review to organize the study findings and to provide a theoretical basis for analysis of results the mesosystem is excluded as it describes interactions between two or more microsystems and thus is unlikely to yield any additional information purpose the aim of this scoping study is to advance the science of toxic stress prevention by exploring the stressors and strengths experienced by vulnerable mothers through application of a theoretical framework for the purposes of this study vulnerable mothers are defined as those who are at a disproportionate risk for experiencing toxic stress due to poverty young maternal age or ethnic minority status with a focus on both stressors and strengths this framework may be used to direct future lines of research and develop interventions and policies to prevent exposure and adverse outcomes of toxic stress through both stressreduction and strengthsbased approaches methods this scoping study follows the methodological framework introduced by arksey omalley which includes five stages identifying the research question identifying relevant studies study selection charting the data and collating summarizing and reporting results we also used enhancements to the methodology as suggested by levac colquhoun and obrien including use of a medical librarian to improve the search strategy and an iterative process for study selection and data charting scoping studies have been proposed as a method to identify literature about a broad topic synthesize a wide range of research material and identify gaps in the literature they also may be used to achieve conceptual clarity guide policy decisions or direct more focused lines of research scoping studies typically address broad research questions include a variety of study designs and allow for intellectual creativity identifying the research question this scoping study is guided by two overarching research questions first what is in the literature regarding sources of stress for vulnerable mothers and second what is in the literature regarding coping mechanisms or strengths for vulnerable mothers these broad research questions allow for a comprehensive approach with direction from the theoretical framework to provide organization and clarity identifying relevant studies search strategyafter consultation with a medical librarian electronic database searching and hand searching of reference lists were used to identify relevant literature electronic databases were searched in the fall of 2017 with the following terms as keywords mother maternal parent caregiver poverty poor lowincome welfare medicaid vulnerable minority underserved stress challenges coping resilience protective and strengths terms were searched in combination with boolean operators until each database was exhausted and no additional references were obtained eligibilitytimeframe and language were applied as eligibility criteria using electronic limits in the databases studies were also limited to those conducted in the united states in order to provide results generalizable to the us population a timeline of 1996 to the present was chosen based on the establishment of the personal responsibility and work opportunity act the most significant welfare reform policy to date this policy places a fiveyear lifetime limit on the timeframe for receiving government assistance and requires persons to obtain employment within two years at which time benefits are reduced or terminated entirely the requirements of this policy have a profound impact on vulnerable mothers and thus the findings of this review reflect sources of stress and strength under contemporary us social policies study selection inclusion and exclusion criteriainitial database searching yielded 2161 results after eligibility criteria were applied and duplicates were removed 409 sources remained the researchers then reviewed each study for relevance to the research questions and inclusion exclusion criteria were applied at this stage studies were included if the authors investigated vulnerable mothers as previously defined studies examining only fathers or other caregivers were excluded however studies including multiple groups were included if findings specific to vulnerable mothers were presented studies were excluded if the maternal stress examined was related to a nongeneralizable condition such as hiv status or preterm birth studies with outcomes pertaining exclusively to pregnancy or children were also excluded for example a number of studies examined maternal stress and its impact on child behavior unless the study offered insight into the source of stress for the mother these studies were excluded charting the data after abstract review 167 studies were selected for inclusion an additional 12 studies were added through handsearching of reference lists in total 179 studies with varying designs were identified for use in the scoping review next key information from each article was applied to a table for organization and synthesis the information extracted included the social ecology level methodology population findings and additional relevant information studies that addressed more than one level of the theoretical model were categorized accordingly for example in a study of multiethnic mothers living at or below the federal poverty level dunkel schetter et al identified multiple sources of stress including personal life events and racism a second reviewer randomly assessed 10 of studies for application to the model and conflicting results were discussed until reviewers reached an agreement on proper categorization an example of data charting is provided and a complete table of references is available online collating summarizing and reporting results a numerical summary of the designs and population characteristics of the included studies is presented in table 2 studies categorized within each level of the bioecological model were examined for patterns and unique themes results are reported according to the identified stressors and strengths within each level of the model a summarization of findings is presented in table 3 with a schematic of relationships presented in figure 3 quality appraisalthe purpose of a scoping study is to obtain the breadth of available literature rather than the depth and thus scoping studies do not serve to assess the quality of the literature reviewed the scoping methodology was selected for the current study based on the breadth of available literature and the overall aim to provide a framework for understanding vulnerable mothers stressors and strengths that will direct future scientific inquiry on toxic stress prevention results stress in the individual physiological disruptions related to a history of toxic stressexposure to persistent stress in early childhood may disrupt development of the brains stressresponse system including brain architecture and the hypothalamicpituitaryadrenal axis due to these physiological disruptions mothers who were raised in environments of adversity as children may have difficult managing responses to stress as adults furthermore mothers who experienced the effects of toxic stress are more likely to be impaired in their ability to form healthy coping mechanisms utilize available social supports and become productive members of society thus physiological disruptions related to a history of toxic stress may function as an individual source of stress amplifying the effects of a stressful environment and prohibiting an effective coping response traumatic personal history mental health disordersa mothers personal history of trauma may have consequences for longterm mental health adverse childhood experiences such as abuse neglect or household dysfunction have been linked with a number of poor outcomes including adolescent pregnancy parenting stress and child removal by social services mothers living in poverty have three times higher rates of posttraumatic stress disorder than women from the general population mothers living in poverty also have higher rates of depression and substance use which may be a vicious cycle while depression and substance abuse can result from exposure to chronic stress they also contribute to greater stress for mothers at risk thus traumatic personal history and mental health disorders not only contribute to maternal stress but also may interfere with effective stress management strengths of the individual selfefficacy and empowermentselfefficacy is described as the belief that one has control over ones own outcome vulnerable mothers have expressed improved selfefficacy resulting from successful breastfeeding or fulfilling multiple role responsibilities and vulnerable mothers with higher levels of mastery experience less depression less stress in the parentchild relationship and have children with better developmental outcomes helping others may also be a source of empowerment for vulnerable mothers in an ethnographic study of black lowincome urban mothers investigators found that the ability to help others like donating a childs clothes significantly promoted a sense of self worth a qualitative study of lowincome single mothers identified volunteer work as a coping mechanism used by several mothers both as a source of empowerment and a distraction from their own economic problems one woman in the study stated helping to empower those people…makes me feel like im still human…it gives me a sense of strength within myself personal resources optimism spirituality and resourcefulnessvulnerable mothers use personal resources such as optimism spirituality and resourcefulness to cope with stressors optimism has been demonstrated to buffer against financialrelated stress and depression in studies of mexican american and african american mothers spirituality may provide a source of comfort during times of stress assist with coping with trauma and function as a resource for resiliency in overcoming problems resourcefulness is also a common source of strength for vulnerable mothers lee katras and bauer described the creative strategies used by lowincome rural mothers to provide their children with a normal birthday party such as planning ahead searching for discounts and pooling resources mothers have also described using techniques to manage the appearance of poverty such as placing food bank bags inside of commercial grocery bags stress in the microsystem unpredictable and absent partnersthe relationship with a childs father is a frequently cited source of stress for vulnerable mothers in a qualitative study of rural lowincome mothers participants described the men in their lives as inconsistent and disappointing even when a childs father is involved mothers have expressed feelings of isolation as they continue to hold the majority of parenting responsibilities mothers in poor relationships with their partners are more likely to report depressive symptoms perceived stress use of drugs and smoking than those in good relationships also of grave concern is the presence of intimate partner violence as higher levels of relationship violence are associated with increased economic hardship neighborhood disorder household disrepair and psychological distress not only may intimate partner violence contribute to psychological or physical injury but it can worsen daily stressors and even prohibit successful employment attainment family conflict and traumawhile the family unit is often a source of support family relationships can be conflicted frustrating and stressful for many vulnerable mothers women who had unreliable relationships with their parents as children often continue to have conflicted relationships with family members in adulthood in some cases families may even refuse to recognize or protect against abuse leading to further stress and potentially physical harm coresidence and shared caregiving with the childs grandparents can often contribute to positive outcomes especially for adolescent mothers however in conflicted family units mothers who continue to reside with their own parents may experience more stress than support kalil and danziger found that for adolescent mothers grandmother coresidence did not decrease depression parenting stress childcare problems or domestic violence the stress related to grandmother coresidence may be the result of a number of processes increased maternal grandmother involvement has been associated with decreased father involvement over time which may contribute to further conflict and stress coresidence with ones parents may also reflect personal factors that both contribute to stress and prohibit a mother from living independently such as young age single parenthood or a history of mental illness children and childcareelevated stress in vulnerable mothers has been associated with an increased number of children in the home children with a difficult temperament or behavioral problems and the hassles of finding childcare poverty is associated with an increased risk for childhood disability which can result in increased stress and depression for vulnerable mothers children with a disability or chronic health condition may contribute to daily stress by quickly depleting both physical and emotional resources for a mother for example mothers of children with asthma experience more life stressors than mothers of children without asthma and poor asthma control has been associated with poor quality of life for lowincome single mothers strengths in the microsystem intimate partner supportalthough an unavailable or unstable partner can greatly contribute to maternal stress partner presence can also have a positive impact on vulnerable mothers emotional support from a partner has been associated with decreased maternal depression and parenting stress as well as improved maternal mastery and child behavioral development a fathers engagement with his children may be largely dependent on the quality of the motherfather relationship as fathers are more likely to be involved over time when the childs mother has a positive relationship with the childs father and his family of note emotional support has been demonstrated to have a greater impact on maternal stress than instrumental or financial support the benefit of partner support is also not limited to the childs biological father as decreased maternal depression is associated with emotional support from other romantic partners as well family support and cohesionin families with a history of trauma family relationships can be a significant source of stress however when relationships are cohesive family members can be a source of both tangible and emotional support in a study of vulnerable mothers with adolescents mothers who reported greater family cohesion also had less parenting stress in a qualitative study of families living in poverty by vandsburger et al participants identified their mutual love and affection for each other their feelings of closeness standing together for each other and their ability to communicate openly with each other as resources they used or as their family strengths by pooling resources extended families can provide a stable support network for financial physical and emotional needs supportive social networksthe importance of social networks that extend beyond the immediate family has been demonstrated in a number of contexts particularly for mothers with limited or unreliable family supports for example social networks have been found to improve maternal responsiveness and buffer against psychological distress budd holdsworth and hoganbruen found that for adolescent mothers living in foster care satisfaction with social support predicted lower parenting stress members of a church community were occasionally identified as a source of support for vulnerable mothers but other sources of support were often not specifically identified in the studies reviewed stress in the exosystem inability to meet basic needs finances housing and nutritiona number of stressors at the exosystem level affect a mothers ability to meet the basic needs of her family primary sources of this stress include financial strain housing insecurity and food insecurity a study of housed and homeless mothers found that housing insecurity is related to high rates of stress and depression stevens found that food insecurity in young mothers is related to income affordable food sources housing and transportation these exosystemlevel stressors create an environment for many women in which meeting their familys daily needs can be a significant challenge unsafe neighborhoodsanother significant source of stress for mothers living in poverty is the neighborhood environment unsafe neighborhood environments cause mothers to worry about the safety of their children and prevent children from playing outside in a study of latina mothers and children enrolled in a head start program aisenberg found that 806 of children had been exposed to at least one act of community violence 71 had heard gunshots near their home and 97 had heard gunshots near the head start site unsafe neighborhoods also have an impact on maternal mental health and the maternalchild relationship neighborhood stress and disorder have been associated with psychological distress and an increased risk for problem drinking in lowincome mothers mitchell et al found a direct effect of witnessed violence on mothers depressive symptoms and aggression which in turn had indirect effects on harsh disciplinary practices parental perception of social disorganization including the physical disorder and lack of safety in a neighborhood has also been associated with perceived parenting stress adolescent depressive symptoms and adolescent delinquency social isolationsocial isolation can also be a source of stress for vulnerable mothers housing developments may be geographically isolated resulting in limited access to necessities availability or affordability of public transportation may create a barrier to obtaining quality food limit employment opportunities or affect relationships among friends and family members who live distances apart mothers living in rural areas with diminished social networks may be particularly vulnerable to social isolation and face added daily hassles such as securing adequate food or finding available babysitters mothers may also experience selfimposed isolation if they avoid social contact due to a history of depression trauma or perceived neighborhood violence strengths in the exosystem public programs and nonjudgmental service providersin the healthcare literature reviewed very few studies investigated the strengths of the exosystem to support vulnerable mothers teitler reichman and nepomnyaschy found that lowincome single mothers rely very heavily on public support programs and stevens identified food banks and federal programs as resources used by mothers to cope with food insecurity the delivery of social services can also impact maternal stress hill and cain found that mothers exhibited lower levels of psychological distress when they perceived their welfare caseworker to be interested caring and helpful stress in the macrosystem limited employment opportunitiesat the macrosystem level the limited availability of secure wellpaying jobs is a major source of stress for many vulnerable mothers social disorganization and low quality school systems often limit opportunities for quality education and available employment opportunities are often low paying offer no benefits and have unpredictable hours the caregiving responsibilities of single motherhood present an added challenge to maintaining regular employment or obtaining safe and affordable childcare work absences related to childcare responsibilities often result in a loss of employment for mothers juggling multiple roles furthermore due to low wages or limited benefits employment may not actually reduce a mothers financial strain even when moving from welfare to work racism stigma and acculturative stressstress related to racism stigma and acculturation presents a daily challenge for many vulnerable mothers in addition to structural disadvantage daily experiences of racism can also be significant sources of stress for vulnerable mothers experiencing racial discrimination is associated with depression risktaking behaviors family conflict and psychological distress vulnerable mothers also may experience stress related to acculturation or stigma and language barriers or povertyrelated shame may prevent women from seeking assistance from social programs or mental health services gendered caring responsibilitiessocietal expectations largely place the burden of caregiving on women this is particularly challenging when paternal involvement is limited variable or nonexistent these caregiving responsibilities not only create an obstacle to maintaining employment but the stress associated with single motherhood can have a negative effect on overall health women are also often charged with an additional burden of caring for ill or older relatives this multigenerational caregiving responsibility can further deplete emotional and physical resources and has been associated with increased caregiver stress and risk for mental illness with the expectation to be the primary caregiver for two generations a situation exacerbated by a lack of financial resources women are burdened with genderspecific responsibilities that may contribute to a lifetime of structural disadvantage strengths in the macrosystem benefits of welfare to work policiesin this review very few studies included sources of support for vulnerable mothers at the macrosystem level there is some evidence to suggest however that the employment required through welfare to work policies can have positive impacts on maternal mental health while not always financially beneficial for mothers employment has been associated with reduced parenting stress improved selfesteem and increased social integration discussion the sources of stress and strength for vulnerable mothers are multilayered and complex the application of a theoretical model allows for a focused examination of the factors influencing each ecological level while also providing an overall picture of the complex interplay of maternal stressors and strengths within this model it is important to be aware that these stressors and strengths are transactional in nature and have a complex influence on caregiving in vulnerable families for example discrimination related to racism at the macrosystem level may have a direct or indirect influence on maternal mental health symptoms at the individual level family relationships at the microsystem level and use of social programs on the exosystem level conversely individuallevel optimism can buffer against depression related to racism at the macrosystemlevel thus the layers of the theoretical model must be seen as fluid dynamic and interpreted within the context of the individual family the results of this scoping study may inform research on toxic stress prevention in a number of ways first researchers can continue to examine sources of stress and strength for vulnerable mothers and work to fill in gaps in knowledge identified for each level of the bioecological model for example on the microsystem level social support was defined in a very general sense in many of the studies reviewed thus limiting usefulness for future research studies and the development of interventions future research with vulnerable mothers should include explicit descriptions of social support such as support offered by friends coworkers or churchbased support groups the role of social networks should also be examined in association with stressrelated outcomes at the exosystem and macrosystem levels large gaps in knowledge highlight the need for community based participatory research as community participants and stakeholders may best describe these stressors and strengths toxic stress prevention also requires an examination of the relationships among stressors strengths and caregiving for each level of the bioecological model in this scoping study personal trauma history family conflict and unsafe neighborhoods were among the many stressors associated with parenting stress and harsh parenting styles in vulnerable families while the relationship between maternal stressors and harsh or neglectful caregiving should continue to receive attention in research studies research on toxic stress prevention must extend beyond simply identifying and preventing negative parenting behaviors in order to promote optimal outcomes for children in vulnerable families maternal strengths and positive components of caregiving must receive equal attention in the literature the results of this scoping study may also be used to guide the development of preventive interventions and social policies that may reduce stress enhance strengths and promote protective caregiving in vulnerable families previously unrecognized individual sources of strength such as the empowerment related to volunteerism offers exciting potential for the development of innovative interventions to support and empower vulnerable mothers future research regarding the role of social programs in reducing maternal stress can also provide valuable insight for future policies and interventions that may have a macrolevel impact on socially and economically marginalized families however stressors identified at the macrosystem level including racism stigma and gendered caring responsibilities also represent challenges to implementing effective policies an upstream approach to reducing maternal stress will require consideration of these barriers and efforts to address them policies such as paid parental leave a minimum living wage and modified work requirements for mothers receiving public assistance will be crucial for promoting strengths in vulnerable families finally findings of this scoping study can provide a basis for future biobehavioral research on the causal relationships among ecological stressors and strengths maternal caregiving and indicators of a toxic stress response in children indicators of toxic stress may include primary mediators of the stress response such as cortisol or inflammatory cytokine levels or health and developmental outcomes associated with toxic stress such as obesity growth delay or impaired cognitive skills with a focus on the complex pathways that promote toxic stress prevention biobehavioral research can significantly contribute to promoting health and reducing health disparities among vulnerable families this scoping study does not provide an exhaustive list of ecological stressors but an overview of stressors and strengths to guide future research on toxic stress prevention following the scoping review methodology we used broad search terms related to stress coping and our target population but did not include keywords related to specific causes of stress or known consequences of stress while great pains were taken to represent a wide range of data sets methodologies and research groups it is possible that important aspects of the literature were missed using this approach due to the breadth of literature included studies were not evaluated individually for their validity or rigor and thus interpretation of the results may be limited future integrative or systemic reviews targeting stressors or strengths within each level of theoretical framework will make a valuable contribution to literature in this area this scoping study only included studies conducted with mothers in the united states while this enhances the generalizability of the study to the us population the stressors and strengths experienced by vulnerable mothers in other cultures require future examination understanding the unique stressors and strengths experienced by other caregivers such as fathers grandparents or foster parents is also an important area for future research finally this study is limited by a focus on literature from the health sciences gaps noted in this review such as a lack of information on strengths at the exosystem and macrosystem levels may be better addressed by the social sciences economics or health policy literature future reviews on the sources of stress or strength for vulnerable mothers would be strengthened by the use of literature from a diversity of fields advancing the science of toxic stress prevention is crucial for promoting the health of vulnerable families researchers can use the presented model and study findings to pose research questions and empirically investigate relationships among maternal stress protective factors and indicators of a toxic stress response in children by examining maternal stressors and strengths through the lens of toxic stress prevention researchers can utilize their unique perspective and significantly contribute to a critical area of research in the fields of toxic stress and family health supplementary material refer to web version on pubmed central for supplementary material

toxic stress is associated with poor health outcomes that extend across the lifespan while caregivers can protect their children from toxic stress through supportive caregiving this can be challenging for vulnerable mothers living in socioeconomically disadvantaged environments we aim to advance the science of toxic stress prevention by exploring the stressors and strengths experienced by vulnerable mothers through application of a theoretical framework bronfenbrenners bioecological model following arksey and omalleys fivestage scoping study framework 179 articles were included key information was abstracted and each article was reviewed for relevance to the bioecological model results revealed that the sources of stress and strength are multilayered transactional and have a complex influence on caregiving in families at risk for toxic stress future research should include empirical investigations of the complex relationships among these stressors and strengths and the development of preventive interventions to support vulnerable families at risk for toxic stress

introduction with the advent of computers which progressively became more powerful over time computing evolved from an arcane world where programmers wrote in computer code on punch cards fed to mainframes to a world where the computer interface is accessible on a smartphones screen this evolution took many iterations to reach the current stage where information can now be accessed using a feed with artificial intelligence running behind the scenes thus artificial intelligence techniques where training data uses backpropagation and parameters to learn the data and predict outcomes and generate new output based on prior training and current stage where information can now be accessed using a feed with artificial intelligence running behind the scenes thus artificial intelligence techniques where training data uses backpropagation and parameters to learn the data and predict outcomes and generate new output based on prior training and user input was born ai is therefore considered a branch of computer science that leverages intelligent entities to make predictions based on patterns in data employing algorithms 12 one of the applications of ai has been in creating language modelsai systems that produce texts similar to humans based on machinelearning algorithms many ai tools such as chatgpt chatbots and language translation 13 are used in various fields for variable purposes including the healthcare industry chatgpt responds to textbased inquiries from the audience to provide helpful responses to specific questions and comments particularly in medicine this tool has been used by many healthcare professionals to obtain fast and accurate responses to healthrelated queries hence accelerating the clinical practice guidelines 4 as such ai has greatly influenced the medical and biomedical research landscape today 12 statistics in particular uses mathematical assumptions such as normal distributions and probability assumptions machine learning extends these ideas leveraging the power of computers to develop a perceptron and run data through such conceptual structures multiple times for example a tree would repeatedly split data to reach a prediction a random forest is a forest of such trees that together capture the meaning of the data in supervised machine learning a known outcome against which predictions are calculated in part of the data and compared to actual outcomes in the output data consider nearest neighbors for unsupervised learning wherein several centroids are initialized in data and distance calculated from each centroid to each data point and the position of the centroid is adjusted until there is no further need for adjustment thus data are partitioned into groups using the concept of eigenvectors multiple variables are converted into principal components in principalcomponent reduction deep learning works on unstructured data using concepts developed in neural networks these concepts are extended further in the sequential analysis of text data with the concepts of selfattention and the entire corpus is considered at the same time in transformer models these ideas are illustrated in figure 1 below medicine has always been at the forefront of seeking technological innovations in disease diagnosis and prevention naturally ai was considered as one of the extrapolatory tools to improve patient outcomes 24 today ai and language models are used as tools to analyze medical images such as echocardiograms and angiograms as well as to develop other interventions to improve the diagnosis and management of medicine has always been at the forefront of seeking technological innovations in disease diagnosis and prevention naturally ai was considered as one of the extrapolatory tools to improve patient outcomes 24 today ai and language models are used as tools to analyze medical images such as echocardiograms and angiograms as well as to develop other interventions to improve the diagnosis and management of cardiac complications 15 ai tools could also play a big role in identifying highrisk populations for hospital injury and guide interventions and preventive actions to improve patient safety 6 recent applications of ai in this domain have been in predicting hospitalizations and determining the mortality associated with covid19 78 the prospects and benefits of ai and machine learning use are well recognized and accepted in healthcare today concerning disease diagnosis risk assessment associated with morbidity and mortality surveillance of infectious diseases and outbreak prediction and policy implications 8 9 10 although ai and machinelearning applications are gaining popularity in these arenas the literature is scarce in recognizing their utility for predicting mortality using important determinants such as digital literacy and the social vulnerability index significant predictors of any disease and allcause mortality many us adults use the internet to access information about health conditions today that are directly correlated with ones overall wellbeing in multiple ways 11 according to a recent nationwide survey nearly 60 of us adults reported accessing health information online within the past year the popularity of online access to information has increased over the years as no costs are involved in garnering such information 12 therefore dl which is defined as ones ability to access understand and apply information retrieved digitally is critical in reaching health equity as it enables individuals from all backgrounds to access health information and medical terms through platforms such as computers and social media 13 14 15 similarly the svi is an important metric for forecasting survival according to the communities assets before during and after largescale publichealth disasters such as hurricanes tornadoes and infectious outbreaks the svi index ranges from 0 to 1 with a higher value associated with lower income higher poverty rates and less access to educational resources rendering communities vulnerable to disasters 16 a stark illustration of the importance of social gradient is provided by an evident 48year spread of life expectancy among countries ranging from 34 years in sierra leone to 819 years in japan 1718 similarly in the united states the death rate amongst the socially disadvantaged is triple compared to that of their higher socioeconomic strata peers 1920 the magnitude of the impact of social factors on physical functioning is similar to those of traditional risk factors 21 where increased deprivation of social privilege is associated with increased cardiovascular mortality 22 an association between living in a socially advantaged area as opposed to a disadvantaged area has been previously described 20 showing a decrease in purchasing power to be associated with an increase in coronary artery disease and its risk factors additionally socioeconomic status was found to favorably modulate the increased acute cardiovascular mortality conferred by exposure to particulate matter in the phoenix area 23 different measures of social status have been used in the past to highlight the effect of disparity for instance marmot 17 in their article illustrates a gradient of mortality from the poorest 20 to the richest moissl et al 20 used purchasing power as a measure while wilson et al 23 used education and income machinelearning techniques have been found to identify novel predictors of cardiovascular outcomes 24 in comparison with conventional techniques thus contributing to advancements in knowledge validation of unsupervised machine learning using principalcomponent reduction at identifying clinically relevant cardiovascular risk factors illustrates the potential of these modern techniques in identifying latent relationships 2526 and adds another dimension to be consideredto expose heretofore unknown relationships in other words traditional statistics and supervised machine learning involve the generation of hypotheses and mathematical techniques such as linear regression in unsupervised machine learning abstract mathematical techniques and computing power are used to understand the underlying patterns in data a prior study on the use of large language models on the uk biobank 27 exploits the ability of such models a llm projects words as vectors into a multidimensional space and identifies relationships using distance measures han et al 27 illustrate how this can be accomplished by converting tabular data to text and feeding it to the llm each row of their data is presented to the llm as a sentence llms exploit relationships found in languages or strings of words rather than tabular data thus the format of the data submitted to the model was modified appropriately by the authors of this paper llms also produce inconsistent results based on the system message the input of the settings in the prompt and the nature of the examples provided in our analysis we use measures of the svi and dl with standard supervised machinelearning techniques for our analysis we used the llm to identify variables and generate code rather than to do the actual analysis of tabular data due to the known limitations of the llm outlined above additionally the python code generated by the advanced analysis module of chatgpt4 was verified by running it on a local machine with local data to verify consistent output both svi and dl can be considered in mathematical models leveraging machinelearning techniques to predict the diseasespecific mortality rates for various geographic locations however machine learning has not been explored as a potential tool to predict cardiovascular mortality using these major predictors this technique can be a useful tool to explore these leading causes of mortality using key predictors such as svi and dl among others the leading causes of death in the us are displayed in figure 2 identifies relationships using distance measures han et al 27 illustrate how this can be accomplished by converting tabular data to text and feeding it to the llm each row of their data is presented to the llm as a sentence llms exploit relationships found in languages or strings of words rather than tabular data thus the format of the data submitted to the model was modified appropriately by the authors of this paper llms also produce inconsistent results based on the system message the input of the settings in the prompt and the nature of the examples provided in our analysis we use measures of the svi and dl with standard supervised machinelearning techniques for our analysis we used the llm to identify variables and generate code rather than to do the actual analysis of tabular data due to the known limitations of the llm outlined above additionally the python code generated by the advanced analysis module of chatgpt4 was verified by running it on a local machine with local data to verify consistent output both svi and dl can be considered in mathematical models leveraging machinelearning techniques to predict the diseasespecific mortality rates for various geographic locations however machine learning has not been explored as a potential tool to predict cardiovascular mortality using these major predictors this technique can be a useful tool to explore these leading causes of mortality using key predictors such as svi and dl among others the leading causes of death in the us are displayed in figure 2 the research question of interest for our study was whether svi and dl predict variability in crude and ageadjusted cardiovascular mortality at the county level our study had two specific research objectives as follows 1 evaluate if svi and dl can significantly predict cardiovascular mortality for the general us population living in various states 2 evaluate the utility of ai tools specifically chatgpt to predict cardiovascular mortality rates for different geographic locations materials and methods data files and merging freely available national databases were utilized to retrieve the variables of interest for our exploratory analysis crude mortality data was obtained from cdc wonder 29 and the ruralurban county designation and years were obtained from the us department of agriculture 30 the cdc wonder websites graphical user interface has several selection choices the stepwise process of variable selection is listed in table 1 below the research question of interest for our study was whether svi and dl predict variability in crude and ageadjusted cardiovascular mortality at the county level our study had two specific research objectives as follows 1 evaluate if svi and dl can significantly predict cardiovascular mortality for the general us population living in various states 2 evaluate the utility of ai tools specifically chatgpt to predict cardiovascular mortality rates for different geographic locations materials and methods data files and merging freely available national databases were utilized to retrieve the variables of interest for our exploratory analysis crude mortality data was obtained from cdc wonder 29 and the ruralurban county designation and years were obtained from the us department of agriculture 30 the cdc wonder websites graphical user interface has several selection choices the stepwise process of variable selection is listed in table 1 below the python census package along with census api and the following python code allowed data on internet access and literacy to be downloaded easily digital literacy is a metric derived from this data the abbreviated python code used is presented below with key steps shown data on social vulnerability is available at cdcatsdr and allows for the selection of year state and county an excerpt from the python code indicating the variable of interest chosen is presented below specify basic variables for age gender household type and race variables b01002001e b01001002e b01001026e b11001002e b11001007e b02001002e b02001003e b02001005e b02001008e autopsyall values iii place of deathall places 6 select cause of death i select the icd10 choice ii diseases of the circulatory system these two files were merged using the federal information processing standards code the fips codes are a standardized set of alphanumeric codes to ensure uniform identification of geographic entities such as states and counties in the united states 31 initial data exploration involved data from 1999 through 2020 from the cdc wonder website for crude cardiovascular mortality using icd10 codes i00i99 and county and ruralurban geographic categorization as choices a linear regression line was fitted for change in crude cardiovascular mortality over time for the different ruralurban categories the final data frame had 65791 rows for each years file missing values were dropped before merging which were checked at every step of the merging process no missing values were generated these data were used to develop model 1 32 the dataset used to calculate the final ageadjusted mortality rate using the same icd10 codes and geographic choices for 2020 had 3118 rows with no duplicates with 32 missing values for the ageadjusted rate and three missing values for the svi and digital literacy a left merge was used in all merging instances using the mortality data as the file on the left thus all the available mortality data was preserved during the merge and these data were used to develop model 2 33 svi and dl as variables were merged using fips resulting in a data frame to predict ageadjusted mortality the final analysis was conducted considering a complete case analysis after removing the rows with missing values in the ageadjusted rate column we were left with 3118 observations for model development selection of chatgpt4 and python integration during the study we used us governmental data which upon early exploration was noted as having the primary drawback of being too broadthat is it contained more variables than needed for our study to address this issue we selected an llm to search the data for the defined parameters by highlighting variables of interest through prompts the llm generated codes to build a commaseparated file the file was reviewed before being fed back to the llm using the parameters to write codes based on the python language code coherency was verified on a local computer by testing the codes dataset against the sources original dataset by looking at the analysis results important consideration of integration chatgp4 itself is in a sandbox state and thus cannot directly access data on the internet the user must provide access by uploading the data to a global cache the data frame generated from running this code locally was then uploaded along with a prompt to chatgpt4 after enabling advanced data analysis a beta feature all data generated by chatgpt4 was downloaded locally any code generated by the llm was run to verify and replicate the analysis use of chatgpt as a beta feature chatgpt4 being an llm is not particularly suited for the analysis of tabular data the advanced dataanalysis beta feature allows prompting of chatgpt4 which in turn generates python code using the advanced analytics and in turn uses the uploaded data file to generate the results requested this python code was then downloaded and modified to appropriately test on data on a local pc for the verification of results chatgpt 4 was prompted to identify variables there are several methods by which one interacts with llms these methods are named prompting a prompt includes a system message and a user prompt an early decision not to use python to interact with chatgpt 4 was made to keep the interaction with the llm simple to follow a paid chatgpt 4 account was the foundation of the analysis such an account allows access to beta features including advanced data analytics additionally custom instructions were given to chatgpt 4 to act as a data scientist using census data and to write output in the american heart association format a prompt includes several technical components including the maximum number of tokens temperature topp and frequency penalty the techniques of the prompts include multipleshot fewshot and singleshot techniques this implies multiple examples of input and output a few examples or a single example of input and output we used a singleshot technique for our study that is to say the prompt included an example of the output desired when appropriate prompting continued to obtain information about crude and ageadjusted cardiovascular mortality data sources and variable names additionally details on the socioeconomic countylevel data variables available for download were sought once these files were obtained in a commaseparated format further prompts to obtain python code for data manipulation were obtained each output was then tested on the local pc and the output was assessed as to whether the desired data manipulationstatistical test was carried out correctly once a final clean data file was obtained this was uploaded to chatgpt4 after enabling advanced dataanalysis tools with specific instructions on the stepbystep analysis to be carried out the results were requested in word and commaseparated format python package python package ydataprofiling showed that all the numerical variables had a closetonormal distribution therefore they did not need any transformations data were used as such without any particular feature engineering variables were chosen based on apriori knowledge of the subject rather than by using machinelearning tools thereafter with the python package sklearnlinearmodel we imported linearregression ridge lasso elasticnet sgdregressor huberregressor ransacregressor and lars for model selection sklearnmodelselection and traintest split were imported and from sklearnmetrics meansquarederror was picked data split using testsize 05 and random state 1 allowed us to run the models chosen above using the particular model developed from the trainingdata mortality predicted with the test data allowed calculation of the mean squared error metric this metric was used to compare the various models data integrity assessment and main analytic steps through the use of the python language ydataprofiling package to verify data integrity and quality we were able to ensure sound reasoning after validating the appropriate conversation of data we were then able to explore the interaction effect between mortality and geographical areas through a mixedeffects model with considerations for changes in mortality over the time studied figure s2a a preliminary exploration of dl was made by analyzing svi with reference to ageadjusted mortality at the county level using python refer to section 241 for a detailed description of the dl formula used in this study changes in temporal trends in crude cardiovascular mortality for counties were explored using a mixedeffects statistical model to explore fixed and random effects of different geographic regions this was necessary to address any potential bias when unifying multiple data groups in order to draw accurate conclusions in this instance variability in crude cardiovascular mortality in relationship to year and ruralurban classification was modeled furthermore several mathematical tools were vetted for ageadjusted mortality to identify the most robust model we established that a third of the variation in ageadjusted cardiovascular mortality was accounted for by the two dependent variables once this was accomplished we used linear regressions using the most recent available data for ageadjusted cardiovascular mortality this analysis was implemented using linear regression dependent variables ruralurban status and year were the two dependent variables studied for the mixedeffects model svi and dl were the two dependent variables studied for the year 2020 to develop models studying variability in ageadjusted mortality calculation of dl measure dl as a dependent variable was used following the steps below 1 no internet percentage 32 percent of households without internet in the county × 100 2 no education percentage percent of households without education × 100 3 digital literacy dl 100 noeducationpercentage × 100 nointernet percentage noteno educational attainment variable was derived from the american survey 34 question what is the highest degree or level of school this person has completed this is tabulated as b15003002e in the data file we adjusted the denominator to account for the overestimation of those without formal education justification of dl measure in the european union a measure of dl is the digital economy and society index which tracks europes digital performance 35 the index includes five dimensions connectivity human capital use of internet services integration of digital technology and digital public services the eu has standardized policies and procedures to monitor and track desi rural dwellers with low levels of education and low socioeconomic status significantly lag in adopting the internet 36 in 2010 the us census started to gather specific information about the internet and data from surveys to assess internet access and education data as education is highly correlated with dl therefore from the census we used the inverse of no internet access measures and no education measures to estimate dl the united states office of internet connectivity and growth spent less money on digital literacy in comparison to that spent on internet infrastructure 37 in the european union a measure of dl is the digital economy and society index which tracks europes digital performance 35 the index includes five dimensions connectivity human capital use of internet services integration of digital technology and digital public services the eu has standardized policies and procedures to monitor and track desi rural dwellers with low levels of education and low socioeconomic status significantly lag in adopting the internet 36 in 2010 the us census started to gather specific information about the internet and data from surveys to assess internet access and education data as education is highly correlated with dl therefore from the census we used the inverse of no internet access measures and no education measures to estimate dl the united states office of internet connectivity and growth spent less money on digital literacy in comparison to that spent on internet infrastructure 37 access to resources schools and colleges often provide computer labs internet facilities and formal information and communications technology courses giving students exposure and opportunities to become digitally literate 39 instructional experience the structured curriculum in educational settings often includes components of dl either embedded within subjects or as standalone courses 40 25 regression model for ageadjusted mortality for 2020 a number of regression models were run from which the ordinary least square model was the simplest and best suited for interpretation purposes an exploratory data analysis revealed 99 complete data therefore the missing values were simply dropped and the outliers had plausible values and were used as such we used two predefined features therefore no feature selection processes were needed data split used a 05 setting hyperparameter tuning involved using the settings as follows ols linearregression ridge ridge lasso lasso elasticnet elasticnetsgd sgdregressor huber huberregressor ransac ransacregressor lars lars regression model for ageadjusted mortality for 2020 a number of regression models were run from which the ordinary least square model was the simplest and best suited for interpretation purposes ridge ridge lasso lasso elasticnet elasticnetsgd sgdregressor huber huberregressor ransac ransacregressor lars lars in general machinelearning models are opaqueblack boxes while ols models have interpretable coefficients when considering geographic migration individuals could potentially look at svi and dl values to adjust for mortality data in the ols model the prediction is made by substituting the values in the regression equation the descriptors for model 2 predicting ageadjusted mortality with svi and dl as dependent variables are shown in table 2 2 conversely to generate a prediction using the lgbm regressor model the input values must undergo preprocessing akin to what was done during the initial model training after that these preprocessed values must be fed into the computational model for execution this procedure necessitates access to a computer with the requisite software to execute the mathematical model and the expertise to handle and format the data appropriately these requirements pose technological challenges unlike the simpler ols model where one can input data directly into a calculator using predefined equations y b1 × x1 b2 × x2 c y b1 × x1 b2 × x2 c machinelearning steps for ageadjusted mortality for the year 2020 executing machinelearning algorithms involves performing more than a thousand iterations to finetune the parameters for models like lgbm rf and xgboost resulting in the creation of a thousand trees each iteration aims to rectify the mistakes made by the collective ensemble of models with each iteration the model recognizes features in terms of their importance and uses various techniques to adjust the loss function each iteration adds a new tree to the ensemble and is fitted to the residuals of the existing tree the lgbmregressor model was chosen for its superior performance in regression analysis evidenced by its lowest mean square error value of 2297 within the lgbmregressor model the dl feature importance was measured at eight and at five for thesvi the ols model mean square error value of 2373 was pretty close to the best model we thus opted for the more concise ols model to limit resource consumption and in the interest of ease of understanding large language modelchat gpt4 as a detective agency chatgpt4 is a llm 41 based on transformer architecture and consists of two main parts an encoder and a decoder the encoder converts the input text into dense vectors or embeddings and considers the position of each word a portion of the encoder focuses on different parts of the input sentence these outputs are passed to feedforward neural networks layer normalization and residual connections form the rest of the encoder structure the decoder has an output embedding with a structure similar to that of the encoder the first step is to break down the prompt into a sequence of tokens which are the smallest units the model can understand these tokens are then embedded into vectors representing them in a highdimensional space each token then considers other tokens in the input when giving a response each attention output is fed into a feedforward neural network that applies learned transformations and this passes through multiple such layers only a certain number of tokens can be considered higher scores are assigned to tokens more relevant to the query and an output is generated the investigative layers of language models summarizing these steps are displayed in table 3 this is similar to the first detective who reviews clues and consults the agencys database to find the most relevant clues compared to past cases feed forward network identified tokens are analyzed with some being combined and others discarded this is analogous to a team of detectives refining the case based on prior cases stacking layers an iterative process each layer builds on the findings of the previous layer using attention mechanisms and backpropagation this is similar to clues being continuously refined in terms of their significance decoder conclusion the process concludes by suggesting a variable name as the output this is similar to a process in which detectives reach a consensus and generate an output contextualization the model considers the n most recent tokens to keep the process in context this is similar to a detective who keeps the case history especially when the investigation is part of a larger context the detectives context the output is based on the clues provided the detectives expertise and their collaborative reasoning if this case is part of a broader investigation the detectives keep a case history to ensure their suggestions are consistent and contextually appropriate similar to how gpt4 maintains context in a conversation therefore using natural language prompts and directing chatgpt4 to find the variables of interest to create specific tables becomes a simple process an example of how chatgpt4 acts as a detective agency to find information about internet use from the census data is demonstrated below in figure 5 results ruralurban level analysis of crude cardiovascular mortality data exploratory data analysis leading to model 1 the regression and rucc1 models for ruralurban categories suggest clearly identifiable trends indicating that they are not properly capturing variability in the 1999 to 2020 crude cardiovascular deathrate data furthermore the polynomial regression model and the rucc have different baselines and slopes suggesting a change in the model from regression to a mixedeffects model please see figure s2ab and table s1 in the supplementary materials mixedeffects model of crude cardiovascular mortality data data available from 1999 to 2020 were represented geographically to support the crude death rates we observe that the rates decreased from nonmetropolitan to metropolitan and rural to urban areas each category follows the us census bureaus urbanrural designations 34 results ruralurban level analysis of crude cardiovascular mortality data exploratory data analysis leading to model 1 the regression and rucc1 models for ruralurban categories suggest clearly identifiable trends indicating that they are not properly capturing variability in the 1999 to 2020 crude cardiovascular deathrate data furthermore the polynomial regression model and the rucc have different baselines and slopes suggesting a change in the model from regression to a mixedeffects model please see figure s2ab and table s1 in the supplementary materials mixedeffects model of crude cardiovascular mortality data data available from 1999 to 2020 were represented geographically to support the crude death rates we observe that the rates decreased from nonmetropolitan to metropolitan and rural to urban areas each category follows the us census bureaus urbanrural designations 34 comprehensive regression model for ageadjusted mortality for 2020 the exploratory data analysis revealed an inverse relationship between ageadjusted mortality and dl and a positive relationship between svi and ageadjusted mortality multiple regression models were used and from these models the ols had an acceptable performance the features of importance of the models are illustrated in figure 9 the rsquared value of the ols simple model was 034 implying that the model captured 34 of the variability in ageadjusted mortality the svi contributed 6 while dl was 18 these rsquare values do not add up to 034 for the full model due to several possibilities including interactions nonadditive effects and the presence of multiple predictors due to mathematical constraints the r squared of the reduced model is always greater than that of the complete model thus the partial r squares do not sum up the 3d graph in figure 8 shows the combined relationship between dl svi and the ageadjusted rate for the year 2020 this graph represents the entire linear regression model results ruralurban level analysis of crude cardiovascular mortality data exploratory data analysis leading to model 1 the regression and rucc1 models for ruralurban categories suggest clearly identifiable trends indicating that they are not properly capturing variability in the 1999 to 2020 crude cardiovascular deathrate data furthermore the polynomial regression model and the rucc have different baselines and slopes suggesting a change in the model from regression to a mixedeffects model please see figure s2ab and table s1 in the supplementary materials data available from 1999 to 2020 were represented geographically to support the crude death rates we observe that the rates decreased from nonmetropolitan to metropolitan and rural to urban areas each category follows the us census bureaus urbanrural designations 34 the exploratory data analysis revealed an inverse relationship between ageadjusted mortality and dl and a positive relationship between svi and ageadjusted mortality multiple regression models were used and from these models the ols had an acceptable performance the features of importance of the models are illustrated in figure 9 the rsquared value of the ols simple model was 034 implying that the model captured 34 of the variability in ageadjusted mortality the svi contributed 6 while dl was 18 these rsquare values do not add up to 034 for the full model due to several possibilities including interactions nonadditive effects and the presence of multiple predictors due to mathematical constraints the r squared of the reduced model is always greater than that of the complete model thus the partial r squares do not sum up the 3d graph in figure 8 shows the combined relationship between dl svi and the ageadjusted rate for the year 2020 this graph represents the entire linear regression model the exploratory data analysis revealed an inverse relationship between ageadjusted mortality and dl and a positive relationship between svi and ageadjusted mortality multiple regression models were used and from these models the ols had an acceptable performance the features of importance of the models are illustrated in figure 9 the rsquared value of the ols simple model was 034 implying that the model captured 34 of the variability in ageadjusted mortality the svi contributed 6 while dl was 18 these rsquare values do not add up to 034 for the full model due to several possibilities including interactions nonadditive effects and the presence of multiple predictors due to mathematical constraints the r squared of the reduced model is always greater than that of the complete model thus the partial r squares do not sum up the 3d graph in figure 8 shows the combined relationship between dl svi and the ageadjusted rate for the year 2020 this graph represents the entire linear regression model all the models rated the dl and svi as features of importance and the coefficient values are similar therefore it would not particularly matter as to which model would be selected as they all seem to have derived a similar understanding of the data regression model for ageadjusted mortality for 2020 when a separate model was run that incorporated 2013 urbanization levels the pvalue coefficients were not significant implying that this variability in the ruralurban divide is successfully captured by dl and svi y 54043 all the models rated the dl and svi as features of importance and the coefficient values are similar therefore it would not particularly matter as to which model would be selected as they all seem to have derived a similar understanding of the data b1 × x1 b2 × x2 b3 × x3 b4 × x4 b5 × x5 b6 × x6 b7 × x7 b8 × x8 b9 × x9 b10 × x10 regression model for ageadjusted mortality for 2020 when a separate model was run that incorporated 2013 urbanization levels the pvalue coefficients were not significant implying that this variability in the ruralurban divide is successfully captured by dl and svi y 54043 the ageadjusted mortality rates using the two regression methods are demonstrated in table 5 with a random selection of counties as demonstrated the ageadjusted rates can be easily predicted using the svi and dl measures to make informed choices about moving to another county certain interesting counties defying expectations are listed in the supplemental methods these counties would be expected to have high mortality and yet did not b1 × x1 b2 × x2 b3 × x3 b4 × x4 b5 × x5 b6 × x6 b7 × x7 b8 × x8 b9 × x9 b10 × x10 discussion in this study we aimed to demonstrate the practical application of an llm specifically chatgpt4 and its benefit to healthoutcomes research because cvd is the leading cause of death in the united states 2842 and underserved areas usually experience higher mortality rates 2842 utilizing machinelearning tools such as llm can help in understanding the geographic imbalances linked to cvd mortality the rationale was to use existing public data from the available quality public resources to feed queries on the variables desired into chatgpt4 to see how closely it would help identify the variable names needed then the rationale was to use chatgpt4 to generate python code to download data and upload the processed data back to chatgpt4 to see how this aligns with the current literature in explaining the variability in mortality due to robust determinants such as dl and svi through chatgpt4 we successfully demonstrated that llms can adequately help demonstrate the relationship between the key determinants such as dl and svi in predicting cvdrelated mortality for various geographic locations innovation in this study we used chatgpt4 to identify variables of interest from large national databases such as cdc wonder and the us census to study the relationship between the explanatory variables and the outcome of interest which has not been explored to date to our knowledge for example the american community survey has roughly 31000 variables for oneyear data and 16000 for fiveyear data 43 with oneyear data available for geographic areas with 65000 people while the fiveyear data was combined to produce data on geographic areas with fewer than 65000 people the adoption of chatgpt allowed us to search through 16000 variables in negligible time which would have been a laborintensive process if done with traditional methods as an llm chatgpt 4 can be relied on to capture the essence of the variables and their meaning thus if we prompted it by asking for a measure of internet access it could be relied upon to understand our query and generate the correct response svi considers multiple factors such as poverty lack of access to transportation and crowded housing that contribute to a communitys ability to prevent human suffering and financial loss in the event of disaster 1636 historically svi has been a key measure to study the management and response to disasters 44 chakraborty 45 and his team demonstrated that socially vulnerable populations are disproportionately exposed to flood risks the application of svi is also popular in the area of infection control 46 where its application allows for the implementation of control measures during pandemics such as covid19 only a handful of studies have used svi as a determinant to study cvd prevalence using national databases 47 48 49 50 using traditional statistical methods dl encompasses a range of skills from basic understanding and usage of computers and internet usage to more complex tasks such as coding and digital content creation 1438 users must possess dl to access digital medical services 15 as such dl is increasingly recognized as a key competency in the 21st century especially in underserved areas as a tool to narrow the equity gaps 1339 through llms we adopted a highly efficient technique to expedite the research process and provide the data to the scientific community at a much faster rate compared to the traditional methods which could also help the practitioners in identifying determinants and making prognosis decisions for patient outcomes to our knowledge this is the first study to use an llm to demonstrate geographic variation in cvdrelated mortality using svi and dl as predictor variables strengths of our study we sourced highquality publicly available data as mentioned above after our data processing and merging steps we were able to retain more than 99 of all us counties in our final analysis the data accessible from cdc wonder 29 one of our data sources is considered the gold standard for these reasons standard datacollection methods rigorous peerreviewed methods ease of geographic search and access to downloadable data for fips timeliness for data archiving and adhering to ethical guidelines for research protocols 51 52 53 similarly our second data source from the us census 3054 demonstrates similar characteristics with regard to its transparency and reproducibility quality control and checks high geographic area granularity with access to fips codes and availability of data via an application programming interface 55 56 57 llms are being widely considered for application in medicine as they can respond to freetext queries without being specifically trained in the task in question however the popularity of llms is mixed with excitement and challenges 58 in this study the investigators devised a plan to use an llm specifically chatgpt4 to bring attention to a major publichealth issuecvdrelated mortality hence we attempted to use chatgpt4 to explore its utility for publichealth research 41 we successfully demonstrated that tools like chatgpt4 can be quite efficient compared to traditional analytical methods proving its utility in healthoutcomes research further with the use of machinelearning tools we demonstrated that determinants such as dl and svi can be used as predictors to study geographicspecific cvdspecific mortality rates automated machinelearning prediction of cardiovascular outcomes correctly identified 368 more cases of first fatal or nonfatal myocardial infarction than the framingham score 59 in the proposed study we followed an approach similar to that adopted by goldstein and colleagues 60 these authors illustrate the benefits of machinelearning approaches in handling nonlinear data reducing the number of predictors and explaining various techniques the authors involved in this study were the subjectmatter experts and statisticians with a vast knowledge of machinelearning techniques when the llm created errors due to various known llm pitfalls reading the code made it easily apparent and fixable for the team one common issue was that the llm failed to import the necessary python packages and assign numerical values to variables before executing the commands despite these challenges the llm generated several functions and newer dataanalysis methods using python and often suggested better and more aesthetic graphics than those conceived by the authors the authors benefited from the collective wisdom of the various coding strategies the llm was trained on and were able to provide highquality visuals for the readers while we used llms to identify the variables of interest we adjusted the model and the data throughout our analysis to minimize biases for example using the standard tabular data approach in these models we took additional steps to identify variables identified by the llm and generate codes which were then applied to the data analysis furthermore for each years file missing values were dropped before merging in addition given that the data was for 20 years for the first model there were only 32 missing values for the crude death rates for the data used from 2020 for the second model barely three values for the svi and dl rates were missing which offers confidence in the results derived at every iteration of the analysis a detailed evaluation of the preliminary results was analyzed adjusted and then fed back into the empirical model to reach the results presented in the study finally as machinelearning models are opaqueblack boxes and the mean square error measure of model fit was similar to the ordinary least squares regression this model was used for testing the relationship between the dependent and independent variables the principal results from the analysis namely that death rates are higher in nonmetropolitan areas than metropolitan and higher in rural areas than urban areas indicate the potential impact of low dl rates and a higher svi on the increased cvd mortality rates in the underserved rural and nonmetropolitan areas our results validate similar results and recommendations obtained with previous studies included in the review of the literature section 1315 the summary of the strengths of our analysis includes the robustness of our underlying data the reproducible codes the varied analytic methods used and the simplicity of the final model chosen data quality is maintained systematically by either the cdc or the u s census using excellent datacuration processes to ensure quality the predictors were carefully chosen to predict adjusted cvd mortality for example svi adequately encapsulates social vulnerability and is a comprehensive measure chosen by the cdc 16 additionally our featureselection processes did not use machinelearning techniques and the completeness of our data approached 100 thus we analyzed quality data from quality sources that did not need dataimputation techniques due to their completeness thus producing reliable and reproducible results limitation of our study admittedly there are limitations to the study given the scope of our study and the available resources for example even though we included ageadjusted death rates as the dependent variable for the second model and limited the regressors to the dl and svi as regressors we do recognize that the model has identification problems mortality due to cvd is also influenced by a shortage of specialists such as cardiologists in the medically underserved areas 6162 low insurance rates among socioeconomic and rural groups and transportation issues among others 63 since our study is at a population level granular countylevel data for traditional risk factors is difficult to come by and not addressed in our study as our study was specifically focused on dl and svi we do not claim that the results represent an overall and comprehensive representation of the causes of mortality associated with cvd as previously recognized 6465 while chatgpt allows huge datasets to be analyzed in a short period of time there are limitations and constraints such as computational calculations constraints the potential for inaccuracies and inadequate inferential capability our research using stateoftheart methods attempted to address several issues related to the use of the chatgpt model even within the confines of the aforementioned limitations additionally we adopted a blended approach wherein a llm was used specifically for two purposes namely to help narrow down the variables of interest and secondly to help generate and correct the python code thereafter a comparison of numerous machinelearning models helped us pick ols as the method of choice thus the strengths of the llm wherein it is able to identify closeness in high dimensional space complemented the interpretability obtained from the statistical techniques giving a suitable result census data is sparse for places with a population of less than 65000 which may have omitted more vulnerable populations in predicting cvdspecific mortality urban counties were overrepresented when dl was considered as the variable of interest in the study when data for the rucc categories was explored it became apparent that the definitions of rucc were revised every decade making comparisons across time less reliable while there was no significant change in classification the underlying population shift by the new definition could have introduced bias in our current findings 66 even though there has been a demonstration of good prediction with ai models when studying mortality and hospitalization rates for certain health conditions such as covid19 there could be concerns about replicability and the bias inherent in the study 7 including ours potential biases there are potential biases that may have arisen in our study due to multicollinearity aggregation bias and modelrelated issues inherent biases from the data chatgpt is trained on and the curse of dimensionality exist in our analysis our exploratory data may be prone to multicollinearity for example people with limited access to the internet are associated with low educational attainment tend to live in rural areas and are more likely to face adverse health outcomes these factors were not controlled in the study further the internetaccess data was retrieved at the household level without accounting for individual factors a careful study by lavery and acharya concludes that the presence of multicollinearity increases typeii error but is unrelated to typei error 67 similarly a power analysis is needed to infer causality 68 furthermore there is a potential bias in using aggregate bias in large datasets as the aggregation of data fails to capture important differences in subgroups a prior study 69 in analyzing the relationship between mortality rates of the broader hispanic population due to cvd discovered that when aggregated data were used as they were in previous studies the relationship between the hispanic population and cvdrelated deaths was insignificant however by disaggregating the data by subgroups within the hispanic population the rates were unique to each of the subgroups van smeden et al 65 spell out a detailed list of questions and biases inherited in using predictive modeling in the medical literature gleaning through this article our study addressed several of the issues although a few biases may still remain generalizability even though our study has a nationally representative sample caution should be exercised during its interpretation however our results validate other studies which link mortality rates influenced by dl 7071 to overcome the access issues for patients especially for rural residents and health education in the general population additional resourcesboth in the development of communication infrastructure and technical literacy educational programs with the massesbeing needed is a generalization or a broader application of this research public health and policy implications cardiovascular diseases such as heart disease and stroke are the leading causes of death in the united states contributing to nearly one third of all fatalities in addition to the loss of life these diseases pose a significant burden on healthcare costs reaching usd 216 billion in annual expenditures 7273 even though medical technologies have improved patient health outcomes social and behavioral determinants cannot be ignored in the equation to improve cardiovascular health outcomes at a population level for example over 90 of cases of myocardial infarctions can be prevented by addressing modifiable risk factors 74 llms such as ghatgp4 are already revolutionizing the field of medicine with their advanced power to detect diseases and create fine images 75 if optimized and utilized with awareness of their biases and error rates such aibased applications could accelerate the identification of social economic and behavioral factors for designing and implementing interventions that influence cvdspecific mortality the most recent infrastructure investment bill and american jobs act has earmarked usd 65 billion for broadband projects to close the digital divide with usd 43 billion appropriated for the broadband equity access and deployment program or bead program which will significantly contribute to the expansion of us broadband infrastructure 76 in addition the states also initiated funds to reach out to vulnerable populations including those who primarily reside in rural areas this study has demonstrated that while broadband access is crucial for reaching out to underserved populations it is a necessary but not sufficient condition to improve access to digital resources and health and wellness information 77 if individuals want to utilize health information from the web they require digital health literacy to make informed decisions historically underserved populations such as minorities and those with low socioeconomic status do not have optimal dl to access their electronic health records 78 these are the vulnerable populations that also live in higher svi areas 16 in examining patterns among users and nonusers of electronic health records mukhopadhyay and his team 78 discovered that encouragement and push from the providers can nudge more patients towards utilization of digital care or health services at a broader level digital training and strengthening local digital champions individuals or organizations such as publichealth officials and the network of united states department of agriculture extension agents can play these roles who help identify design and deliver skills training for underserved populations 79 conclusions in this study we demonstrated that incorporating dl and svi among other variables is essential in predictive modeling as these factors can largely explain diseasespecific mortality for individuals residing in various parts of the country additionally we demonstrated that using an llm such as chatgpt4 can greatly expedite similar analyses for specific health outcomes that pose a significant publichealth burden this approach can be instrumental in implementing interventions to improve health outcomes by informing policies data availability statement data from cdc wonder and the us census bureau were made available for free download

cardiovascular disease remains a leading cause of morbidity and mortality in the united states us although highquality data are accessible in the us for cardiovascular research digital literacy dl has not been explored as a potential factor influencing cardiovascular mortality although the social vulnerability index svi has been used previously as a variable in predictive modeling utilizing a large language model chatgpt4 we investigated the variability in cvdspecific mortality that could be explained by dl and svi using regression modeling we fitted two models to calculate the crude and adjusted cvd mortality rates mortality data using icd10 codes were retrieved from cdc wonder and the geographic level data was retrieved from the us department of agriculture both datasets were merged using the federal information processing standards code the initial exploration involved data from 1999 through 2020 n 65791 9998 complete for all us counties for crude cardiovascular mortality ccm ageadjusted cardiovascular mortality acm had data for 2020 n 3118 rows 99 complete for all us counties with the inclusion of svi and dl in the model a composite of literacy and internet access by leveraging on the advanced capabilities of chatgpt4 and linear regression we successfully highlighted the importance of incorporating the svi and dl in predicting adjusted cardiovascular mortality our findings imply that just incorporating internet availability in the regression model may not be sufficient without incorporating significant variables such as dl and svi to predict acm further our approach could enable future researchers to consider dl and svi as key variables to study other health outcomes of publichealth importance which could inform future clinical practices and policies

the researcher was fortunate to conduct diversity research in one of the most dynamic educational organizations in the country it was a rare opportunity since like most other organizations in the philippines this company had never allowed researchers access to its employees and internal culture the specific objectives of this study were to a identify the diversity characteristics of employees in the context of a perceived homogeneous culture in terms of age gender tenure and position b examine the relationship between perceptions of diversity inclusion and organizational climate and c investigate the relationship between diverse characteristics and organizational climate methods table 1 diverse characteristics of the sample characteristics procedures a consent form with information about the studys purpose and the significance of participants participation was first obtained those who gave their consent were able to continue with the study forty participants responded to an online survey through google forms the data collection instruments utilized in this study were divided into four parts profile of the participants diversity climate perception scale inclusionexclusion scale and organizational climate scale these scales show a good model fit internal consistency and crosstime consistency with evidence for content convergent and divergent validity measures diversity characteristics participants were asked to indicate their age gender tenure and position while the personal dimension contains personal diversity value and comfort with diversity all items are added to create a composite diversity perceptions score including four reversescored questions that aim to prevent a response set the scale uses a sixpoint likert scale ranging from strongly disagree to strongly agree higher scores on the scale indicate a favorable opinion of a diverse climate asian additionally the dimensions and factors can be separately summed and analyzed to learn more about how employees perceive diversity finally the scale and its factors demonstrated strong to adequate internal consistency with cronbachs alphas of 83 86 80 77 and 71 respectively inclusion mor barak measured the perception of inclusion using a 15item scale the inclusionexclusion scale was developed to gauge how much an employee feels a part of critical organizational functions like information access involvement and participation and influence over decisionmaking it uses a matrix system with three inclusion dimensions intersected by five workorganization system levels the scale items are added to prevent a response set to create a composite inclusionexclusion continuum score with three reversescored questions it uses a sixpoint likert scale ranging from strongly disagree to strongly agree higher scores on the scale correspond to a greater sense of inclusion the initial version of the measure showed good internal consistency in a sample of 3400 employees of diverse racial and ethnic backgrounds in a californiabased hightech company with a cronbachs alpha of 88 furthermore the 17 scale has regression weights from the confirmatory factor analysis on the second 50 of the data suggesting that each scale is factorially distinct highly statistically significant and has acceptable levels of reliability asian journal of multidisciplinary data analysis following the data collection the researcher utilized spss statistics 290 to perform accurate data analysis and presented the results in tables in line with the studys objectives descriptive statistics were first used to ascertain the diversity characteristics of the employees and the level of the measures next a pearson correlation coefficient examined the relationship between organizational climate inclusion and diversity after that several welchs anovas were conducted to investigate group differences for unequal sample sizes of diversity characteristics to organizational climate results descriptive analysis table 2 displays the means and standard deviations of the organizational climate diversity and inclusion in addition a percentile range was created for each measures score to ensure uniformity in interpretation the results show that participants perceptions about diversity m 385 sd correlation analysis table 3 on the other hand shows the relationships between the three measures diversity perception was both significantly and favorably correlated with inclusion and organizational climate however there was no statistically significant association between the organizational climate and the perception of inclusion analysis of variance the relationship between four diversity characteristics and organizational climate is shown in table 4 welchs analysis of variance revealed no difference in the relationship between age and organizational climate however a significant relationship between gender and organizational climate was found by welchs anova the anova posthoc test dunnett t3 suggested that genderdiverse employees had a more favorable perception of the organizational climate followed by women and men likewise welchs anova of the relationship between tenure and organizational climate revealed a significant difference fwelch 317223 discussion and analysis this study aimed to identify filipino employees diverse characteristics in a perceived homogeneous culture examine the relationship between perceptions of diversity inclusion and organizational climate and investigate the relationship between diverse characteristics and organizational climate in the filipino cultural context results indicate that diversity climate was significantly and favorably correlated with inclusion as the study predicted it is consistent with previous research on the association between diversity and inclusion in the workplace furthermore participants views of diversity and inclusion within their organizations were generally fair similarly llantos found that academic managers and leaders of selected higher education institutions in the philippines believed that multiculturalism and diversity management should be embedded in organizational programs it means that filipino organizations are moving towards diversity and inclusion similarly diversity perceptions and organizational climate were positively correlated however the present study has found an insignificant relationship between the organizational climate and the perception of inclusion nevertheless participants viewed relatively their asian journal of multidisciplinary research review issn 2582 8088 volume 4 issue 4 july august 2023 © 2023 all rights reserved by the law brigade publishers organizational climate cho and mor barak argued that peoples perceptions of their organizations can be influenced by their diverse characteristics even though they differ from one culture to another as such it seems reasonable that people identify themselves based on their diversity characteristics and this actual diversity would then affect their perception of the organizations climate including its inclusive practices in addition this study identified four diverse characteristics such as age gender tenure and position with organizational climate however the age factor was not statistically significant with the organizational climate it seems plausible given that most of the participants in the sample were relatively young only gender tenure and position were closely linked to employees positive perceptions of the organizational climate more specifically genderdiverse employees new employees and those in teaching positions have a more favorable perception of the organization the findings suggest a more positive view of the organization among employees in teaching positions since the sample is from a tertiary educational institution hastings also argued that it is likely for new employees to have a more positive outlook than tenured employees however they taper off over time in the philippines heis implementing genderfair learning and gender mainstreaming efforts have facilitated gender diversity awareness among universities and college workplaces in sum assessing the organizational climate is highly relevant in promoting and improving inclusion and diversity in the workplace it is essential to remember that employees can get along with each other but that does not change the fact that they are still different from one another thus while the philippine organizational culture may seem homogeneous it is diverse conclusion in the present study key findings show that most employees have average perceptions of organizational climate diversity and inclusion additionally perceptions of inclusion and organizational climate were significantly and favorably correlated with perceptions of diversity however there was no statistically significant association between the organizational asian journal of recommendations organizations should emphasize the value of diversity management competencies consideration should also be given to developing a diversity management strategy that highlights each employees unique attributes and interpersonal relationships furthermore this study also provides many possible directions for future research it is recommended to replicate this study using samples from different types of organizations such as comparing employees of public and private organizations and those of small and large enterprises in the country limitations some limitations in this study require careful interpretation of the results the sample size was limited to 40 employees at one of the tertiary schools in cebu philippines participants in the study also had short organizational tenures and were relatively young in addition this company had never given researchers access to its employees and internal culture due to the traditional confidentiality of filipino companies the sample was not randomly selected due to the lack of a sampling framework and time constraints nonetheless this was a rare opportunity to conduct the study additionally the study was restricted to a single company in cebu city to maintain sample homogeneity as such the findings may need to be more generalizable or representative of filipino culture despite these limitations the information obtained in the present study offers a unique insight into the diversity of the filipino workforce asian journal of

there is a misconception that diversity is irrelevant to understanding the workplace in other parts of the world particularly in asia in other words countries in asia like the philippines are homogenous today western countries and other developed regions are not the only places where the workforce is becoming more diversified hence this study aims to make a unique contribution to the diverse literature in the country by examining the relationships between diversity inclusion and organizational climate in the context of a perceived homogeneous culture the influence of demographic characteristics like age gender tenure and position was also considered in the study using a sample of 40 filipino employees in a higher education institution in cebu city the results show average employee perceptions about diversity inclusion and organizational climate the perception of diversity was positively linked to inclusion and the organizational climate however perceptions of inclusion and organizational climate were not statistically meaningful on the other hand gender tenure and position were closely linked to employees perceptions of the organizational climate specifically genderdiverse employees new employees and those in teaching positions have a more positive perception of the organizational climate therefore assessing the organizational climate is highly relevant in promoting and improving inclusion and diversity in the workplace

introduction individuals experiencing adverse social determinants of health are more likely to have poorer health outcomes than those with advantageous social determinants 1 in australia socioeconomically disadvantaged groups generally have a lower life expectancy and a higher risk of chronic disease 2 acknowledging a patients social circumstances such as access to transportation and their housing and economic situation in clinical settings may significantly influence the effectiveness of healthcare outcomes for that patient 3 information about patients social and economic living conditions is not routinely collected in clinical settings but could help clinicians to contextualise patient care such information may sometimes be available to clinicians but it is not routinely or systematically collected allen et al argue that clinicians often underuse opportunities to improve their patients sdh 1 they recommend routinely taking a patients social history together with a medical history introducing a social health screening tool would give clinicians information about constraints that some patients experience in their lives including unemployment low income and insecure housing it would also give clinicians a better understanding of potential reasons for noncompliance with clinical advice and inform them about general adversities in patients lives that affect how they experience illness 4 research population health and health service planning would benefit from integrating information from the tool into electronic data collection systems the data would support examination of the detailed ways in which sdh affect health equity and peoples access to and effective use of health services 3 barriers and facilitators to using shs tools in clinical settings include time cost reluctance to ask about taboo topics such as domestic violence and clinicians unfamiliarity with hardship in their patients lives 56 beck et al 5 suggest that further research is needed to determine what would encourage clinicians to ask sensitive questions suggested explanations for clinicians reluctance to engage in these conversations with patients include a sense of powerlessness in being able to address the root causes underlying difficult circumstances or feeling that the causes are beyond the scope of health services to help 37 however increased interest in the effects of social factors on patient care and recovery has seen rapid growth in sdh interventions integrated into electronic healthcare delivery systems particularly in north america a recent review identified 67 tools that include questions about one or more sdh including legal aid education literacy levels and food security 8 other studies identified shs tools used in europe and new zealand 5 9 10 11 12 13 14 15 16 17 the studies reinforced the importance of developing social history tools and recognised the importance of information about sdh to good clinical practice no tool was sufficiently brief to allow patients to complete the questions while waiting for clinical appointments a focus on specific sdh and particular groups made some tools unsuitable for a wide range of clinical settings because some questions would be irrelevant for example the dipcareq 1617 is not selfcomplete the pqol 18 includes items specific to particular cultural settings and the nzidep 14 refers exclusively to material disadvantage none of these studies included clinician and patient attitudes to sdh or the acceptability of sdh tools or their usefulness during clinical appointments this study sought to fill the research gap by determining the views of clinicians and health consumer advocates on shs tools and their usefulness based on this information we developed a brief selfcomplete shs tool that would inform clinicians about social determinants in their patients lives that could be discussed in more detail during consultations this proofofconcept study was conducted in anxiety and sleep disorder clinics which often treat patients with conditions that have underlying inequity issues the social inequality risk factors for mental illness include low income unemployment low social capital and social exclusion 19 in addition poorly managed physical chronic disease is partly responsible for the 1015year lower life expectancy of people with severe mental illness compared with the general population 20 a major risk factor for obstructive sleep apnoea is obesity which has also been linked to socioeconomic disadvantage 21 osa incidence has increased from around 3 to 16 since the mid1990s 22 the following section describes the development and piloting of the shs tool this study was approved by the southern adelaide clinical human research ethics committee methods the methods are summarised in figure 1 stage 1 in stage 1 we developed the draft tool using items from existing instruments and theoretical frameworks 5 23 24 25 and from the research groups expertise in sdh the criteria for inclusion were that domains reflected the social and material conditions of living that potentially affect a patients ability to comply with treatment which would affect recovery the initial stage included focus groups with three females and three males recruited from an independent volunteer health consumer group all of whom had consumer experience of health services and most of whom were retired allied health professionals focus groups create an environment of collaboration and allow for consensus to develop through the collaborative process of constructing a joint perspective and agreement 26 the focus groups examined health service users attitudes and orientation towards using an shs tool in clinical settings they were moderated by the second twelve clinicians reviewed the information on the tool before seeing new patients after the consultation each clinician completed a brief feedback questionnaire on use and content validity when 50 patients had completed the tool the first and second authors undertook audiorecorded interviews with six clinicians to determine the perceived barriers and facilitators to using the tool and whether the tool was beneficial to clinicians in approaching sensitive issues the interview transcripts and focus group data were checked and initial coding performed based on the sdh and shs tool topics covered using framework analysis through familiarisation indexing charting mapping and interpretation of the data the codes were further expanded and references to sdh and key topics for inclusion were identified 27 we created a coding framework and identified the emergent sdh themes focus groups were attended by both the first and second authors who took detailed notes on health consumer feedback and the issues raised their notes were compared and coded for emergent themes all the themes identified were used to guide the development of the shs tool results focus group and clinician input both the focus groups and the clinicians were positive about the use of an shs tool and viewed it as a conversation starter with patients a common approach repeated by clinicians was that occupation and subjective visual cues were often relied on as proxies for a patients financial situation and additional information would be useful clinicians acknowledged there was no systematic way of collecting such data key issues raised about the tool included legibility length and the need for a broad question probing abuse author with the first author acting as observer and notetaker participants were compensated for their time with a 35 gift voucher individual interviews were held with a range of clinicians including doctors nurses and psychologists from two clinics one for anxiety disorder conditions and the other for sleep health the third and fourth authors are directors of the respective clinics and the first author carried out the interviews in addition to the topics covered in appendix 1 the first author asked clinicians to state specific information about sdh that they would find useful items for inclusion were further developed during regular research team meetings based on the data collected in focus groups and interviews stage 2 based on the outcomes of stage 1 we refined the draft shs tool we held an additional health consumer focus group using the same recruitment methodology the focus group determined the appropriateness of the questionnaire length wording of questions response options and face and content validity before piloting the draft selfcomplete questionnaire was then piloted with 50 new patients the first author approached new clinic patients explained the project and obtained written consent consenting patients completed the questionnaire before their first clinical consultation and gave verbal feedback to the researcher about its content wording and language degree of difficulty and time needed to complete patients were asked if they were willing to participate in a followup telephone call to answer questions about their consultation experience using the shs tool and received a 35 gift voucher for their time proofofconcept trial the tool took 6 minutes to complete on average all were selfcompleted the questions were considered easy to read and not too sensitive all 50 participants said they would be comfortable completing the tool in other clinical settings telephone interviews were undertaken with five patients which reinforced previous feedback the following is a typical response fine no worries nothing majorly personal it was easy to understand and straightforward none of those interviewed had noticed whether the clinician had used the information they provided and were unsure whether it had affected their first consultation the small sample size did not include any patients with adverse sdh similar to the immediate feedback after completing the tool some participants acknowledged that they might have felt less comfortable filling out the tool if they had experienced some of the issues explored such as precarious housing or domestic violence twelve clinicians from both clinical settings participated in the proofofconcept trial the key responses are shown in box 1 focus group members noted the following • a streamlined shs tool designed for clinicians to start a conversation about social issues that may affect health and recovery was viewed positively and there was a need for it • there is variation in literacy levels and language fluency so the questionnaire should aim for primary school reading level • some patients may need help completing the questionnaire • patients get tired of filling out the same information in numerous forms so there is a need to avoid duplication clinicians noted the following • some of the information was already gathered in disparate ways in both clinics but having a brief consolidated tool would save time and be useful in settings where this information is not collected • a streamlined shs tool would save time • the tool would be useful because they may get this information during several consultations but there is no systematic approach in place • the tool should be brief simple and selfcomplete it should definitely not be completed facetoface with clinicians as they are too busy • it is important to know about social issues and financial issues for ongoing compliance with treatment this information would signpost potential problems • the overall language is easy to understand and read and the questions are well grouped • knowing whether a patient has internet access is important because patients often search for medical knowledge there first • the patients family and level of network support is very important to include we made the following changes in response to this feedback • included transgender in the gender question • simplified the wording to allow for low literacy levels • introduced emojis in questions 20 and 25 for visual representation • removed terrace house from housing type and included caravan or mobile home • added retirement village to options and cut down to own or rent • added questions to capture emotional physical and financial abuse • condensed the tool into four pages • added an opportunity for comment at the end • removed duplicated demographic information routinely collected deidentified data could potentially be useful epidemiological data to examine interactions between health service use and sdh such data would also be helpful to determine which social determinants affect the likelihood of readmission to hospital as well as frequent use of health services the shs tool promises to be particularly useful when clinicians see a patient for the first time such as in an oncology clinic or emergency department the tool requires piloting with a larger sample in different clinical settings with individuals from different backgrounds experiencing adverse sdh to ascertain its effectiveness box 1 key openended responses from clinicians after using the shs tool conclusion clinicians are aware that social and economic circumstances have a profound impact on a patients ability to access health services and to manage health conditions and outcomes this proofofconcept study of an shs tool is the first stage in helping identify patient social determinants for clinical and public health use we would recommend piloting the tool in busy clinical settings where people presenting for first clinical consultation are more likely to experience a range of socioeconomic disadvantage overall the feedback from clinicians was positive and all recommended using the tool in clinical settings especially with patients they are seeing for the first time the clinicians also said the tool would be useful in emergency departments and busy general practices where a rapid overview is required patients identified as having adverse sdh could be given appropriate support and treatment tailored to their circumstances to increase the likelihood that treatment will be effective and patients will comply with therapies limitations both clinics used in this study had existing mailout assessment tools that collected sdh data from new patients which may have affected our ability to assess the efficacy of the shs tool the anxiety disorders clinic tool included patient social history questions about general distress occupation and social support the sleep clinic tool included questions on occupation and employment another limitation was that the small sample size did not include patients with adverse sdh discussion there is growing recognition of the importance of patients sdh information to good clinical practice 1 however only a small number of brief selfcomplete shs tools exist and none of these can be easily adapted for universal clinical settings the streamlined selfcomplete shs tool developed in this study captured the key social determinants that influence health and wellbeing it could be used by clinicians to start a dialogue with patients about their individual needs and to aid compliance with treatment and recovery 3 the tool was easy and efficient to use the selfcomplete nature of the tool allowed patients to disclose topics that may be raised in the consultation all the clinicians involved stated that the shs tool would be useful in clinics where sdh information is unavailable the contradictory response findings where clinicians were positive about the tool but reported not using the tool in their consultation can be explained by the small sample size not having reported any adverse social issues this shows that the clinicians read the patient responses to determine this during telephone interviews patients reported being unaware whether their clinician had used the tool this uncertainty needs to be addressed to avoid patients feeling that they are providing information unnecessarily we would recommend for future use that clinicians acknowledge to the patient that they have read the tool clinicians did not report feeling uncomfortable broaching sensitive topics but previous literature suggests they might 5 we suggest that training for clinicians about use competing interests none declared

objective and importance of study the importance of social determinants for individual health recovery outcomes is well recognised in public health however no succinct social health screening shs tool exists that has been developed with information from clinicians and patients this proofofconcept study asked health consumer advocates patients and clinicians about their attitudes towards social determinants of health sdh and the usefulness of an shs tool for collecting these data for use in clinical settings we then developed a streamlined shs tool to bring this knowledge to clinicians and conducted a proofofconcept trial to check its acceptability with patients and clinicians methods this qualitative study had two stages stage 1 involved focus groups with health consumer advocates and interviews with clinicians about the draft shs tool stage 2 involved refining the shs tool and piloting it with 50 new patients in anxiety disorder and sleep disorder clinics which often treat patients living in disadvantaged socioeconomic conditions the tool was evaluated by patients and clinicians the data were analysed using framework analysis results all interviewees were positive about the benefits of addressing sdh in clinical practice to help reduce health inequities we developed and refined an shs tool that could be completed by patients selfcomplete the response to introducing an shs tool in clinical settings was positive further piloting across diverse clinical settings is required to determine efficacy this tool promotes public health equity outcomes by improving clinician understanding of individual social circumstances and has the potential to provide useful epidemiological data on sdh

introduction a large body of evidence suggests that socioeconomic position is an important determinant of cardiovascular and metabolic health 12 lower childhood and adult sep are associated with a higher risk of type 2 diabetes and cardiovascular disease partly through chronic inflammation which is associated with chronic stress 3 people who experience social deprivation are thought to be subject to environmental psychological and behavioural stressors which eventually wear and tear the neuroendocrine nervous and immunological systems a process that is known as allostasis and is associated with an increased risk of chronic disease 45 systematic changes in sep across the lifespan which are best described by the term social mobility are also associated with subsequent risk of chronic disease people in upward social mobility ie having higher sep in later stages of the life course compared to earlier stages have decreased risk of various detrimental effects on health such as psychiatric disorders 67 insulin resistance 8 type 2 diabetes 39 cardiovascular mortality 10 and allcause mortality 11 compared with those in downward social mobility although downward social mobility is associated with an increased risk of various chronic diseases 91112 its link with subclinical form of disease which is very important in terms of disease prevention remains underinvestigated inflammatory and metabolic markers such as creactive protein fibrinogen glycated haemoglobin and highdensity lipoprotein cholesterol are implicated in pathogenic processes 13 and widely used as predictors of cardiovascular and metabolic health 14 their association with social mobility however remains poorly understood to our knowledge scarce evidence suggests that downward social mobility is associated with increased levels of inflammatory markers such as crp and fibrinogen 315 and decreased levels of metabolic markers such as hdl 8 while the association with hba1c has yet to be explored our study aims to examine the associations between changes in sep over the life course and inflammatory and metabolic markers in older adults and add to the current knowledge of how social mobility might be associated with pathological processes and subclinical form of disease with a particular interest in the role of laterlife sep and upward social mobility in reversing the harmful effects of social disadvantage in childhood on laterlife inflammatory and metabolic profiles of older adults methods data source and study populations the english longitudinal study of ageing is a prospective observational study of communitydwelling people aged 50 years or older it began in 200203 with a core sample of 11391 participants who had earlier participated in health survey for england 1998 1999 and 2001 and were selected by using a multistage stratified random probability design after the baseline followup interviews and health examinations including blood sample collections took place at regular 2and 4year intervals respectively the national research and ethics committee has approved elsa while informed consent has been obtained from all participants more information on elsa can be found at our study uses data from elsa wave 2 elsa wave 2 had two components the first followup interview and the first health examination survey out of the 11391 participants 8780 took part in the followup interview of which 7666 participated in the health examination among those who participated in the health examination 6652 were eligible for blood sample collection and consented to give blood sample our analytic sample comprised 6142 participants to gain a better understanding of the nonresponse and its potential implications for our findings we conducted an analysis of nonresponse which is presented in supplementary material table s1 measurements assessment of social mobility childhood sep was measured using fathers or main carers occupation when participants were 14 years old participants whose fathers worked in managerial professional administrative traderelated and servicesrelated occupations or were business owners were assigned to the high childhood sep category whereas low childhood sep was assigned for those whose fathers had manual or casual occupations or those whose fathers were unemployed sick or disabled participants whose fathers were in the armed forces or retired when they were 14 years old and those whose information about paternal occupation was missing were excluded from analyses as their childhood sep could not be classified adult sep was measured using data from the last main job of participants which then was dichotomized into low and high occupational class according to the national statistics socioeconomic classification scheme participants in managerial professional or intermediate occupations were assigned to high adult sep while those who worked in routine manual or semimanual occupations were assigned to low adult sep the small numbers of participants who had never worked or were of unknown occupation were excluded from analyses because they could be classified in any of the existing categories we then combine dichotomous childhood sep and adult sep to derive a social mobility variable with the following four categories stable high sep downward social mobility upward social mobility and stable low sep inflammatory and metabolic markers crp fibrinogen hba1c and hdl were measured from blood samples collected by nurses at participants homes during the elsa wave 2 health examination survey more information on the measurement of these markers can be obtained from the hse 2004 technical report and women with hdl levels 13 mmoll in the suboptimal hdl group 17 covariates based on previous evidence we used age age squared sex and baseline cardiovascular and noncardiovascular diseases as potential confounders of the examined association 1518 and elevated depressive symptoms 18 smoking 19 physical activity 2021 and frequency of alcohol consumption 22 as potential mediators of it 1523 we also adjusted our models for the following anthropometric measures body mass index waist circumference and waisttohip ratio which had also been measured during the wave 2 health examination 24 and categorised using established cutpoints 2526 we include in the analysis different anthropometric measures as each one of them may confer uniquely to cvd risk and be differential associated with social mobility 26 statistical analysis we analysed the sample characteristics according to social mobility categories and estimated multivariable linear and logistic regression models of the association between social mobility and the four markers we adjusted our models for age age squared and sex then for prevalent cvd and noncvd and finally for health behaviours including obesity alcohol consumption smoking physical activity and elevated depressive symptoms we reported the pooled sample as we did not find any significant sex interaction the analyses were conducted using stata version 12 results table 1 presents the characteristics of the sample compared with participants with stable high sep or upwardly mobile those in stable low sep and downward social mobility were more likely to be older obese physically inactive smokers and depressed they also had more comorbidities and consumed alcohol less frequently table 2 shows the overall distribution of inflammatory and metabolic markers crp fibrinogen and hba1c levels were the highest among those in stable low sep participants who were downwardly mobile had the second highest levels of the markers and were followed by those who were in upward social mobility trajectory those in stable high sep had the lowest levels in all these biomarkers hdl levels were the highest among people with stable high sep and the lowest among those with stable low group proportion of prediabetes was the highest among those experiencing downward social mobility but was the lowest among those in stable high sep in contrast proportion of having suboptimal hdl levels was the highest among those with stable high group but was the lowest among those with stable low group we also found a similar pattern of the association between social mobility and fibrinogen participants in upward social mobility did not differ significantly in terms of their hba1c levels from those in stable high sep whereas those in downward trajectory or those in stable low sep had significantly higher levels of hba1c the association between social mobility and hdl followed a slightly different pattern showing that participants experiencing downward social mobility had slightly higher hdl levels than those experiencing upward social mobility the statistical controlling for health behaviours obesity and elevated depressive symptoms fully explained the associations with fibrinogen and hba1c but only partially those with crp and hdl interestingly after adjusting for all covariates crp levels of those in upward social mobility were not significantly different from those in stable high sep while the crp levels of participants in downward drift or stable low sep remained significantly higher c table 4 shows the results from logistic models we found that the risk of prediabetes among participants in upward sep did not significantly differ from the risk of participants in stable sep however those downwardly mobile showed an increased risk of prediabetes by 25 compared with those in stable high sep independent of age sex and chronic conditions the risk of having suboptimal hdl levels among those in upward downward or stable low sep were significantly higher than that among those in stable high sep regardless of age sex and chronic conditions nevertheless the strength of these associations was attenuated after accounting for health behaviours page a odds of participants who have prediabetes compared to those who have normal hba1c levels b odds of participants who have suboptimal hdl levels ie hdl 10 mmoll or 13 mmoll compared to those who have optimal hdl levels ie hdl ≥ 10 mmoll or ≥ 13 mmoll abbreviations ci confidence interval hba1c haemoglobin a glycosylated hdl highdensity lipoprotein cholesterol page methodological considerations our study is among the first to investigate the associations between social mobility and inflammatory and metabolic markers and provide insight into the dynamic association between sep and subclinical disease markers over the life course an obvious strength of our study is the use of a large national communitydwelling sample and rich observational data from elsa which is a wellestablished survey the first made our findings more applicable and generalizable to older adults and the latter allows for a fuller exploration of the role of potential confounders and mediators our study also had several limitations which need to be considered when interpreting our findings first childhood sep has been measured retrospectively and thus might be susceptible to recall bias nevertheless this measure of childhood sep appears to have good predictive validity as it has been successfully used to predict the incidence of disease 18 and mortality 27 second it is uncertain whether the results can be generalized to younger generations especially given changes to the structure of the labour market in the last fifty years our supplementary analysis found significant differences between respondents and nonrespondents on a number of characteristics to an extent our study has been affected by attrition and nonresponse bias and our analytic sample might not fully represent the original elsa sample making our findings a rather conservative account of the true associations between social mobility and inflammatory and metabolic biomarkers third we could not account for important mediating factors such as diet and medication usage particularly hmgcoa reductase inhibitors 25 our social mobility variable did not encapsulate information on early adult sep ie education and thus is an imperfect indicator of social mobility it also did not capture sep at a householdor a statelevel which were also reported to be associated with inflammatory markers 2829 in addition due to the lack of appropriately prospective data we could not establish the temporality of events and draw causal conclusions about the role of covariates such as unhealthy behaviours in the observed association with regard to the missingindicator technique used in dealing with missing covariates the benefit outweighs the impact on distorting the results as only small proportion of data was missing comparison of our findings with other studies in accordance with previous studies 315 we found that participants in stable low sep group had the highest crp levels followed those in downward social mobility trajectory and those in the upward social mobility while those with stable high sep had the best crp levels these findings are also consistent with those of an earlier study suggesting that the association between adulthood sep is associated with crp levels independent of childhood sep 23 our fibrinogen findings concur with those by ploubidis et al who reported negative associations between both childhood and adult sep and fibrinogen levels in older adults 30 nevertheless previous evidence failed to find an association between social mobility and fibrinogen levels 15 unlike lawlor et al who found that in comparison with participants in stable high sep only those who experienced low sep throughout their life had significantly increased risk of low hdl 8 we found that those in upward and downward social mobility also had an increased risk of suboptimal hdl levels the discrepancy between our findings and theirs possibly can be attributed to sample implication of our findings our study highlights the importance of changes in sep for metabolic and inflammatory markers the implications of our findings are considerable first the association between social mobility and crp indicates that adult sep is important for chronic inflammation independent of childhood sep and likely can partially mitigate the effect of experiences of social disadvantage in childhood on it the lack of any difference in hba1c levels between participants in stable high sep and those in upward social mobility groups further strengthens our argument about the role of upward social mobility as a factor that ameliorates the effect of social disadvantage in childhood however the findings that people who started off better but later experienced downward social mobility have better hdl levels compared with those in an upward trajectory suggest the importance of childhood sep for hdl irrespective of adult sep in accordance with previous evidence 18 our findings also suggest that social mobility is associated with the inflammatory and metabolic profiles of older people through unhealthy behaviours obesity and depression regarding physical activity role in the examined associations evidence suggests that people in stable high sep and those in upward social mobility were likely to increase their levels of physical activity and physical fitness when they became adults 20 while increased physical activity was found to be associated with reduced levels of crp 31 and blood sugar 32 but increased hdl levels 33 downward social mobility has also been associated with poorer selfreported mental health in men 34 and depression independent of childhood or adult sep 6 while associations between elevated depressive symptoms and increased crp levels have also been demonstrated 35 further downward social trajectory is associated with obesity 36 which in turn is associated with increased crp 31 and blood sugar levels 32 but decreased hdl levels 33 one study also suggested that the upward social trajectory could protect women but not men from having highrisk adiposity profiles 37 downward family income trajectory is also associated with increased tobacco and alcohol use in adolescence 19 which are associated with increased crp 31 and fibrinogen levels 38 but decreased hdl levels 33 the risk of unfavourable alcohol drinking in men was also found to be increased in a group of downward social mobility the potential mechanisms that health behaviours might interplay with social mobility was described in more detail in supplementary material conclusion social mobility is associated with inflammatory and metabolic markers in older adults with some associations persisting after full adjustment for covariates compared to participants in stable high sep or upward social trajectory those who were in stable low sep or experienced downward social mobility were more likely to have elevated levels of crp fibrinogen and hba1c participants who experienced upward downward or stable low sep tend to have lower hdl levels with no discernible patterns compared with those who remained in high sep throughout their lives health behaviours explain some of these associations upward social mobility seems to be associated with a partial reversal of the effect of social disadvantage in childhood on older adults inflammatory profile keypoints what is already known on this subject childhood and adult socioeconomic position are associated with inflammatory and metabolic markers which are excellent predictors of cardiovascular disease at older ages what this study adds the systematic changes in sep across the lifespan which are best described by the term social mobility are also associated with inflammatory and metabolic markers at older ages participants in stable high sep or upward social mobility were more likely to have a healthier biomarker profiles ie lower crp fibrinogen and hba1c compared with those in stable low sep or downward social mobility trajectory health behaviours obesity and depressive symptoms provided a partial explanation of the associations between social mobility and these markers adult sep is important for chronic inflammation independent of childhood sep and likely can partially mitigate and reverse life time inflammationand metabolismrelated pathogenic processes that are associated with experiences of social disadvantage in childhood acknowledgement the data were made available through the uk data archive the english longitudinal study of ageing is supported by the national institute on aging and a consortium of the uk government departments coordinated by the office for national statistics the funding bodies had no role in the study design in the collection analysis and interpretation of data in the writing of the report and in the decision to submit the article for publication competing interest none declared to our knowledge there are two main mechanisms that explain the association between social mobility and health behaviours the social causation theory explains that social mobility influences health behaviours for example people who experience a downward social drift may encounter massive stress which makes them engage in smoking and heavy alcohol drinking in contrast people who engage in heavy alcohol drinking may later confront a financial problem and mental illness which result in a lower sep as they cannot study or work properly this is known as the social selection theory 4 although a combination of social causation and social selection processes may account for the association between sep and health behaviours the social causation theory is mostly endorsed 4 5 6 7 8 9 10 11 12 13 and many studies simply define risky health behaviours as potential mediators for the association between life course sep and clinical outcomes 1415 a study by burrow et al showed that british men who upwardly mobile from manual background to the middle class were less likely to engage in risky health behaviours in terms of smoking and binge drinking while those middleclass men who have remained within their class of origin have a greater odds of engaging in risky health behaviours this would undermine a claim of the social selection process 7 these findings are consistent with a study on alcohol use during adolescence which shows that children on the downward drift in the family income trajectory measured from 1 month of age through 15 years were more likely to drink alcohol when they are 15 years 6 social causation theory also explains the associations between social mobility and mental health and obesity heraclides et al suggested that downward socially mobile women had a higher prevalence of overweight and obesity in adulthood than the socially stable of high sep 520 vs 361 the results were still consistent even after excluding participants who had been obese as adolescents to reduce the possibility of reverse causality risk for depressive disorders in adolescent children and these findings support the social causation theory because of an apparent time sequence 4 due to the fact that our study used crosssectional data we cannot establish a clear temporal sequence and draw a causal conclusion about the exact role of unhealthy behaviours therefore our

because our knowledge of the associations between socioeconomic position sep over the life course and inflammatory and metabolic markers which are excellent predictors of cardiovascular disease remains limited we examined the association between social mobility over the life course and these markers at older agesour study used crosssectionally collected data from 6142 participants aged 50 years and older from the english longitudinal study of ageing we estimated linear and logistic models of the associations between social mobility using information on childhood and adult sep and creactive protein crp fibrinogen glycated haemoglobin hba1c and highdensity lipoprotein cholesterol hdl our models were gradually adjusted for age sex chronic diseases obesity physical activity alcohol consumption smoking status and depressive symptomsparticipants who experienced upward social mobility had higher crp fibrinogen and hba1c levels compared with those who had stable high sep over the life course but lower compared with those who experienced downward social mobility or had stable low sep they also had lower hdl levels compared with those who had stable high sep or downwardly mobile adjustment for covariates partially explained the associations between social mobility and crp and hdl and fully explained those between social mobility and fibrinogen and hba1csocial mobility is associated with inflammatory and metabolic markers at older ages with some of the observed associations persisting after accounting for covariates upward social mobility appears to partially reverse the damaging effect of childhood social disadvantage on inflammatory profiles in older ages

introduction from 2000 to 2010 the native hawaiian and pacific islander population grew by 40 1 2 3 making nhpis the second fastest growing population in the united states people indigenous to the pacific regions of polynesia melanesia and micronesia are considered nhpis 4 over one million pacific islanders reside in the us and the us census bureau estimates the population will reach two million by 2030 5 the majority of the nhpi population is concentrated in hawaii california washington and utah 6 however there has also been significant growth of the nhpi population in southern and midwestern states such as arkansas kansas nevada and oklahoma 3 while nhpis are an increasing population they are underrepresented in health research 7 their underrepresentation in research is compounded by the historical practice of aggregating nhpis with asian americans in populationbased health data which masks the marked disparities that exist between these two heterogeneous populations 8 9 10 11 12 despite being underrepresented in research the available literature on nhpis provides strong evidence to suggest that the nhpi population experiences substantial disparities in health and healthcare access compared to the general us population 13 14 15 16 17 18 19 in this article the authors will examine what is known about diabetes disparities among nhpis and review interventions that have demonstrated promise in addressing diabetes disparities diabetes disparities the centers for disease control and preventions national health interview survey documented the prevalence of selfreported diagnosis of diabetes among nhpis as ranging from 120 to 191 compared to 94 in the general us population 20 21 22 23 the cdcs behavioral risk factor surveillance system from 2011 to 2014 showed statelevel prevalence of selfreported diabetes diagnosis among nhpis ranged from 134139 to 191 24 studies focused on nhpi subpopulations indicate that the prevalence is even higher than these national surveys for example a study of 401 marshallese adult participants in arkansas found that 326 had glycated hemoglobin levels indicative of prediabetes and 384 had levels indicative of diabetes 25 of those with hba1c levels indicative of diabetes 546 had an hba1c over 9 which is considered poor glycemic control 25 most notably 519 of those with hba1c levels indicative of diabetes did not selfreport a diagnosis of diabetes by a healthcare provider and diabetes was only confirmed through the studys measurement of hba1c 25 therefore many of the national studies of selfreported diabetes may underrepresent the prevalence of diabetes in the nhpi population and nhpi subpopulations 2526 while nhpi community members have a high prevalence of diabetes research suggests they face many challenges in accessing health care and education for diabetes prevention and management the available literature documents low rates of adherence to selfmanagement behaviors 27 limited access and participation in formal diabetes selfmanagement education 25 27 28 29 30 31 and high rates of medication nonadherence 32 33 34 furthermore nhpis experience higher risks of endstage renal disease and myocardial infarction as a result of uncontrolled diabetes 3536 while the reasons for diabetes disparities are not well understood studies document challenges at multiple social ecological levels 37 nhpis often face racism linguistic barriers and inadequate pacific language translators constraining access to health care and health education 30 38 39 40 41 42 43 44 some nhpi communities are less likely to have health insurance than the general us population 1945 nhpis who migrate to the us from compact of free association countries in the us affiliated pacific islands have especially high uninsured rates 25 46 47 48 for example the cofa agreement between the us and the republic of the marshall islands allows pacific islanders to enter work reside and study in the us without a visa 49 however cofa migrants were deemed ineligible for medicaid after the 1996 personal responsibility and work opportunity reconciliation act excluded them from the qualified migrants category while cofa migrants can purchase health insurance through their employers many are unable to afford insurance 3950 additionally nhpis experience higher rates of poverty and lower educational attainment than the general us population 1951 populationbased studies of nhpis have documented a correlation between diabetes and diabetesrelated risk factors such as inadequate sleep poor nutrition or eating habits food insecurity and obesogenic food environments and physiological distress all of which may be consequences of economic instability 52 53 54 nhpi community members have faced a significant nutrition transition with changes in lifestyle and food systems resulting from colonization and nuclear testing which has contributed to a higher prevalence of noncommunicable diseases the loss of traditional diet has led to a reliance on imported canned and processed foods that are high in saturated fat sodium and added sugars and void of many essential nutrients and dietary fiber 55 the marshallese community provides an example of the impact of us colonization on nhpis lifestyle and food practices from 1946 to 1958 the us military tested nuclear weapons in the usapi 56 the denotation of 67 fission and thermonuclear weapons equivalent to 7200 hiroshimasized bombs 56 contaminated local food sources and the marshallese became reliant on imported commodity foods such as rice and canned meats 5758 studies have shown that nuclear exposure among the marshallese has resulted in a transition to a diet high in simple carbohydrates and fat with a low consumption of fruits and vegetables 5759 additionally environmental changes have caused a marshallese diaspora as migrants relocate to the continental us where high carbohydrate and fatty foods continue to be staples of the marshallese diet due to their low cost and familiarity 58 despite nuclear testing and environmental food changes there have been no published epigenetic studies of nhpis living in the us that explore the epigenetic correlates of diabetes or other cardiometabolic diseases the lack of epigenetic research with nhpis in the us is particularly concerning because studies in the independent nation of samoa and new zealand have found important genomic risk and protective factors with obesity and cardiometabolic conditions 6061 epigenetic studies with samoans show promise and may provide insights on how nutrition health and societal transitions may influence human biology and health 60 however genetic studies among nhpi populations have been sporadic resulting in a lowlevel of understanding of genetic contributions to cardiometabolic diseases 61 promising interventions while nhpis in the us have been underrepresented in research there is an emergence and strengthening of some academic centers with an explicit focus on the nhpi population 62 63 64 65 partners in care the pic intervention integrates the american diabetes association standards of care into a culturally adapted communitybased dsme program for nhpis 66 based upon community input pic was held in a group setting to increase social support and to offer classes in a convenient community location to overcome transportation barriers for study participants peer educators delivered the 3month intervention in 12 weekly 1 hour group lessons in community settings the pic curriculum is written in plain english and in a conversational tone and features images of nhpis engaging in selfmanagement behaviors the curriculum materials are intended to be read verbatim to ensure fidelity across several different sites and peer educators the pic peer educators used local language images and examples to engage participants and encourage selfmanagement behaviors analogies and talk story was used to convey some of the educational content a study designed to evaluate the pic intervention enrolled 82 nhpi participants who were randomly assigned to either the intervention or wait list control group in the intentiontotreat analyses baseline hba1c was 99 and 98 for the intervention and wait list control group respectively at 3 months data collection the intervention group mean hba1c was 89 compared to 94 in the wait list group participants in the intervention group experienced significant baseline adjusted reductions in hba1c at 3 months compared to the wait list control group in both the intenttotreat and complete case analyses intervention participants also increased their understanding of diabetes selfmanagement and performing diabetes selfmanagement activities such as medication adherence and foot care 66 a subsequent trial of pic was conducted with a semistructured support group component to examine the effects of this support group on maintenance of improved glycemic control after receipt of the pic intervention participants received pic and were then randomized to either a 3month 6session semistructured support group or a control group assessments were conducted at baseline postpic and postsupport group baseline to 3month results showed significant improvements in hba1c diabetes selfmanagement knowledge activities and diabetesrelated distress however there were no significant differences between the semistructured support group and the control group the semistructured social support group experienced a significant decrease in systolic blood pressure from 3months to 6months while the control group did not 67 materials for pic can be found at partnerships for improving lifestyle interventions ohana program diabetes prevention program lifestyle intervention the pili dppli is a culturallyinformed dppli that was adapted using a communitybased participatory research approach to integrate nhpi cultural perspectives as well as familyand communityfocused components to encourage longterm weight loss maintenance 68 both surface structure modifications and deep structure changes were made 69 based on community input two additional topic areas were added to the dppli which focused on the economics of healthy eating and talking with your doctor to make the pilidppli feasible to be delivered across different community settings with limited resources it was condensed from the original 16 lessons to eight lessons while maintaining all the original lessons strategies and foci and designed to be delivered by community peer educators 69 in a pilot study of the pili dppli among 169 nhpi adults who were overweight or obese the average weight loss from preto post3month followup was 15 kg with 26 losing 3 of their baseline weight 69 in a larger study 239 nhpi overweightobese adults yielded an average weight loss of 17 kg after 3 months of the pili dppli with improvements in systolic and diastolic blood pressure physical functioning and exercise frequency and reductions in dietary fat intake 69 the pili dppli was also further modified as a worksite intervention for native hawaiian serving organizations 70 among 112 employees who were overweightobese across 15 worksites pili dppli yielded significant weight loss reductions in systolic and diastolic blood pressure improvements in physical functioning exercise frequency and reductions in dietary fat intake 70 importantly both of the plpdppli interventions were delivered by peer educators who were members of or were employees of the participating community organizations and a majority were nhpi the pili dppli materials can be accessed at the pili dppli is currently being tested in a comparative effectiveness trial with marshallese in arkansas 71 culturallyadapted family model dsme the family dsme intervention was culturally adapted for marshallese participants using a communityengaged approach with multiple qualitative pilot studies 72 73 74 the resulting intervention included 10 hours of education delivered over 8 weeks the culturallyadapted family dsme was consistent with the national standards from the american diabetes association and american association of diabetes educators and covered the topics of healthy eating being active understanding blood glucose and taking medications problemsolving reducing risks and healthy coping mitigating complications of diabetes and goal setting 75 the family dsme was adapted to a family context as well as marshallese cultural practices 7476 was assetbased and worked to overcome barriers facing marshallese participants by leveraging culturallyspecific facilitators of healthy behavior change the intervention included family members as participants and focused on family motivational interviewing family goal setting and family behavioral change the intervention also focused on how to access affordable healthy foods and free or lowcost health services the intervention was delivered by community health workers in participants homes to overcome transportation barriers the results of the pilot study showed patients with diabetes had a significant change in hba1c from a mean baseline of 97 to 90 postintervention 76 a fullypowered randomized controlled trial examining the comparative effectiveness of culturallyadapted family dsme compared to standard dsme has recently been tested participants were marshallese adults with hba1c indicative of diabetes adjusted linear mixed effects regression models showed that there were significantly greater declines in hba1c for the culturallyadapted family dsme arm compared with the standard dsme arm at immediate postintervention and 12 months postintervention the culturallyadapted family dsme yielded significant reductions in hba1c from baseline to immediate postintervention 6 months and 12 months the family dsme materials can be accessed at resources common attributes of interventions that have shown promise the interventions that demonstrated effectiveness among nhpis have several common attributes first cultural adaption of the intervention using a communityengaged approach was an effective strategy used across all studies the promising interventions all included cultural adaptations that focused on integrating specific nhpi cultural elements such as nhpi analogies based on nature and use of talk story the success of culturallyadapted diabetes interventions has also been documented in other racial and ethnic groups 77 78 79 80 second each of the promising interventions made an effort to address social determinants of health based upon pilot studies that showed barriers to healthy food lack of health insurance coverage and limited access to transportation to buy healthy food or go to healthcare appointments 376669 each of the interventions sought to mitigate these barriers promising interventions educated participants on how to choose healthy inexpensive food items and connected participants with lowcost or free food programs that provided healthy foods the interventions worked with healthcare centers that provided free or lowcost health care and referred patients without a healthcare provider to these services and all interventions held classes in or near participants homes to remove the barrier of transportation costs third engaging social support networks and including family members in the intervention was an important cultural aspect that each intervention integrated nhpis are interdependent with characteristics ascribed to a collectivist culture 85• 8688 decisions regarding food and exercise behaviors are often strongly influenced by extended family members 28298990 finally each intervention hired and trained nhpi community members as peer educators or chws the peer educators recruited participants and delivered the education which was cited as an important part of the success of the promising interventions community members who work as peer educators or chws can serve as an important cultural bridge between participants and researchers diabetes selfmanagement interventions are often delivered by certified diabetes educators who are registered nurses registered dietitians or pharmacists with an additional 2000 hours of specialized education however the three studies discussed in this article suggest that peer educators and chws are effective in addressing diabetes disparities in the nhpi community through the delivery of dsme and dppli 80 100 101• diabetes interventions delivered by chws have been shown to be effective in other populations and are particularly effective when there are significant cultural and linguistic differences between the patients and the majority population 100 conclusion disproportionally high rates of selfreported diabetes diagnosis have been documented across multiple populationbased studies that include nhpis and studies that captured both selfreported diabetes diagnosis and hba1c measures suggest that the actual prevalence of diabetes could be much higher because of undiagnosed diabetes 2526 data aggregation and underrepresentation in health research have impeded the development and testing of interventions and hampered policy and resource apportionment necessary to address the health of nhpi populations 7 8 9 10 11 12 the inadequate investment in nhpi research and programs as well as multiple social ecological barriers has perpetuated the diabetes disparities additional investment in research with the nhpi population and specific nhpi subpopulations is needed to understand and address these significant diabetes disparities agencies such as the national institutes of health patientcentered outcomes research institute and centers for disease control and prevention must focus strategic investments towards addressing the significant disparities in type 2 diabetes for the nhpi community as we consider future research and programs to address health disparities in the nhpi community much can be learned from existing success fill interventions these promising interventions share several attributes the interventions were culturally adapted using a cbpr approach addressed specific social determinants of health that influence disease control and prevention honored the collectivist culture of nhpi communities by integrating social networks and extended family members and utilized nhpi community members including peer educators and chws for intervention implementation these promising interventions can and should be scaled for regional and national implementation in addition additional interventions should be tested with appropriate costeffectiveness data to understand the value of chws and inclusion of family members in the interventions

reviewthe native hawaiian and pacific islander nhpi population is rapidly growing in the usa nhpis face significant health disparities and have a high prevalence of diabetes compared to the general us population recent findingsrecent culturallyadapted diabetes interventions have shown promise in addressing these disparities among nhpi communities the interventions showed success by utilizing a communitybased approach that honored nhpis collectivist culture addressed social determinants of health that influence disease control and prevention and utilized nhpi pearl a mcelfish

recorded sound in the 1870s some manner of piracy has existed whether it was counterfeit wax cylinders outofprint 78s reproduced by jazz and opera collectors bootleg lps of live performances and studio outtakes remixed samplings of recordings circulated on cassettes and cds by aspiring hiphop artists or mp3s of new and old music alike shared on sites like napster and limewire in the case of outandout counterfeiting within the united states europe or other established markets where unofficial recordings were passed off for the original releases by reproducing not only the sound content but also the original packaging the deleterious effect on the record industry is apparent but for other types of piracy the true economic consequences are harder to discern many times piracy simply filled in the cracks between official supply and real demand by satisfying consumers interest in obscure forgotten or emerging music that did not offer the financial rewards expected by the industry the logic of supply and demand however did not compel the record industry to change its practices and try to reach underserved audiences instead it called for stricter laws and stiffer penalties over the course of the twentieth century to tamp down unauthorized reproduction of any sort and to confine consumers as much as possible to popular music that brought the greatest returns on investment while no business is begrudged for pursuing profits the expanded protections the record industry sought often ran counter to the foundational liberties of us copyright law designed not only to reward the work of artists and craftspeople but also to encourage subsequent creative expression by others for much of the century legislators and courts resisted applying copyright protection to sound recordings which for a variety of reasons did not come under federal law until the sound recording act of 1972 though certainly a milestone in the record industrys efforts to quash piracy cummings notes that this new law was a harbinger of more changes to come and it marked a turning point in american thought about culture technology and property of all types as the copyright act of 1976 and subsequent laws and rulings would later reflect the new way of thinking emphasized protection of capital outlays…rather than incentives for artists to create new works by reinterpreting copyright in this way congress showed a willingness to view whatever was good for business as being good for copyright and the public in general this is one of many strong compelling points conveyed in the book characterizing not only how copyright was remade during the twentieth century but also how large media companies have gained the upper hand though ultimately the record industry lobbied successfully for changes in the law to protect its interests cummings observes a growing uneasiness about the current state of copyright noting a diverse movement among scholars and activists that has emerged to counter the perceived excesses of intellectual property law in the twentyfirst century with democracy of sound cummings joins that movement expanding and reframing ideas put forth in other notable recent books that grapple with the past present and future of technology copyright and personal liberty such as lewis hydes common as air revolution art and ownership and siva vaidhyanathans the googlization of everything along with serious appraisals of the record industry like steve knoppers appetite for selfdestruction the spectacular crash of the record industry in the digital age uncritical support for intellectual property rights places private interests high above those of the public cummings concludes and democracy of sound is an important resource to inform further such critique for that reason this book should be part of every library collection and it is essential reading for all librarians who will benefit from the historical lessons and be reminded of the fundamental freedoms our work relies on and must strive to upholddj hoek northwestern university tomas a lipinski the librarians legal companion for licensing information resources and services chicago nealschuman 2013 734p paper 13000 lccn 201218173 the librarians legal companion for licensing information resources and services will prove to be the bible for librariansparticularly academic librarianswho seek to learn and navigate the intricacies of licensing agreements as professor at the school of library and information science indiana universitypurdue university indianapolis author tomas a lipinski jd llm phd is well positioned to present the legal issues of licensing in a manner narrowly tailored to his principal audience librarians and library administrators his research is comprehensive and impressive particularly when he cites case law and legal literature as evidence best of all this handbook is useful to readers with multiple levels of experience with licensurefrom the novice to the expert rendering it an invaluable reference tool in the preface lipinski clearly articulates his authorial intent he states my reason for writing the librarians legal companion for licensing information resources and services is simple to allow you to read and understand the law surrounding the contracting of information content and to a lesser extent information services in library and related settings he emphasizes the role of contract law as foundation for all discussion of licensing he emphasizes the role of contract law explores the intersection of licensing and copyright and discusses more

the unauthorized reproduction of sound recordings today is generally discussed only in terms of the internet and the unprecedented ease by which digital files can be copied and transferred in democracy of sound music piracy and the remaking of american copyright in the twentieth century alex sayf cummings shows that the filesharing activities and concerns of recent decades are just the latest chapter in more than a century of technological legal and social change shaping this history is the persistent tension between consumerswho find enjoyment entertainment and identity through musicand the composers performers and to the greatest degree corporations that own the associated copyrights and seek to maximize profit by controlling the availability and use of their products also part of this equation are pirates those individuals and organizations that reproduce and distribute recordings in violation of the law clearly disrupting the authority of copyright holders as well as diminishing their profits in some cases as cummings demonstrates though the motivations and effects of music pirates are as diverse as the wide range of music being pirated and as legal restrictions and penalties have become increasingly severe a valuable aspect of creative culture is being lost cummings is certainly critical of the record industry but his purpose is not to support or justify piracy rather he sets out to understand piracyits origins its functions its costs its benefitsand the reactions to it in doing so he presents the most nuanced balanced and complete assessment of unauthorized music copying yet published since the advent of

introduction research background with the changes in times and the development of society the creation of chinese mythological animated films is constantly evolving and developing since the release of the animated film monkey king hero is back in 2015 the animated film adapted from mythology has broken into the publics vision the appearance of the 2019 film nezha birth of the demon child once again pushed the creative adaptation of mythological films to the climax of national discussion according to the statistics of chinese literature retrieved by cnki advanced search with the theme of nezha birth of the demon child the number of relevant documents reached 138 in 2019 there is a big difference between hightech mythological animated films and traditional mythological films zhao wang concluded that the myth narrative in the current domestic animation is not a simple retelling of classical myths but a new creation 1 it is no longer simply depicting mythological stories but through mythological elements and exploration of current social issues it provides readers with a new perspective for thinking and cultural experience according to fang shichengs research new mythological animation films are an innovative form of animation screen which started in 2015 and are dominated by technocracy and have a certain commercial value 2 these new mythology animation films feature cultural narratives such as returning to classic legends and reconstructing traditional themes shaping the unique charm of national culture completing the subversion of the mythological subject and the construction of social consensus of values thus profoundly influencing the cultural identity of the audience 3 whether it is a contemporary rewriting of a specific myth or a new narrative after mixing collaging grafting and transforming various nonhomologous myths all of them inject contemporary concepts while retaining the typical visual the new narrative is a mixture of contemporary concepts while retaining the typical visual symbols of mythological images and drawing heavily on traditional chinese art styles providing a new way of thinking for the development of chinese animation 1 with the continuous development of chinas film industry chinese mythologicalthemed animated films have gradually received more attention however chinas research has not yet formed a complete system in this field through cnkis advanced search 54 chineserelated documents were retrieved with the theme of chinese new myth animation film most scholarsarticles mainly study chinese new mythology animated films current situation and development direction in contrast few scholarsarticles have studied the construction of national cultural memory in mythological animated films thus it can be seen that the creative adaptation of mythological animation is an important proposition in modern animation creation in recent years the research on the construction of national culture in chinese new mythological animated films is still superficial animation creators are faced with the plight of the lack of understanding of the construction of national culture in traditional mythology and the exploration of mythological animation is still fragmented lacking a more comprehensive and indepth discussion research design therefore this paper will provide a systematic analysis of the new chinese mythological animation films through literature research methods as well as case study methods through journals essays industry reports and websites myth is the story of aesthetic imagination and explanation of supernatural phenomena with common directivity produced unconsciously in a specific historical period it is the metaphysical spiritual condensation in the collective consciousness and contains the common aspirations of people at that time 2 so after understanding the state of film development and the current state of research a specific analysis is made in relation to the new mythological animated film nezha birth of the demon child then by analysing the characters portrayed in these mythological animation films the social rules embedded behind the characters relationships and then seeking group memories based on individual differences and seeking the spiritual world whose depths can evoke national emotional empathy we conduct a case study and strategic research on the construction of national cultural memory in chinas new mythological animation animated films based on classic chinese myths are based on folklore and mythology encoded transcoded and decoded during the long transmission process reconstructing a surreal time and space where heaven earth man gods and ghosts coexist the narrative vehicle of the classic mythological themes is rooted in the original memory and symbolic accumulation of chinese culture preserving the nations historical memory and emotional experience 4 in the following development new myth animated films should be firmly based on traditional culture follow the industrial creation process of modern films dig out the resounding theme of the story and bring forth new ideas in the local characteristics to stand firm and walk steadily 2 2 case description scholars have pointed out that chinese animated films center on the transformation of traditional mythology relying on the storytelling properties and the efficacy of cultural memory storage that traditional mythology has touching the spiritual world of human beings in the reproduction of mythological meaning on the one hand and reshaping mythology in the structural simulation of the modern world on the other generating the basic path of modern mythological narrative 4 since the release of monkey king hero is back in 2015 many films relying on traditional mythologys framework for creative adaptations have emerged although this will result in a pileup of subjects and fierce competition in the short term it also gradually expands the market and accumulates a certain number of fan viewing groups building up momentum for the fire of nezha birth of the demon child nezha birth of the demon child is a new mythological animation film directed by yang yu adapted from the traditional chinese mythology the legend of the gods to be released in the summer of 2019 the film tells the story of nezha who is born as a demon but fights against the heavens to the end the film was a huge success at the box office and in terms of wordofmouth the adaptation of nezha birth of the demon child is a subversion of the traditional image of the folk gods but it is also a folklore animation narrative relevant to the current social and cultural context and reflects the aesthetic and ethical interests of the general public the film builds a bridge between history and current reality from the perspective of the folk public 5 although the release of the movie nezha birth of the demon child has set off a wave of new mythological animated film adaptations no mythological film of the same level has been produced yet 3 analysis of problem characterisation some scholars point out characterization is the films soul 6 a brilliant animated film cannot be made without good characterisation in the creation of new chinese mythological animation films character reimagining is a crucial part of the process with different characterisations giving plausible motivations and explanations for different characters actions first new mythological animated films often incorporate period features while retaining the attributes of the original characters in order to appeal to audiences traditional mythological animated characters have evolved over a long period of history to become a distinctive national cultural group memory so the creators can draw on the mythological system unique to the nation in the groups cultural memory to reduce the audiences unfamiliarity with the new story when these traditionally animated characters appear in the story the creators do not need to spend too much time introducing their original identities personalities and chains of relationships as these elements are already imprinted in the audiences mind and even though they are different from the classic images this inherent familiarity helps the audience to integrate more quickly into the plot 1 for example in the animated film nezha birth of the demon child the previous image of nezha as a fat doll who could not tell if he was a man or a woman was reversed nezha wears smoky makeup has a big belly and holds a dogtailed straw in his mouth this image of a mischievous teenager breaks away from the conventional image even though nezhas image has been subverted the audience can still remember to match it with its classic symbolic features and other characters distinguish themselves therefore preserving the traditional character traits and drawing on the memory of the national cultural community is undoubtedly a wise way to adapt todays new mythological animation films second the subversive transformation and creative reinvention of traditional mythological animation characters is an important way of creatively adapting new mythological animation films and modernising and interpreting the cultural memory of traditional ethnic groups in the process of creation the creator usually places the traditional mythological character in a modern context reshaping the character and personality breaking the traditional character stereotypes and implanting new memory points so that the character does not become completely assimilated by the frozen memory while following the tradition maintaining the continuity and subversive relationship with the traditional mythological archetype 4 as a cultural symbol like nezha and sun wukong has become synonymous with brave rebellion and is deeply rooted in the hearts of the chinese people and the image of nezha has been constantly updated enriched and developed to meet the increasing demands of contemporary audiences for the identity of the role 7 for example in the animated film nezha birth of the demon child nezha is transformed from a perfect god into a human being with the breath of life he is hottempered and irritable when he encounters disappointment he will have emotions and problems the distance between nezha and the audience has been shortened from a single flat image of hatred of evil to a complex and diverse characterization from a grand educational implication to the personality growth of small people paving the way for the subsequent development of the story and the growth and transformation of the characters compared to the early film images nezha incorporates many modern expressions no longer a simple binary opposition between good and evil but a representative of rebellion against destiny in line with the emotional tendency of contemporary people to freely control their destiny and realise their selfworth the familiar mythological figures are defamiliarised so that the characters can find themselves from different backgrounds complete the remodeling of selfworth break away from the oldfashioned plot and give the characters and stories a new soul 4 third myth as a form of cultural heritage carries peoples recognition and expression of their own national culture the revival of myth can not only carry on the cultural tradition of myth but also meet the various needs of modern society for cultural inheritance whether it is to excavate the origin of mythology or to strengthen the reproduction of mythology it embodies the combination of historical and cultural thinking on the one hand adhering to the core spirit of the origin of myth is the respect for history and culture the reverence and spiritual foothold of a nation for its own origin and the historical memory and sentiment of the national spirit and imagination for its own traditional culture on the other hand the reinterpretation of myth is the expression of the mainstream consciousness in the context of time and space that meets the needs of the people and then calls for the spiritual return of the whole nation activates the origin of cultural memory in the hearts of the audience and gets close to the foundation of traditional culture whether it is to excavate the origin of the myth or to strengthen the reproduction of the myth it reflects the combination of historical and cultural thinking on the one hand adhering to the core spirit of the origin of myth is the respect for history and culture the reverence and spiritual foothold of a nation for its own origin and the historical memory and feeling of the national spirit and imagination for its own traditional culture on the other hand reinterpreting the myth is the expression of the mainstream consciousness in the context of time and space that meets the needs of the people and then calls for the spiritual return of the whole nation activates the origin of cultural memory in the hearts of the audience and gets close to the foundation of traditional culture 5 as a wellknown representative of mythological figures nezha has evolved in the long historical process always adhering to the spiritual core of mythological origin absorbing the nourishment of realistic culture in different spacetime contexts and cultural backgrounds explaining and narrating the selfneeds and selfrepresentations of different people under the social coordinates of the time which is also the core of nezha and has become the output form of selfexpression and selfidentity of folk culture bearers within the group as one scholar said the image of a film character should not be confined to the traditional form while highlighting the balance of personality and emotion in the image of the character it is also necessary to achieve the complementarity between the external shape and the internal character of the character and to effectively integrate traditional culture and the spirit of the times so as to create a film character image that meets the aesthetics of the new era audience 6 social rules the transformation of myth is a dynamic process of symbolization and each evolution of symbolic connotation is not an unconscious accidental change but is influenced by the characteristics of a particular era social atmosphere and other factors 8 on this basis chinese animated films reconstruct the new form of modern mythology by resetting and reconstructing the characters and their relationship with the world thus completing the recoding of traditional mythology 4 first modern mythology is not merely a mapping of the real world it also often provides a reflection and critique of reality through the actions and choices of mythological characters modern mythology attempts to explore how humans should deal with the problems and challenges of reality some authors have split the adaptation of nezhas image into three from resistance to traditional feudal patriarchy and social order to the dichotomy between good and evil and the realisation of educational purposes for younger viewing subjects to the rewriting of his origins against the odds focusing on human nature and the fact that the relationship between gods and demons is no longer titfortat 5 nezhas image changes from rebellion against the social order to one of selfworth and development beginning to explore his path to selfredemption modern mythology draws on the essence of traditional mythology while simultaneously incorporating the realities of modern society and reflecting the common rules of human society viewers can gain insight into the problems and challenges people face in reality through the portrayal of mythological characters and storylines in addition modern mythology can help people to establish the right values and realise the true meaning of freedom and responsibility second the transformation of the thematic proposition embodies a contemporary emotional quest for example the transformation of nezhas mother lady yin from the image of a woman who is subservient to her husbands orders to that of a career woman reflects the changes in family structure and identity roles brought about by the rise of female power in modern society the mothers role is not only to take care of her husband and son but also to have a say in external social and educational matters for her children the fact that nezhas mother lady yin has to be absent from her sons upbringing because she is so busy subduing demons every day in order to protect the local people leads to nezhas emotional absence and inexpressive character flaws which is a troubling issue for working women today regarding how to balance work and family 7 the virtual world presented by chinese new mythological animated films is often a microcosm of the current real society which has certain social practical significance and entertainment and educational significance how the characters are narrated in different historical stages to some extent also constitutes an observation perspective of the social and cultural reality at that time 1 third in the cinematic space viewing is both a process of witnessing personal growth and a search for fragments of memory at the same time several elements of the mythological matrix are reorganised and modernised according to actual needs 2 mythological stories need to be constantly interpreted with new themes because of their different social rules and characteristics of the times on the premise that the original spiritual core remains unchanged we should eliminate the outdated emotional needs and integrate them into the characteristics of the new era the attitude of combining breakingandestablishing is not only the modern transformation of mythological resources but also the mythological expression of modern peoples spiritual world 4 suggestions when making creative changes in chinese new mythological animation films it is necessary to consider the national culture and the characteristics of the times need to be rooted in national culture the film respects nezhas original rebellious attributes and continues the traditional chinese educational philosophy of pursuing a happy ending first respect for the characters own resistance properties in adaptations of new mythological animated films some original portrayals of the characters or stories are often borrowed to reduce the unfamiliarity of the characters in the movie nezha birth of the demon child despite the numerous creative adaptations of nezha some of the characters own personality attributes such as the setting of defiance are retained in the film nezha constantly rebels against the mandate of heaven and redeems himself in the face of the people he is unyielding and strives to eliminate prejudice in the face of his parents he refuses to be misunderstood while daring to act in the face of the irreversible mandate of heaven he resists tenaciously not bound by prophecy and strives to redeem himself through his own cultivation in protecting his will nezha encourages resistance to old ideas and regulations a characterization that also offers a glimpse of resistance growth and redemption in traditional chinese culture second continuing the educational philosophy of teaching by example teaching by example is a very important way of education which enables the educated to learn the correct way of behavior and doing things through behavioral demonstration and verbal guidance in the movie nezha birth of the demon child li jing is a typical representative of teaching by example in the film li jing is still a strict father with a more humanistic approach than in previous literary works although li jing is not a man of many words he loves his child deeply and attempts a miracle knowing that nezha will be destroyed as a demon child because of this love in his heart li jing is willing to give his life in exchange for guarding nezha this act of his fathers profoundly affected nezha as he did not accept his fate and shouted that his life was up to him but he also found his value thanks to li jings teachings nezha was transformed from a devil child scourge to a young hero who saved the world third the pursuit of a happy ending in chinese culture family is an important concept and many people believe family harmony and harmony are the foundation of happiness in the movie nezha birth of the demon child nezha and ao bing are dead but their souls are still alive leaving room for future story development the happy ending satisfies the audiences emotional needs and conveys positive values making it more acceptable to more people the creation of new chinese mythological animation films must be based on traditional national culture in order to be recognized by the public need to incorporate the zeitgeist the film and television creators of chinas new mythological animated films integrate the characteristics of the times values aesthetic orientation and spiritual connotations on the basis of exploring chinas highquality traditional cultural resources in order to make the traditional mythological stories told in a new way 9 the creators modern vision and the inclusion of period elements are key reasons for the success of the film nezha birth of the demon child the struggle against the powerful is replaced by the themes of resistance to fate selfgrowth and redemption which people recognize today 10 first audience identification todays film creators try to gain recognition by evoking a sense of recognition from the audience the uncertainty of life often leads people to identity anxiety some scholars have pointed out that chinese films in recent years have reflected peoples need for identity from different perspectives one type of film is youthful nostalgia films which define their own identity by evoking memories another type of film is animated films such as monkey king hero is back which emphasise individual responsibility and commitment in shaping selfidentity in practice another type of film is melodramatic films which another category is the melodramatic films which emphasise national identity inspired by national rescue and the films represented by the science fiction disaster film wandering earth which express the quest for identity of human beings as a community 11 the film also reflects the demand for identity taking the misplaced identities of nezha and ao bing as a starting point overlapping the miseducation of parents and teachers with the coloured vision of the other to speak of the difficulties and embarrassment of establishing selfidentity in the process of growing up insinuating the identity dilemma of contemporary people while attempting to resolve the reality of identity dilemma by reducing identity to the soul 11 therefore by alluding to the issues of the time and incorporating the characteristics of the times the film is more likely to evoke a sense of identification with the audience second the integration of modern values the incorporation of modern contemporary values has made the film more accessible to the general public with the development of the times peoples values are also changing and evolving with more emphasis on values such as equality respect pluralism and diversity in current animated films more and more works also begin to highlight humanistic concerns for example the theme of rebellion against fate was usually opposed to the oppression of feudal kingship or religious theocracy in previous literary productions yet in todays society the kernel of the story of fate by god becomes fate by oneself 12 the theme of the film is no longer one of obedience and revenge no longer one of rebellion and struggle no longer one of pure individual heroism and absolute opposition between good and evil but rather one of my fate is mine in response to the changes of modern society 13 the change in the theme of the film nezha birth of the demon child is one of the reasons why the film is such a success therefore the adaptation of the new chinese mythological animation film needs to incorporate modern values only by taking into account the national culture and the characteristics of the times can chinas new mythological animation films be better developed this is the inheritance and development of traditional national culture and reflects and expresses modern society conclusion suppose chinese new mythological animation films want to achieve better development in the future in that case they have to rely on traditional national culture and bring together collective memory while incorporating a modern vision and popular recognition of the times such creative adaptations include but are not limited to characterisation social rules and the spirit of the times as the chinese film market continues to expand and grow in influence chinese mythological animated films are gradually gaining attention as an important category using the animated film nezha birth of the demon child as an example this paper examines the new chinese mythological animated film which positively contributes to the construction of a national cultural consciousness in chinese mythological animated films and the future development of mythological cinema this paper examines the construction of national cultural consciousness and the future direction of chinas new mythological animation film through the study of nezha birth of the demon child through the analysis of characterisation and cultural connotations it reveals the close connection between traditional mythological culture and modern life highlighted by the film and reflects the profound influence of the group memory of national mythology on modern life contributing to a deeper sense of cultural identity and the realization of cultural confidence however there are some shortcomings in this paper firstly this paper mainly adopts a documentary research method to analyse and study the construction of national cultural awareness in chinese new mythological animation films this leads to a heavy reliance on secondary data and a lack of use of primary data which may lead to inaccurate or missing information secondly as the scope of research on the national consciousness of chinese new mythological animation films is too large this paper only selects a few aspects of chinese new mythological animation films such as the paving of traditional national memories and the integration of contemporary features this makes the study somewhat onesided and requires further refinement the above issues can be studied in greater depth and more extensively in the future through case study analysis and data collation and analysis

chinese neomythological films are emerging as a new genre of cinema attracting more and more creators and audiences taking nezha birth of the demon child a representative of the new mythology animated films as an example this paper analyses the national cultural awareness embodied in the characterisation and social identity of chinese new mythology animated films through a documentary research method and points out that chinese new mythology animated films can only be better developed if they take into account the national culture and the characteristics of the times that is on the basis of preserving the traditional group memory of the nation creative adaptations are made using a modern vision to gain contemporary popular recognition the author believes that valuing the uniqueness and value of chinas new mythological films in the construction of national cultural awareness will lead to more masterpieces in the future contributing to the development of the chinese film industry and even the worlds animated films

conflict of interest the author have no conflict of interest to declare that they are relevant to the content of this article

all living things have the right to live on the earth there should be no difference even among highranking people transgenders are human beings like male and female they should also be treated as equals and be respected as a living being but they are ridiculed and teased in society people who are inferior in levels of caste occupation politics sexual status economic status can be termed as marginal but the dalits black women transgenders etc are always considered as the margins among such marginalized ranks the social esteem of transgenders are very low castebased atrocities treat women as inferior because they are women overall they are human beings and should be treated equally in society this article investigates about the notes on transgenders in tamil literary works

rowing up in cole harbour nova scotia you can likely appreciate the prominence of hockey felt in the community the area has had a few notable hockey players achieve significant success and you might think of obvious names such as sidney crosby and nathan mackinnon it was actually joe dipenta who was the first player to bring the stanley cup home in 2007 alexis miller who represented team canada at the 2012 u18 womens worlds hockey championships and went onto captain boston university should also come to mind its safe to say that the area in which i grew up contributed to my fascination with hockey though my father was a fan especially of guy lafleurs montreal canadiens neither of my parents were overly eager for me to join organized hockey they were hesitant of the time commitment early mornings and cold temperatures it required i distinctly remember asking each night as one of my parents turned my bedroom light off when can i play hockey eventually my youthful persistence paid off as my parents registered me for hockey i was officially a cole harbour bel ayr red wing a real hockey player i thought to myself i did not play at the top levels but i was all ini lived and breathed hockey at a young age i was inspired by the heroics of both canadas mens and womens national teams at the 2002 winter olympics my dream became clear without any significant consideration of how i might attain it i would represent my country one day and obviously make the national hockey league i mean how difficult could it be unfortunately i lacked the important combination of skill and discipline to achieve that goal for whatever reason i struggled to accept responsibility for my actions on the ice a lesson i only learned after stepping away from competitive hockey at the age of twenty i did learn many other lessons though as i moved through hockey lessons like how the game thrives in its ability to create immense lows and how it rationalizes those moments with the promise of immeasurable highs i have much to be grateful for in my experience playing hockey however when i reflect on it i recognize that as much as it gave me it also took away and as unkind as i was to hockey the game also did not hold back before i explain what that means its likely helpful for you to know that i am a registered indian as defined within the indian actmy father mikmaw my mother nonindigenous i am a 6 indian to be more specific which represents a cutoff point in the canadian governments acknowledgement of indigenous identity with that said in simpler and preferred terms i am mikmaq from a young age both of my parents were vital in both shaping and helping me to understand my identity i was always proud to be mikmaq but it has been a journey to appreciate what that means one that continues today to not just know but to feel and in many ways reclaim my band acadia first nation was always supportive of my various activities some years this included sponsoring my jersey bar for the season i wore this proudly as other teammates had various family and community businesses as theirs this was likely the only indication opponents had of my identity because i pass as nonindigenous to most people walking or skating past me as i alluded to earlier my discipline throughout my youth hockey experience is best described as poor this at times put me in regrettable situations i was always amid chaos often the g creator but never at fault at least from my perspective one of the rare times where this statement is true occurred at the conclusion of an unnecessarily intense u13 game where i found myself in a scrum i was surrounded by most players on the opposing team near their bench not eager to leave without making my point one of my assistant coaches intervened and ushered me towards our end of the ice in that process an opposing coach decided to have the final few words he grabbed my attention by calling me an offensive slur which i had never heard before i could not say with certainty what was said to me i still cannot but i remember that it was directed at me with a harsh intent that left me confused and indignant at the time i was offended by the expletives spewed because i was not familiar with the racial slur a formal process took place but hockey nova scotia ultimately decided that whatever occurred was indiscernible unfortunately denial and collaboration prevailed my understanding is that the person who uttered the words and his staff acknowledged the incident but denied saying anything racist revisiting this experience the quotation often attributed to mark twain history doesnt repeat itself but it rhymes resonates my story is not unique and there are experiences far more severe and frequent than the incident i experienced in 2019 logan prosper of whycocomagh first nation was the victim of racial taunts from opposing players after an investigation hockey nova scotia concluded that insulting remarks were made but that they were not racial we hear stories of racism in sport every so often and we are generally outraged each time the rationale or context is a bit different but the outcome eerily similar the decision on what constitutes racism is almost never made by the one harmed rather it is typically made by those operating within an upheld structure that holds all power and continues to enable malicious intent regardless of the words used it is in these moments in particular that it tires me to hear of the many wellintentioned individuals within this structure working so earnestly towards a safer and more accessible environment for participants i know many of these people and i would agree they are lovely kind and indeed wellintentioned however in my opinion there is little to no active engagement with the broader institutional structures they find themselves in that perpetuate systemic racism specifically i find that these individuals fail to recognize that no one owns hockey and there is no right or best way to participate in it so while they may be working hard to include all in the sport they do not make room for everyone to be themselves and have their own goals or reasons to join in to simply invite someone to participate rarely results in meaningful inclusion and the creator of the problem cannot be the lone problem solver wellintentioned individuals cannot themselves dismantle and lead change in a system that enables and empowers racism in the harshest description and ignorance in the most generous terms what is a hockey player can it be a toddler hitting a ball around with a mini stick a young child playing road hockey in their driveway a teenager skating freely on a frozen pond with a stick in hand the adult participating in a weekly new to hockey program a team jacket and travel cannot be the threshold of who is and who is not a hockey player in hockey a distinct culture has been allowed to become interchangeable with an activity one does the idea that someone who does not play mainstream organized hockey may not be seen as a hockey player simply because of the environment they have chosen to partake in is inherently exclusive it is probable that the setting in which the person has chosen to participate in hockey is the one they feel safest and most represented in at that specific point in their journey we must work towards a solution in which an individual has the choice on how they choose to interact with the sport the system in its obsession with professionalization and perceived elite competition has taken more responsibility in defining what a hockey player is than it has in ensuring that whatever pathway is chosen the individual feels supported seen and celebrated specifically it is impossible to create a safer and more welcoming environment when the game protects itself and its reputation ahead of its participants at the 2020 hockey conference policies and governance scholar marina nocesaporito observed that the phrase travesty of the game is often used to justify severely penalizing players this approach focuses on protecting the reputation of the game and does nothing to address the harm caused by the action of the player to the victim imagine in a workplace setting an employee making an obscene gesture to another employee their boss witnesses it confronts the situation and exclaims how damaging their actions were for the company all while overlooking the employee at whom the gesture was directed and its impact on that person the question then does not become how to have that individual fit within the established system but rather how that individual needs to be supported for them to continue interacting with the activity in a way that is comfortable for them building recognition and capacity for all possible touchpoints is necessary to make the game more accessible and welcoming to all this approach allows separation between the state of hockey and the activity of hockey and more importantly gives the participant the power to interact with the activity in the way they choose after much planning the indigenous girls hockey program was launched in 20192020 in three nova scotia locations this program focuses on supporting leadership capacity and providing opportunities for indigenous girls aged 614 to experience hockey with their peers potential barriers such as equipment and other expenses are addressed but the programs success is the fact that it draws attention to a more meaningful sense of belonging this program runs for approximately ten weeks each year there are no organized games against other teams and no officials or scorekeepers jerseys are often mismatched and do not display a players name or a chosen number because of that they may not fit hockey cultures narrow definition of a team yet you will hear participants affectionately use the term team to refer to their fellow peers in the program without a second thought in a community that hangs banners along their main street to celebrate their high school graduates from that year one of the coaches from the program was featured as one participant of the program drove past these banners with her mother she became audibly excited thats my coach she exclaimed proudly these examples are a reminder of the importance of identity and representation neither can be found or solved by a structure only by the individual themselves with this in mind the responsibility of the structures in power becomes clear allow individuals to choose the way in which they interact with the activity and make genuine efforts to ensure the space needed and access necessary exists throughout whatever that journey looks like this requires prioritizing the person above the power structure and socalled integrity of the game prioritizing the person means giving ownership to them and through relationships valuing power neutral support that meets the needs of the whole physically mentally spiritually and culturally when a holistic approach is taken the connection between person and environment becomes powerful why do the participants of the indigenous girls hockey program so confidently speak of their fellow participants as a team i have come to understand that it is because gathering is spiritual systems that are siloed by design have created criteria that prohibit such a concept to even be considered or recognizable teams are not created by membership or insurance but through a true sense of belonginga sense of belonging created by the freedom to choose how you interact with hockey and as a result being represented in the game on your own terms free of conformity to an exclusive culture throughout my work with the indigenous girls hockey program i have learned more about myself and the concept of team than i did in my fourteen years of playing the sport ive also learned that my story is only one of many and that change is made by creating a safe space for the voices of others like the participants of the program it will be the interconnection of each of our stories that reveals the way hockey isand ought to beexperienced as opposed to the way the system has chosen to define it

and is a member of acadia first nation he played hockey in the united states while he completed an undergraduate degree in sport management before returning to canada to obtain a master of physical education in administration curriculum and supervision he is currently employed as manager of provincial outreach and coordination for the nova scotia department of communities culture tourism and heritage in its communities sport and recreation division he is also the first ever visiting indigenous fellow at saint marys university where he is leading projects in research and community collaboration all related to indigenous sport participation and education ryan is perhaps best known for having helped launch the indigenous girls hockey program nova scotia a role that contributed to his nomination for the national hockey leagues prestigious willie oree community hero award he wrote this essay in his capacity as a mikmaw hockey player and sport administrator about his perspective on racism in hockey and how the structure of mainstream hockey in canada perpetuates exclusion

introduction as a result of the incredible development of the internet wireless communication tools and mobile technologies take place in every level of education 202627 based on this development smart systems and robotic applications which make human life easier have become more integrated into our lives 24 in many countries there are software projects in this field constituted by support from companies governments and universities however companies in north cyprus report that there is paperimportance of coding education and robotic applications for achieving 21stcentury skills in north cyprus insufficient number of good software developers and there are no such attempts enough therefore there is a need for students to acquire skills for producing solutions for problems develop new ideas in an area of profession human sciences and social sciences by using computer sciences and applications beginning from early childhood education 31 recently it is frequently mentioned that students need to receive coding education at early ages all around the world 4 since basic skills in which 21stcentury individuals must have could be acquired by teaching coding and computational thinking skills 13342932 21stcentury skills are shown in figure1 30 it is really important to acquire 21stcentury skills including computational thinking 22 according to literature there is a lack of research on computational thinking in the context of robotic applications in north cyprus computational thinking and robotic applications are closely related with each other 2 coding education and robotic applications in order to objectify coding education might be effective for teaching 21stcentury skills to students in north cyprus problem statement it is observed that coding education and robotic applications are integrated or being integrated into education systems of countries for the students at early ages throughout the world in this context the question of what is the importance of coding edu method this is a descriptive study based on literature review in order to reveal the current situation obtained data were evaluated by the researcher and interpreted based on a descriptive approach 9 coding education and robotic applications coding education is the basis of robotic applications and programming skills constitute the basis of coding in addition algorithm is the basis of programming problemsolving skills constitute the basis of all of these mentioned skills especially being unable to acquire competences of problemsolving approaches and designing solutions effectively makes learning programming skills a difficult approach 33 in recent years it has become lively again through visual programming languages such as alice code codeogr and scratch 19 it is possible to make computer programming easier and clearer for everyone through these applications 3617 at this point computational thinking arise as having essential knowledge skills and attitudes for using computers as production tool in solving problems of daily life 15 computational thinking is a method for understanding human behaviors through emphasizing problemsolving designing systems and basic concepts of computer science 25 furthermore algorithmic thinking skills are important in acquiring problemsolving skills algorithmic thinking includes skills for understanding applying evaluating and producing algorithms 8 algorithm was invented by ebu abdullah muhammed ibn musa el harezmi who is a muslim mathematician not by a western scientist 23 in a research in which the effect of programming on the development of mathematical and computational thinking was examined it was figured out that programming education is effective for teaching mathematics developing problemsolving strategies and for collaborative systematic and creative thinking 38 many operations and concepts remain as discrete when teaching programming language and students experience difficulties in objectifying knowledge robotic applications might be an appropriate approach for making this process concrete 21 robotic applications require coding education in table 1 some skills application and robotic application tools related with coding education which can be used in school levels are demonstrated 3 in the environments mentioned in table 1 primary goal is to develop learning outputs and increase student motivation through using as a tool which enables 21stcentury skills rather than teaching coding itself 28 technological innovation named as robotic has been integrated with various disciplines it has also become an important part of especially science technology and engineering education process 10 robot as a word has been derived from robota which means compulsory labor of slaves in old czech and todays slovak languages 18 today robots are defined as selfcontrolled and programmable devices including electronic and mechanic departments 1 paperimportance of coding education and robotic applications for achieving 21stcentury skills in north cyprus studies on integrating coding education into curriculum as part of fatih project applied in turkey are being conducted and robotic applications are being discussed 40 educational political and social developments occurred in turkey are also reflected in north cyprus since cultures of turkish cypriot and turkish students are close to each other and there are strong relations between two countries 11 cloud computing social network increased mobility increase in commercial values of opensource coded software are the most remarkable issues in north cyprus and they increase the demand for information sector informatics island vision is being conducted in the country and there are five basic targets included in this vision • taking an active role in informatics world • providing solutions for humanresource problem in informatics world with qualified human power through benefitting from universities in north cyprus • converting regional research centers into central informatics laboratory • achieving technology transfer through enabling leading producer companies of the world in informatics to invest in our country and • undertaking informatics island role through providing product and services to new technologies in order to achieve these targets information technologies communication institution continues to work for the country however there should be more emphasis on coding education and robotic applications in addition universities in north cyprus take an active role in achieving these targets 7 activities of some universities in north cyprus in parallel with informatics island vision some universities in north cyprus have developed robotic applications and tools near east university 1 • in near east primary school coding education is given as part of educational activities one hour a week on codeorg website since 1st year of primary school in addition necessary materials and ipad tablets have been brought this year in order to give robotic education through lego wedo and studies for program development towards robotic education have started • neu hospital provides surgery services with robot robotic surgery system which is at surgical console shortens the treatment duration of patients • neu educational sciences faculty has conducted the first and only experimental study in north cyprus for 9th grade students from secondary education in the study scratch education was given during an academic term and it was figured out that students achievement scores increased and students reported positive views towards scratch program 39 cyprus international university 2 • students from the department of ciu electrical and electronic engineering designed lightsensitive robots which follow line solve labyrinth and engage in sumo wrestling robot which follows line and lightsensitive robot in free category as a course project and sumo robot and robot which solves labyrinth projects were shown in a special platform as a part of ciu robot 2013 activities girne american university 3 european university of lefke 4 • two leopard ges robot appropriate for nasa standards were produced by teachers and students from the department of lau electronics and communication engineering department the ecofriendly robots were produced for defense and security they use green energy and they are designed with a technology which can charge themselves on electromagnetic waves mechanisms of the robots are sensitive to moving objects and they have features including helping each other and recording audioimage through using different connections such as wifi gprs and bluetooth besides they can move between humansfind their direction send data instantly and record them apart from these mentioned universities there are no studies conducted in other universities in north cyprus related with coding education and robotic applications or projects designed in private sector there is a need to increase coding and robotic applications since universities are effective in scientific and educational areas universities need to prepare more environments and motivate students north cyprus government must provide support to universities coding and robotic education have to be started and integrated in preschool primary school and high school levels method conclusion and recommendations recent technological developments require individuals to tend towards consumption rather than production coding education is given beginning from early childhood in many countries in the world 637 15 eu countries have already integrated coding in their school curriculum these are austria bulgaria the czech republic denmark estonia france hungary ireland lithuania malta spain poland portugal slovakia and the england among them france and spain have integrated coding only recently finland announced it will integrate coding in its curriculum in 2016 and belgium is currently debating whether to integrate coding at school 9 eu countries already integrate or will integrate coding at primary school level soon already integrate estonia france spain slovakia uk will integrate belgium finland poland portugal 12 eu countries already integrate or will integrate coding at upper secondary school level in general education austria bulgaria denmark estonia france hungary lithuania malta poland slovakia spain and the united kingdom 121416 in turkey information technologies and software course are included in 5 th 6 th 7 th and 8 th grades as elective course based on the curriculum published in 2012 in north cyprus it is observed that there is still insufficient importance given to coding education and robotic applications it is revealed that there are effective robotic studies as a result of institutional efforts by universities however there is no attempt to integrate coding education into primary secondary and university education programs and there is a little number of academic research related with coding education and robotic applications on the other hand many countries have included or are including coding education into curriculum domestic market habit being noninstitutionalised focusing on short dated targets lack of projects in informatics sector and unable to receive investmentpromotion support are the most remarkable inhibitive factors in terms of informatics in north cyprus legal basis of cyprus localorigin companies is not secure in international platforms because of political problems in the country there is burnout and hopelessness among companies and individuals in the sector because of ongoing isolations in the country in addition since there is no opportunity to conduct comprehensive projects and there is uncertainty in the sector products which are short dated and require less investment are more preferred by companies 5 companies universities and government of north cyprus need to make investments and serious attempts for coding education and robotic applications in order to inform and educate next generation new professions will emerge in the near future and many existing professions will not be needed children will play an active role in north cyprus in terms of being a society which produces products with high technology therefore it is crucial to teach 21stcentury skills to children 16 paperimportance of coding education and robotic applications for achieving 21stcentury skills in north cyprus in this context recommendations for achieving coding education and robotic applications which have received great attention throughout the world in north cyprus as well are provided below

coding education and robotic applications are integrated or being integrated into education system for students at early ages all around the world aim of this study is to reveal the importance of coding education and robotic applications for achieving 21stcentury skills in north cyprus this study is a descriptive study based on literature review the obtained data were evaluated by the researcher to reveal the current case with a descriptive approach it is really important for students to receive education on coding and robotics applications in order to be able to acquire 21stcentury skills develop produce and achieve informatics island vision of north cyprus in this research it is observed that importance given to coding education and robotic applications in north cyprus is insufficient it is also revealed that there are effective robotic studies as a result of institutional efforts by universities however there is no attempt to integrate coding education into primary secondary and university education programs and there is a little number of academic research related with coding education and robotic applications it is expected that this study will be a guide for academicians who would like to conduct research in this field provide information about the present condition and set an example

introduction mobile phone addiction is not a new social problem but a new symptom of internet addiction set in the rapid development of mobile internet technology as early as the 1980s sherry turkle was concerned that new technologies could be so sticky that people could not break away from their dependence on them in recent years mobile phones have become the most dominant device for people to access the internet due to their independent operating system and running space convenience and portability however the more ubiquitous and powerful mobile phones are the harmful 2021 51 of middleaged and older people spend more than four hours online each day and using mobile phones day and night becomes a daily routine more than 99 of minor internet users spend more than two hours online per capita on weekdays of chinas 244 million migrant population more than 13 million are elderly of which 43 choose to migrate to care for their younger generations due to this groups environmental and cultural incompatibility social interaction and interpersonal conflicts have become social problems that cannot be ignored social interaction is a basic need of human beings elderly migrants devote much time to various new social media platforms to seek newly attached human relations and obtain social support 2 problem statement although scholars have examined the causes of mobile phone addiction in older adults the existing studies in intergenerational family relationships are insufficient to provide a complete understanding intergenerational differences may lead to diverse characteristics of mobile phone addiction in different generational groups which may reflect the problem within the family system therefore this grounded theory study plan to extract the characteristics of mobile phone addiction of elderly migrants and adolescents and then explore and analyze the intergenerational differences in mobile phone addiction between the two groups limitations this grounded theory study is only an exploratory study and still has shortcomings first of all considering the adequacy of previous research on adolescent mobile phone addiction this study collected secondary data on the topic of characteristics of adolescent mobile phone addiction which is likely to affect the analysis results second due to the epidemic this study interviewed older adults on the internet lacking timely feedback interactions and onsite observation details which may also affect data quality literature review media use and generational differences intergenerational differences are group characteristics that vary significantly across generations regarding values emotional preferences cognition and behavior influenced by birth years and upbringing at present chinese society is facing an increasingly new media and an increasingly old population structure population aging is becoming increasingly severe different generations were being called digital natives and digital immigrants by mike prensky because of the differences in the timing and skill level of their access to media technology although the values and attitudes of different groups and generations are presented and debated in the new media the expanding media have brought about implosionlike social changes resulting in the subversion challenge and even rupture of otherwise stable social relations such as ethical relations and power structures scholars study intergenerational differences mainly focusing on intergenerational differences in media use behavior the proximate use of different types of media and the motivation of media use intergenerational differences in media use behavior primarily manifest in specific media preferences and participation variation in media usage across different types of media reflects individual inclinations towards particular media platforms additionally disparities in motivation for media consumption examine psychological needs and overall satisfaction with media engagement the most fruitful results on intergenerational differences in media use behavior several studies have confirmed intergenerational differences in media use behaviors especially online media use a survey of cloud services across spain found that teenagers have more significant needs than seniors for cloud service storage space and privacy protection at the same time older users are more sensitive to the security experience of cloud services zhao found that the post70s lagged behind the post80s and post90s across the board regarding information acquisition online dating and online expression which may be caused by the short time the post70s spending on the internet it has also been found that the liking behavior of the post70s is mainly to improve communication while the post90s are both improving and avoiding communication in addition there are also intergenerational differences in the use of web buzzwords with the use of web buzzwords by the childrens generation being significantly higher than that of the parents generation and after indepth analysis it was found that the parents generation mainly use buzzwords that are more widely spread and accepted scholars have also researched the use of different media types with different generations showing other service habits under the double line of a media development cycle and audience life cycle a swedish research study shows that the older generation tends to use traditional media while the new generation embraces social media more actively there are behavioral differences across generations even when faced with the same social media younger generations focus on showing themselves on social platforms are active and creative and are willing to try new social software older adults have conservative attitudes and mainly obtain information about useful services like health and weather information in addition a few studies examine different generations motivations for using social media focusing primarily on audience media use and gratification scholars have found significant generational differences in media use on socialized trust however data from a survey of 10 european countries showed that levels of media trust did not differ between generations other studies have found that the same medium does not bring about the same need satisfaction for example there are no generational differences in using facebook and blogs to satisfy social and emotional needs still there are generational differences in selfish motivation mobile phone addiction and generational differences we are living in an addictive era where addiction caused by excessive mobile phone use has a significant negative impact on the physiological and psychological wellbeing of individuals while research in this area began in 2008 with the introduction of mobile phones it was in 2014 that the real focus of scholars was placed on it wang and wang reviewed that the study of mobile phone addiction mainly focuse on the adolescent group and it needs to expand the research population further studies have found that mobile phone addiction not only affects adolescents physical and mental health and academic achievement but also leads to adolescents frustrated interpersonal relations in real life and social interactions and can even induce adolescents to form a criminal mentality and inclination towards crime several scholars have empirically demonstrated that gender personality traits anxiety depression selfefficacy and social support of adolescents can predict mobile phone addiction others have used mobile phone addiction as a predictive variable to explore the relationship between mobile phone addiction and sleep quality academic achievement and physical activity compared to mobile phone addiction research in adolescents there is a lack of research on mobile phone addiction in older age groups vasiliu et al noted that it is crucial to differentiate the characteristics of addictive behaviors in different subjects due to differences in age culture and experience a study of mobile phone users aged 18 to 70 found that mobile phone addiction had a more significant negative impact on younger people than older adults in summary along with the increasing popularity of digital survival research on media use focusing on different generations is emerging in china and many research results on youth mobile phone addiction have been accumulated still few studies have explored the characteristics of mobile phone addiction from the perspective of intergenerational differences even studies on mobile phone addiction focusing on older groups are still limited to empirical descriptions peng lan pointed out that the difference in digital survival between generations will also increase the intergenerational cultural gap and even lead to cultural rupture this study will undoubtedly enrich the existing research results it will not only help to guide the healthy existence of different generations in digital space but also provide a reference for relevant governing bodies to carry out media literacy education bridge intergenerational cultural differences and promote intergenerational harmony research objectives 1 to study the characteristics of mobile phone addiction in the elderly migrants 2 to explore the characteristics of mobile phone addiction in the adolescents 3 to examine the differences in the characteristics of mobile phone addiction between these two groups research questions this study will to answer these questions 1 what are the characteristics of mobile phone addiction in the elderly migrants 2 what are the characteristics of mobile phone addiction in the adolescents 3 what are the differences in the characteristics of mobile phone addiction between these two groups research methodology the grounded theory method was initially proposed by barney glaser and anselm strauss grounded theory is not a theory but rather an alternate comparative interactive and hypothetical inference approach that allows for using multiple sources for research it is recognized as the most scientific type of qualitative research it emphasizes bottomup induction of concepts and propositions from information in natural contexts and the theoretical construction of socially specific phenomena this study aimed to investigate the intergenerational differences in the characteristics of mobile phone addiction and to develop a preliminary theoretical construction of the intergenerational differences in the parts of mobile phone addiction therefore this study used grounded theory to code primary interview data and secondary literature step by step the study was concluded by open coding axial coding and selective coding of interview materials and collected secondary sources based on the formulation of questions and systematic literature review and only after passing the theoretical saturation test in the open coding stage the selected texts were coded and categorized after repeatedly deliberating word by word and sentence by sentence in the axial coding stage the categories from the open coding stage were again summarized and the main categories were refined finally the main types were organically related to examining the latent pattern and for this purpose the theoretical paradigm of a → b → c → d → e wu and li is outlined and the theoretical model of intergenerational differences in the characteristics of mobile phone addiction is explored and interpreted and compared by repeatedly comparing the collected data and sorting out the storyline considering that this study is to explore the intergenerational differences in the characteristics of mobile phone addiction we will not construct a selective code for each group separately but will compare the concepts and categories extracted from the study on the two groups to form a standard theory that is applicable data sources this study focused on the core issue of mobile phone addiction in these two groups the primary data selected for the study of mobile phone addiction among elderly migrants were indepth interviews conducted with people aging 60 years and above who had symptoms of mobile phone addiction the selection criteria for mobile phone addiction were mainly based on the selfassessment of the elderly and other assessments by their family members such as mobile phone use for 5 hours or more per day through purposive sampling eight interviewees were finally selected in this study who are now living with older people in chengdu nanjing xining and yinchuan in china the interviews were conducted through facetoface and online discussions to understand their awareness of mobile phones mobile phone use and the influences of mobile phones on their life the interviews were conducted from november 2021 to february 2022 with a single interview lasting about 30 minutes secondary data include authoritative media reports such as guangming daily and china youth daily and some reports totaling 23 documents as mentioned in the previous section scholars have studied mobile phone addiction among adolescents and this study is intended to compare the intergenerational differences in the characteristics of mobile phone addiction so the data on mobile phone addiction among adolescents were mainly selected from the research literature on the internet because the concept of mobile phone addiction is used interchangeably with mobile phone dependence cell phone addiction internet addiction and problematic mobile phone use the abovementioned similar concepts were also included in the literature search in the cnki database the papers were indexed and included in cssci by searching all cssci source literature published before january 1 2022 after removing duplicate articles a total of 65 research articles highly related to the study topic were selected by manual screening the study randomly selected two interview transcripts of older adults and 15 pieces of adolescent mobile phone addiction research papers for further theoretical saturation testing based on its principle theoretical saturation was considered to be reached when the information could not be generalized to new concepts or relations data analysis open coding open coding reviews textual information word by word tagging keywords and then summarizes them which is the first stage of conceptualization in the open coding stage of the characteristics of adolescent mobile phone addiction out of 65 documents related to this topic 50 were randomly selected for classification and reorganization labeling summarization and coding and 243 original event records were compiled based on objective judgment and comprehensive understanding and were conceptualized classification because of the homogeneity of many research hypotheses in the knowledgebased literature this study invited academic experts to integrate compare screen and label the actual events conceptual understanding and determination of categories and finally formed 63 initial concepts twenty categories were developed after reclustering by judging these concepts correlation similarity subordination or causality based on the same idea and operation procedure 23 pieces secondary papers and 6 primary interview transcripts were compiled on the issue what are the characteristics of mobile phone addiction of elderly migrants 182 prior event records were obtained and 44 initial concepts and 17 categories were proposed after further abstraction and categorization axial coding the axial coding stage extracts the main categories based on intercategory relatedness and logic in the open coding stage the initial categories have been removed from the original text to ensure the categories mutual exclusivity and rigor however to clarify the intergenerational differences in mobile phone addiction characteristics and present a clear and explicit model of mobile phone addiction characteristics it is still necessary to deeply analyze the attributes of the categories and dig out the logical relationships among them therefore in the axial coding stage we further analyzed 20 categories of mobile phone addiction among adolescents and 17 categories of mobile phone addiction among elderly migrants and formed five main categories which are external environment individual characteristics cognitive characteristics addiction motivation and behavioral choice these five main categories can integrate the categories of addiction characteristics of elderly migrants and adolescents and are conducive to forming a unified theory selective coding selective coding is to analyze the main categories that have been summarized around the initial categories explore the internal connections and sort out a storyline in this study the characteristics of mobile phone addiction among older adults and adolescents who have moved with them have been clearly identified the external environment and personal characteristics provide the conditions for mobile phone addiction between the two groups however the differences in these conditions constitute cognitive differences and different intrinsic motivations of the two groups and create other behavioral choice characteristics which ultimately both lead to mobile phone addiction and this consequence reverts to the two groups figure 1 model of mobile phone addiction characteristics of elderly migrants and adolescents saturation test to test the theoretical saturation of the mobile phone addiction characteristic model we conducted saturation tests on the 2 original interview transcripts reserved under the topic of mobile phone addiction among elderly migrants accompanying and the 15 documents among adolescents following the steps described previously for open coding axial coding and selective coding in sequence and the test is passed the results show that the extracted main categories initial categories and relations portrayals are clear and abundant finding and conclusion this study distils and summarizes the heterogeneity and homogeneity in the characteristics of mobile phone addiction in two groups older migrant adults and adolescents and then constructs a model of intergenerational differences in the characteristics of mobile phone addiction since this study explores the intergenerational differences in the characteristics of mobile phone addiction the findings on the consequences of addiction are not discussed external environment and individual characteristics from the use and satisfaction theory perspective users needs are determined by the external environment and personal characteristics mobile phone addiction of the two groups of people is strongly influenced by the family environment elderly migrants compensate in the mobile phone world because they do not want to interfere with their childrens work and study or because of the lack of emotional support and little communication in their families teenagers on the contrary feel that they are studying for their parents expectations because of the deficiency of warmth brought by parents roughness and excessive monitoring they feel that they are studying for their parents expectations and are bored with their phones both groups are deeply affected by life events such as divorce of parents experienced by teenagers and death of relatives and retirement experienced by the elderly in addition different personality traits of adolescents can significantly influence mobile phone addiction behavior still the available data do not show how personality traits of older adults predict mobile phone addiction mobile phone device manufacturers network operators and various software developers have created a social environment for mobile phone addiction and they make great efforts to cultivate young people into loyal players by developing playing games for points providing phone credits data traffic and small gifts and benefits for games although the two groups are in different life cycles they share the commonality of poor selfcontrol and strong curiosity making them hard to resist and easy to become addicted in addition the government as the main body of governance has formulated different regulatory policies for them such as to guide the elderly group to access digital life and enjoy digital convenience the government requires internet enterprises to upgrade their own appssmall programs for aging thus creating an ageappropriate environment like creating the addictive conditions of bigger fonts and simpler functions more direct and comfortable to use in contrast the establishment of an antiaddiction system for mobile games among youth groups has become inadequate in the establishment and implementation of the system and poorly supervised resulting in greatly reduced protection cognitive characteristics the cognitive characteristics of mobile phone addiction among elderly migrants show contradictory perceptions of self and the world they complain that they always forget and have trouble hearing and seeing in the face of drastic changes in their living and digital environments and along with the promotion of agingfriendly products and applications they often defy ageism and stereotypes meanwhile they are confident that they can learn by themselves and think it is easier to learn online on the one hand older adults believe that society is full of dishonesty and they are afraid of being cheated and getting their children into trouble by interacting with others or even being legally responsible on the other hand they believe that the country is thriving both in reality and online world they believe the government is thriving and full of positive energy the community and family are friendly and harmonious and they have a positive attitude towards social ecommerce and moneymaking tasks at the same time the solid emotional dependence on my mobile phone is my companion also exacerbates mobile phone addiction among elderly migrants compared to the cognitive characteristics of older adults the cognitive characteristics of adolescents mobile phone addiction include three categories wrong selfperception misguided worldview and positive mobile phone perception reflecting the adolescent groups overall perception of themselves the world and the mediated world created by mobile phones and the cognitive dissonance of themselves and the environment they live in is a critical factor in mobile phone addiction individual adolescents negative evaluations of themselves lower levels of selfefficacy and selfesteem and unclear selfconcept predict high levels of addiction they argue that school is like a badly designed game and that only the internet can give what the real world cannot in addition adolescents have gradually moved from a spiritual dependence on mobile phones to show their popularity and increase confidence and satisfaction through virtual socialization to a functional support the mobile phone is a tool to make shopping more convenient payment more efficient study more efficient etc the mobile phone also isolates parents and teachers while can facilitates private communication between younger groups addiction motivation meeting the social and emotional needs information needs and entertainment needs are the core demands of elderly migrants at the same time technology empowerment is most fully reflected in the information empowerment level they are eager to keep up with news from their hometowns and mobile phones help them easily cross spatial barriers and replicate their established social circles they do this by video chatting with family and friends and browsing their friends and colleagues wechat moments at the same time older adults fear being left behind and want to have common topics with their children therefore they prefer to read current affairs news and care about national events they also listen to history and read mysterious martial arts novels to satisfy their hobbies they say they have no time for themselves during the day because they are trapped in the family vegetable market and kindergarten at night they dont want to go to bed and feel that this is their own time so they endlessly browse tiktok it also shows that elderly migrants achieve a certain degree of selfcertainty when they use mobile phones social and emotional needs information needs and entertainment needs are also the primary motivation of adolescents adolescents seek friends and communicate with their peers on mobile phones and after gaining emotional support and comfort they continue to strengthen their dependence on mobile phones in addition information satisfaction helps them cope with social uncertainty which significantly predicts the degree of mobile phone dependence in addition escaping from negative emotions is also the primary motivation for adolescents mobile phone addiction mobile phones games and entertainment functions are the best tools to eliminate negative emotions behavioral choice the distinctive features of a highly mediated society make the media and reallife form an intertwined relationship and people in the mediated existence are given a new way of living this study found that mobile phone use among elderly migrants has formed a habit on the one hand they take their mobile phones as a tool to record exercise data sign to receive coins and watch videos to earn money and also to maintain or improve interpersonal communication they like their sons and daughtersinlaws wechat moments whenever they see them and support their friends requests however intergenerational cultural differences can lead to an absence of presence even under the same roof cultural isolation is another kind of imprisonment in the interview the elderly migrants said that when they go on holiday at the weekend family members each brosing with their phones without communication however they also indulge in the accompanying time and space enjoyment brought by phones looking through headlines in the morning browsing tiktok in the evening and almost all daily life on the mobile network when doing housework opening short video apps listening to history broadcasts or watching the video to earn money they find that time passes quickly in terms of information selection they prefer entertainment content to have fun they love positive energy social order family ethics and health care content they are enthusiastic about national events and actively participate in the network to gain group identity once i posted a comment about liu guoliang in my headline more than 10000 people liked me and everyone agreed with me james carey in his discussion of the ritual view of communication emphasizes the role of communication as a temporal sustainer of society and an expression of shared beliefs in contrast to the elderly migrants the adolescent group views the phone as a tool to express their selfidentity and gain social status and influence among their peers despite academic pressures their phone addiction was characterized by what james carey describes as daily practices for example they are online when attending an event or class and play games instead of doing homework when they encounter academic problems they will find answers on their phones first and even use qq groups to copy answers from each other regarding addiction preferences the youth group is fond of social software games videos and other apps and they often play phone games share moods and selfies through wechat moments and ask for views and likes intergenerational differences in mobile phone addiction this study conceptualized and analyzed the characteristics of mobile phone addiction in two groups the elderly migrants and the adolescents it compared intergenerational differences in five dimensions external environment individual characteristics cognitive characteristics addiction motivation and behavioral choices the study results showed that the two groups were in their life stages which led to significant differences in the environmental perceptions dependency tendencies preference types behavioral choices and resulting interpersonal relationships of mobile phone addiction the cyber world has drawn up a new world picture yet older adults are gradually withdrawing from the new world due to the decline of their physiological functions still teenagers have a vigorous vitality and are eager to enter explore and even transform the new world the online world is unfamiliar to older adults and cannot be explained or fully dealt with empirically but everything is available online makes it difficult for them to withdraw adolescents believe that the online world is manageable compared to realworld encounters and challenges and this sense of accomplishment of being in control fuels phone addiction at the same time the elderly migrants because of their late involvement in the digital world have a strong sense of separation between the online world and the real world and their dependence on phones is more like seeking emotional dependence and spiritual support but teenagers sense of boundary between the natural world and the online world is blurred and they survive here as a functional dependency that they cannot get rid of it is worth mentioning that although the behavioral preferences of mobile phone addiction are significantly different between the two groups overall their media literacy is still lacking media literacy has gradually become the ability to acquire and retrieve understand and evaluate create and share information which is essential for citizens of a country the theoretical framework of new media literacy was divided into basic media literacy critical media literacy creative media literacy and consumer media literacy in this study adolescents preferred creative basic media skills while older adults preferred consumer basic media skills however critical media literacy has always been an essential dimension of media literacy along with the renewal of the media environment and communication technology the two groups lacking critical media literacy face the great challenge of living in a highermediated society mobile phone addiction among elderly migrants and adolescents also profoundly impacts interpersonal relationships as young people make new strange friends online and tend to interact with peers still their offline interpersonal skills weaken exacerbating interpersonal isolation and even causing serious conflicts with their families the online interpersonal relationships of elderly migrants tend to be selfcontained and socialization is limited to acquaintance socialization in offline interpersonal relationships elderly migrants are also subject to their childrens anger for playing with their phones their children think they set a bad example for their grandchildren they often show a compromising attitude when dealing with family conflicts but they also expect to demobile to communicate harmoniously with their children and grandchildren by conducting a grounded theoretical analysis of primary and secondary data this study constructs a theoretical framework of the characteristics of mobile phone addiction among elderly migrants and adolescents it compares the intergenerational differences in the characteristics of mobile phone addiction between the two groups which expands the study of mobile phone addiction the study found that older adults phone addiction is based on emotional demands while adolescents addiction has gradually transitioned from emotional to functional dependence in addition due to the development stage of their life the accessibility of the internet and the difference in their usage skills the elderly group fears quitting the new world since they are not proficient in the basic usage skills of retrieval uploading and downloading therefore， they mainly rely on the preinstalled applications on mobile devices and their behavior shows a passive consumption type lack of media literacy in contrast the youth group tends to enter the new world creatively and enjoy a sense of control in the online world they have basic media literacy but lack critical media literacy finally mobile phoneaddicted elderly migrants are lonely but they usually choose to compromise to avoid family conflicts at the same time adolescents addicted to phones frequently cause family conflicts recommendation future research can improve the interview design for adolescents it can also deepen the comparative study of intergenerational differences and further expand the study population to explore the characteristics of mobile phone addiction among three generations of families in addition this study unexpectedly found that the consequences of addiction were not only differences between the two groups but also the older adults with mobile phone addiction had higher selfrated happiness this finding needs to be confirmed by future research acknowledgement throughout the writing of this paper i have received a great deal of support and assistance i would like to acknowledge professor dr asif who is also my supervisor for his guidance during this research and inspiring my research interest in addition i am grateful to my parents and husband for their support of my research endeavors

with the penetration and popularity of mobile phones among the elderly and adolescents the problem of mobile phone addiction has become a new focus of academic attention to explore the characteristics of mobile phone addiction and its intergenerational differences between elderly migrants and adolescents this study uses the grounded theory and constructs a generational difference theory model the study found that mobile phone addiction in elderly migrants addicts are prone to consume because they fear withdrawing from the world however adolescents addiction is the product of entering the new world to create and they believe that they can control the online world at the cognitive level while the elderly say they cannot completely deal with it in addiction dependence emotional dependence is basic need for elderly migrants while the youth are functionally dependent in addition mobile phone addiction will deepen intergenerational conflicts interestingly elderly migrant often compromises to avoid conflicts the intergenerational difference model of mobile phone addiction characteristics between different groups proposed in this study will provide a reference for targeting media literacy education and promoting intergenerational harmony

introduction essential workers have gained attention during the current pandemic as they have played the most crucial roles in combating covid19 1 they have helped maintain the socioeconomic infrastructure by putting themselves at greater risk of being infected and infecting their families essential workers are defined as those who conduct a range of operations and services that are typically essential to continue critical infrastructure viability such as healthcare workers those in the law enforcement sector grocery services food services delivery services and others 23 a longitudinal survey conducted in canada found a significant increase in stress during the covid19 outbreak 45 studies on healthrelated essential workers have been more prevalent and have reported high rates of depression anxiety stress and other mental health issues in this group 6 a few studies on nonhealth essential workers such as grocery workers 7 and protective services workers 8 also found an increase in mental health issues among these workers due to covid19 according to the mental health research canada national polling initiative anxiety and depression have increased greatly among the overall population since covid19 began 9 the number of individuals with a high level of anxiety has tripled and the number of those with a high level of depression has doubled since the beginning of the pandemic 9 a study involving both health and nonhealth essential workers in spain and brazil found that around 827 of people suffered from depression anxiety or both 10 in addition to healthcare workers 11 nonhealth essential workers such as domestic workers and police personnel were also reported to have inadequate access to personal protective equipment resulting in increased fear and worries 1213 they were reported to be overworked stigmatized and isolated from their family members which increased stress on their mental health 11 14 15 16 some studies on healthcare essential workers during previous pandemics such as severe acute respiratory syndrome in 2002 ebola in 2014 middle east respiratory syndrome in 2016 and others also reported increased mental healthrelated effects such as depression and anxiety symptoms and insomnia each ranging from 2750 1718 the effect of a pandemic on mental health may be influenced by many factors related to sociodemographic characteristics workplace environment and individual characteristics previous studies found gender age education level income status occupation and support from colleagues and employers to be related to mental health symptoms 19 pandemics are a special situation in which different individuals from different occupations may experience the effects disproportionately for example people with higher education may comprehend the risks and dangers better than those with lower educations and practice healthy strategies to cope with that whereas their counterparts may panic and adopt selfharming practices 20 in addition the ongoing covid19 pandemic has highlighted social support and healthand wellnesscarerelated inequities within various population groups including essential workers according to a report by the american psychological association both health and nonhealth essential workers were less likely to receive mental health treatment from professionals despite being almost three times more likely to be diagnosed with a mental health condition due to the pandemic 21 many reported adopting unhealthy practices such as poor eating and drinking habits 22 according to a study involving food and retail service workers some individuals employed potentially dangerous coping mechanisms such as consuming alcohol smoking and social avoidance 23 in another us study about 1018 of the people who needed mental health support during this pandemic including essential workers and the general population did not receive any counselling or therapy 24 individuals with mental health issues may not access proper psychiatric support because of cost barriers or lack of time 25 the nonhealth essential workforce such as grocery workers transportation workers food and delivery service workers and many others have received little attention despite their selfless and unceasing efforts throughout the pandemic many studies including literature reviews have been conducted on the mental health effects of pandemics specifically on healthcare essential workers 1726 and general populations 2728 however despite the fact that nonhealth essential workers may experience worse mental health symptomseffects due to covid19 compared to healthcare workers and the general population there are limited studies on this population group 29 while nonhealth essential workers were at risk of contracting covid19 similar to that of health workers they may not have the same level of understanding or confidence of how to stay safe from the virus because of a lack of adequate training or safety measures promoted and practiced by their employers 29 given the accelerated globalization merging societal and political structures and comparable worldwide actions against pandemics in recent decades often guided and monitored by various international health organizations we undertook this scoping review to capture the mental health effects of previous pandemics on nonhealth essential workers in the last 20 years we also attempted to identify factors affecting their mental health and the coping strategies they adopted methods we opted to undertake a comprehensive scoping review for this study as they provide a detailed snapshot of the existing literature on a certain topic and identify research gaps to offer future research directions 30 we followed arksey and omalleys methodological framework for scoping reviews 31 formulating the research question a scoping review allows us to answer a broader question by exploring studies that used diverse methodologies 32 for this scoping review we asked the following questions what were the mental health effects on nonhealth essential workers during pandemics in the last 20 years what were the factors affecting their mental health what were their coping strategies to combat the mental health effects identifying relevant studies we conducted an extensive search using appropriate keywords to determine the relevant literature for this review we used all possible searchterms related to mental health the six pandemics in the last 20 years and essential workers we explored both the academic and grey literature by searching the most common electronic databases for both types of articles the potential literature was further included by snowball sampling from the reference lists of selected articles different keywords for each term were connected by the boolean operator or and were later collectively linked for each main term using the boolean operator and study selection a comprehensive literature search generally culminates in a large number of articles encumbered by duplicate and irrelevant studies which requires screening vigilantly by applying clearly defined inclusion and exclusion criteria corresponding with the research question we included all studies that met our criteria based on the population interventionissue comparison outcome study type tool 33 data extraction charting and synthesis we extracted the following information about each study author year of publication type of study objective of the study location of the study type and method of the study location and time of the study population size age of the population name of the outbreakpandemic mental health issues instruments used to identify the mental health issues factors associated with the relevant mental health issue coping strategies and occupations of the participants microsoft excel 2016 and microsoft word 2016 were used to compile and organize the data all data were compared and contrasted by the authors both individually and conjointly we undertook descriptive analyses to outline the study literature and to detect the scope of research on the mental health issues of nonhealth essential workers including attributable factors and coping strategies results were analyzed and discussed to identify key themes and findings interpreting and reporting results the goal of a scoping review is to retrieve a larger general description of the research that has been undertaken on a topic through the charting in stage four we delineated the mental health issues experienced by different groups of essential workers factors affecting them and coping strategies we documented seven groups of nonhealth essential workers and reported our findings according to the following categories factory and production occupations farming fishing agriculture and forestry occupations food preparation and serving occupations installation maintenance cleaning and repair workers sales and related occupations social care practice and support and others results literature search overview a systematic search of four academic databases yielded 9353 articles an additional 502 articles were identified through google scholar as grey literature after removing duplicates using mendeley reference manager 2021 software we undertook the title and abstract screening of 8434 articles following screening 209 articles remained for fulltext screening fulltext screening yielded 29 articles eligible for this review through hand searching we identified three additional articles for a final total of 32 eligible articles content overview table 4 demonstrates the study characteristics extracted from the eligible studies of the 32 articles 20 studies were quantitative 10 were qualitative and 2 were mixed methods almost all articles pertained to covid19 except for one on ebola most of the studies regarding covid19 were conducted during marchjune 2020 most studies were conducted in spain followed by the usa china and serbia one study was conducted in each of india the uk turkey australia new zealand bangladesh and liberia three studies covered several regions that included brazil kenya ireland canada austria germany switzerland the netherlands and hong kong three common mental health issuesanxiety depression and stresswere explored by most of the studies stress or distress was studied the most followed by anxiety and depression other mental health issues included in the studies were worries nonspecific mental health issues fear emotional turmoil burnoutworkload sleep qualityinsomnia alcohol disorder and decreased selfesteem instruments used for identifying the mental health issues we also extracted information on what instruments or scales the researchers used to identify the various mental health issues twentyseven studies reported a total of 34 types of validated instrumentsscales for diagnosing various types of mental health issues we organized them into eight groups anxiety depression stress and distress fear and worries mood and emotional effects general mental health and quality of life sleep and burnout and others ten studies did not report any validated instrumentscale for determining mental health issues some of these studies used oneitem questions for different mentalhealthrelated issues andor used questionnaires they developed while many studies used specific scales for anxiety depression stress or other mental health issues some studies used broader general mentalhealthrelated scales most of the studies explored the effect of the pandemic on the mental health issue of interest a few studies investigated further to identify the factors affecting the issues and even fewer to understand the coping mechanisms employed by their target population group some studies compared the effects of the pandemic on different professions two studies explored how exposure to information knowledge and beliefs affected individuals mental health data collection strategies most of the studies used surveys to collect data from individuals among them 10 surveys were conducted using online questionnaires seven studies used interviews as their method of data collection one of which was conducted online one study used roundtable discussions and in one study the author reflected on their experience using that format only two studies used mixed methods that collected data through a survey focus groups interviews or free responses through a survey the focus group was conducted over zoom and the interviews were conducted over the telephone 316 outbreaks covid19 was studied in all the reviewed articles except for one on ebola we found no studies that explored the mental health effects on nonhealth essential workers caused by the other four large outbreaks in the last 20 years sars h1n1 influenza zika virus and mers mental health effects of outbreaks by nonhealth essential occupations factory and production occupations individuals involved in any type of industrial production and manufacturing were included in this category examples included factory workers electronic device manufacturing beverage manufacturing biopharmaceuticalrelated industry workers and more one study that compared factory and production workers during the pandemic with the prepandemic general population found an increased prevalence of depression among factory and production workers 45 sleep quality among these workers was good to excellent for most another study found female participants had a higher risk of depression than their male counterparts 46 • apart from worries due to being covid19positive from exposure due to work the first responder participants including police officers felt stigmatized by friends and family that they might be the source of infection and people recoiled from them • nr nr farming fishing agriculture and forestry occupations a study found that the farmersworkers experienced comparatively less stress than that of the health workers 35 a study that investigated farmworker families found women in farmworker families experienced fear worry and anxiety about being sick and unable to look after their children they were afraid they might contract covid19 from their workplace and some stopped working to care for their children at home since schools were closed and they could not afford childcare 38 food preparation and serving occupations individuals in the service sector including food service and delivery workers were found to feel less stress and anxiety compared to those in the health sector according to the dass21 scale 40 experts in a roundtable discussion expressed concern over the increased anxiety among lowwage essential workers including food and dairy workers due to their uncertainty about the future and employment 43 the fear of contracting covid19 and infecting others especially their loved ones placed them under constant stress it was also mentioned that many of these populations were immigrants and had joint families including older parents at home in addition despite there being a substantial number of deaths among this population due to covid19 it was unknown if they were provided with any resources to grieve the demise of their coworkers 43 a study that included health and nonhealth workers from food and other nonhealth essential services as participants but which did not distinguish between them found a high prevalence of depression anxiety and comorbidity amongst the groups 10 another study reported that 10 of 27 participants in their study experienced posttraumatic stress disorder symptoms with women being the most likely to report symptoms another study categorized the mechanism of covid19 affecting individuals in the service sector into four themes being infected and infecting others during work or transportation to and from work uncertainties regarding the virus including its effects on their health and jobs feeling isolated because they were not able to meet with other people and work and customer demands including mixed messages from employers understaffing lack of protective resources and customers not adhering to protective measures 23 installation maintenance cleaning and repair workers a study that included health and nonhealth workers from cleaning and other nonhealth essential services as participants but which did not distinguish between them found a high prevalence of depression anxiety and comorbidity amongst these groups 10 they compared brazil and spain and found that all symptoms were significantly higher in brazil than in spain 10 a study exploring the anxiety of domestic workers found that 25 of their sample had probable anxiety during the pandemic 13 one study reported that ageing workers in housekeeping jobs were worried about working in covid19 units they experienced increased stress levels when they realized individuals on the units were more vulnerable to covid19 because of their advanced age and comorbidities 43 researchers in one study expressed concerns that some less regulated groups of essential workers such as housekeepers and landscape workers were not covered by covid19 prevention plans that subsequently put them at greater risk 43 protective service occupations anxiety and depression were prevalent among community workstation staffpolicemenvolunteers 42 protective service workers were reported to be less likely to have a severe psychological impact compared to other essential workers including healthcare workers grocery workers and media professionals in one study 8 another study found protective service workers were impacted psychologically similarly to the general population however they were worried about passing the infection on to others and making them follow covid19 regulations such as staying home added to their stress 12 a study that included armed forces and specialized state security forces found that while 264 of the participants felt a current need for psychological help 526 felt they would probably need psychological help if a new wave of the pandemic were to arise using the maslach burnout inventory subscale they showed 289 had experienced burnout 47 a study on military personnel found low anxiety and depression levels among the participants but the participants expressed concerns that despite protective measures they could still contract covid19 50 sales and related occupations a study involving retail grocery store workers found that 24 of participants had at least mild anxiety workers with anxiety were less likely to report being able to follow covid19 regulations at work consistently than those without anxiety a similar finding was observed in workers with depression 7 another study found that 652 of grocery workers had experienced severe psychological impact due to covid19 over half of the grocery worker participants also mentioned they were depressed female grocery workers were found to have higher psychological impacts than males 8 another study on fashion retail workers found that covid19 caused an increase in their mental workload which was associated with burnout syndrome among them women had higher levels of emotional exhaustion a burnout dimension higher levels of emotional demands and a mental workload dimension while men showed a higher level of cognitive demands and performance requirements which are mental workload dimensions 55 social care practice and support a study reported that 464 of child welfare workers experienced mild or severe distress being single experiencing financial hardship having poor physical and mental health young age and being nonheterosexual were associated with a higher level of covid19 peritraumatic distress 34 a qualitative study that interviewed family caregivers revealed there were seven types of concerns that caregivers encountered social isolation of a family member and caregiver a decline in the mental health of a family member a decline in the physical and cognitive functioning of a family member keeping family members safe from covid19 lack of caregiving support and caregiver stress 41 according to a study that was conducted in the jiangsu province of china the top three sources of stress among community workers were being worried about passing on the infection to family members from work personally contracting covid19 and noncooperating residents however they had better selfrated mental health compared to residents in other areas of china 52 another study exploring informal caregivers found that those who provided care to their family members reported lower mental health dimension scores compared to those providing care for nonfamily members 53 transportation and delivery occupations a study that interviewed rickshaw pullers who had lost their income amid the pandemic found they experienced psychological stress as a result most of the respondents in the study reported being anxious over uncertainty regarding buying food paying rent and supporting their family 49 a study that included transport workers in their nonhealth essential worker participants found a higher level of depression anxiety and stress among them compared to healthcare workers 10 other one study that included media professionals as nonhealth essential workers found that about half of them had a severe psychological impact about 37 of respondents also expressed being depressed 8 we found three studies that were conducted among nonhealth essential workers that did not mention any jobs specifically they reported 651 of respondents had psychological distress that differed by gender 363744 factors demographic factors age some studies reported that a younger age affected the mental health of nonhealth essential workers 81045 while one reported that older people may have added stress due to their advanced age and comorbidity being risk factors for covid19 and its complications 43 sex gender and sexual orientation some studies reported gender and some reported sex however in both of these studies women andor females showed higher levels of psychological impacts 810 including anxiety 50 depression 45 stress 52 and burnout 55 some studies did not find any differences 59 heterosexual or straight individuals were less likely to have psychological effects than nonheterosexuals 34 marital status one study found that marital status had no impact on the psychological effects of covid19 8 another study found married individuals had a lower distress score than singles 34 education level education level was found to be a protective factor against psychological impacts such as stress 8 essential workers with a higher level of education showed less depressive symptoms and better sleep quality 45 regions one study found that people living in regions more severely impacted by covid19 reported higher psychological impacts 8 in contrast another study that compared brazil and spain found depression anxiety and comorbidity of both were higher in brazil than spain despite spain having four times the number of covid19related deaths than brazil during the time they collected their data 10 financial status and expenses a study reported the monthly income of essential workers including factory and manufacturing workers was associated with their depressive symptoms and sleep quality 45 another study found that individuals who always have extra money had lower distress scores than those who could not or could barely make ends meet 34 increased expenses due to the pandemic were also found to be associated with higher levels of depression anxiety and stress 40 workrelated factors risk of exposure participants in most of the studies reported that the risk of being infected and subsequently infecting ones family members and loved ones was a source of their worries and anxiety advanced age housekeepers indicated concerns about being assigned to covid19 units and the high risk of exposure 43 domestic helpers showed higher levels of anxiety if they were working in a crowded household 13 grocery retail workers who were less likely to practice social distancing or commuted using public transportridesharing were more likely to be depressed 8 increased work hours and workload overworking and increased workload due to the pandemic was related to increased psychological impacts for grocery workers and media professionals 8 domestic workers also reported an increased workload as their source of anxiety 13 community work administrators also felt stressed due to increased work hours 52 being unable to care for children and see families a study investigating farmworker households revealed that the women in those households were afraid they would contract covid19 at work and would be unable to take care of their children moreover many had to reduce their hours or leave their job to look after their children because they could not afford childcare costs with their lowpaying jobs 38 police personnel in one study expressed their concerns about being unable to spend time with their family during the lockdown 12 lack of workplace support one study reported that individuals felt stressed over not having daily allowances of food and refreshments given that restaurants were likely to be closed during the lockdown 12 a lack of available protective equipment was also expressed as a source of stress and anxiety 12 domestic helpers were also worried about getting fired if they contracted covid19 13 community work administrators also expressed that not wearing disposable protective equipment caused them stress 52 other factors according to one study facetoface communication and exposure to webbased information about covid19 might be associated with increased depressive symptoms and worsened sleep quality however positive information regarding covid19 such as effective treatments vaccines etc was associated with better mental health 45 having had a previous diagnosis or treatment for mental health disorders in the past year and low selfrated health were also associated with higher levels of depression anxiety or both 10 worrying about the fate of the pandemic an uncertain future and physical wellbeing were also related to higher mental workload and burnout 55 coping strategies individualinitiated coping strategies some individuals found that applying active coping strategies was useful in coping with stress 35 spending time outdoors and daily exercise were reported to be useful coping strategies 23 others reported watching movies listening to music and reading books helped them to cope with their mental health condition some found spending time with family and engaging in hobbies useful avoiding news about covid19 and thinking about the situation were used as coping strategies by some while most of these reported practices were harmless one study reported that some participants used potential harmful activities such as drinking alcohol smoking and social avoidance as their way of coping 23 available support individuals expressed that they may need psychosocial support to cope with the effects of the pandemic the availability of protective equipment and a spirit of teamwork cultivated in the workplace were also helpful 47 receiving support from employers was reported as being helpful by some professionals such as grocery workers in one study 8 this study also reported that those grocery store workers who received economic support during the pandemic found it helpful for reducing the psychological impacts of the pandemic 8 discussion the objective of our study was to identify the effects of the six pandemics that have occurred in the last 20 years on nonhealth essential workers we found that other than one article on ebola all articles involved covid19 none of the other five pandemics lasted as long as covid19 has did not result in as much loss of life or did not uproot the existing societal infrastructure as greatly for some reason researchers did not consider exploring the mental health of nonhealth essential workers during those other pandemics the articles we found discussed the mental health implications of covid19 on seven types of nonhealth essential jobs which we categorized as factory and production occupations farming fishing agriculture and forestry occupations food preparation and serving occupations installation maintenance cleaning and repair workers sales and related occupations social care practice and support and others the studies reported many mental health issues such as anxiety depression stress and distress fear and worries mood and emotional effects general mental health and quality of life sleep and burnout and others most of the studies found evidence of an increase in these mental health effects when compared with the general population andor health professionals these increased effects may have arisen from a lack of adequate training against protection from the disease a lack of supply of protective equipment and a lack of sufficient support from employers one major concern of nonhealth essential workers from across sectors was a worry about infecting others especially older parents and children contracting covid19 this concern was also prevalent among healthcare workers as found in other studies 60 nonhealth essential workers were also overworked which led to burnout and additional stress similar reports were documented regarding healthcare workers 61 unlike healthcare workers who were praised everywhere and considered superheroes we did not find any studies reporting a similar phenomenon amongst nonhealth essential workers on the contrary some workers mentioned it had been a rather unpleasant experience and that they felt stigmatized by friends and family who avoided and kept their distance from them 48 a lack of supply of ppe was mentioned by nonhealth essential workers as being stressful in several studies early during the pandemic the media highlighted the lack of adequate protective equipment for health workers 62 which helped raise awareness of the issue however despite encountering similar difficulties and being at comparable risk of contracting covid19 the concerns of nonhealth essential workers were not considered equally one of the factors affecting the mental health of nonhealth essential workers was inadequate training to protect themselves against covid19 this factor was less likely a concern for healthcare workers since in addition to regular covid19specific training at their workplace 63 they had the foundational knowledge to address how this type of virus was transmitted and what protective measures to take to prevent it from spreading mixed messages from employers and exposure to media social media and others also contributed to increasing their stress and other mental health effects which were found to affect the general population 28 and healthcare workers similarly 64 generally women were reported to be more vulnerable to experiencing mental health effects due to the pandemic than men except among those who worked as protective service workers or media professionals 8 one study pointed out that this phenomenon could be related to the overall higher rate of mental health disorders among women which may be linked to a different neurobiological response in women compared to men and the overrepresentation of women who work in grocery retail the service industry and healthcare 2865 a younger age lower education level being unmarried and being migrant workers also arose as affecting the mental health of nonhealth essential workers in our sample of articles which were also found in a systematic review of the effects of covid19 on the general population 28 interestingly one study found that people in brazil were more affected by mental health effects due to covid19 compared to those in spain despite the number of deaths due to covid19 being four times higher in spain than brazil the researchers reasoned that additional social structural and political problems in brazil may have exacerbated the mental health effects of the pandemic 10 coping strategies were predominantly initiated by nonhealth essential workers themselves and included physical activities positive thinking relaxation and communicating with friends and family these activities have been supported by previous studies on mental health as being good practice 6667 nevertheless some selfharming coping mechanisms such as increased smoking consuming alcohol and suppressing emotions also arose similar practices particularly increased drinking have also been found in healthcare workers 68 and the general population 69 substance use is another negative coping mechanism people often practice 70 we did not find any evidence of substance use in our reviewed articles however the studies did not specifically explore that issue and people might be more conservative about sharing this type of information 71 in some studies participants mentioned having institutional support from their workplace 7 whereas others mentioned a lack of support 39 however no detailed information on the type and extent of the supports was explored a strength of our study was that we undertook a comprehensive search to capture any research on mental health effects of pandemics on nonhealth essential workers the research questions were clear and we were able to identify and synthesise relevant findings from the studies in our sample however we only found studies on covid19 and ebola on this topic and population despite our best efforts this review also has some limitations we tried to identify findings for different occupations within nonhealth essential workers however only a few studies involved occupationspecific roles rather presenting their findings as part of a larger population group the effects of a pandemic may not be the same for each of the nonhealth essential worker groups but we could not address that in this review we included articles from all sources including qualitative and descriptive quantitative studies but we could not establish a causal relationship between mental health issues and the factors affecting nonhealth essential workers further while we included studies from diverse methodologies in our review we did not assess the quality of the literature in addition only a handful of studies addressed the coping strategies of participants which did not provide us with a comprehensive understanding of this important aspect of mental health conclusions this scoping review compiled knowledge about the effects of recent pandemics on the mental health of nonhealth essential workers who play a crucial role during a pandemic a lack of nonhealth essential occupationspecific research on this topic warrants a future detailed study on this population group some qualitative and crosssectional studies explored various factors related to mental health during pandemics however more longitudinal studies would help establish any causal inferences coping strategies is another important area for future research moreover studying the postpandemic mental health effects of covid19 would be useful to provide a baseline for comparison purposes the efforts of nonhealth essential workers were not sufficiently recognized during this pandemic based on our learnings from this study we surmise that these individuals might not receive the support required to help them recover from their mental health issues developing mental health support and rehabilitation programs and strategies specific to these various nonhealth essential workers is highly recommended furthermore the knowledge gained through this study can be used to help design public health measures to help mitigate the effects of the pandemic on other groups critical to the social and economic welfare of populations and help them recover quickly from the socioeconomic effects of the pandemic data availability statement not applicable

essential workers those who work in a variety of sectors that are critical to sustain the societal infrastructure were affected both physically and mentally by the covid19 pandemic while the most studied group of this population were healthcare workers other essential nonhealth workers such as those working in the law enforcement sector grocery services food services delivery services and other sectors were studied less commonly we explored both the academic using medline psycinfo cinahl sociological abstracts and web of science databases and grey literature using google scholar to identify studies on the mental health effects of the six pandemics in the last 20 years we identified a total of 32 articles all of them pertained to covid19 except for one about ebola we found there was an increase in depression anxiety stress and other mental health issues among nonhealth essential workers they were more worried about passing the infection on to their loved ones and often did not have adequate training supply of personal protective equipment and support to cope with the effects generally women people having lower education and younger people were more likely to be affected by a pandemic exploring occupationspecific coping strategies of those whose mental health was affected during a pandemic using more robust methodologies such as longitudinal studies and indepth qualitative exploration would help facilitate appropriate responses for their recovery

introduction there has been considerable discussion regarding returning individual research results to participants in genomic research studies the debates have focused on what constitutes a result when should such findings be communicated who has the ethical duty to disclose findings and for which kinds of research study should they be disclosed with largescale longitudinal genomic research studies data and samples are collected in a repository for use in future research studies in this context the policy has been that individual results would not be returned either on grounds of cost or uncertainty regarding the value of the results in a clinical setting pending further verification however this stance is now changing in this article we present the historic position taken by population biobanks the new drivers that are pushing projects to either review their policies or build in procedures to deal with this issue and examples of how some biobanks are moving forward in response historic position population biobanks have traditionally provided two kinds of results to participants the first are the results from the assessment that individuals undergo as part of joining the study individuals are usually given a series of tests and measurements in addition to in some cases being asked to complete health and lifestyle questionnaires results from these initial assessments can be given to the participant at the end of their induction session often in the form of a written summary if during this preliminary session an assessment level is considered unsafe biobank staff will direct the person to speak about the result to their general practitioner or if necessary urge them to go immediately to a hospital or clinic to have the problem investigated many potential participants see these initial assessment results as an incentive to join the biobank godard et al found that for participants in the cartagene biobank t he most important criteria for participating in the…project would be the possibility of obtaining the results of the biochemical test performed at the time of the interview secondly once the biobanks resources have been used by outside researchers general results from these studies are provided to participants and others through various media such as on the biobanks website or as newsletters and leaflets that might be made available through medical professionals or through the post to participants this reflects the ethical imperative to publish as well as a way to show respect for and acknowledge the efforts of study participants on the other hand it has been suggested that individual level research results and particularly genetic information not be fed back to participants and this has been reflected in the consent materials of biobanks there are several arguments for this population biobank studies are not intended to find clinically significant information for individuals but to produce generalisable knowledge for future research and therefore it could be argued that there is no case for returning results to individuals as biobanks are designed as resources for future research there is also the difficulty of securing adequate consent from participants with regard to as yet undiscovered outcomes some of which might be highly significant while others may be of more limited value such as a slightly raised predisposition to a common disorder commentators also have argued that the depth of the relationship between the researcher and the participant should be a factor in the feeding back of results when considering obligations such as returning results …researchers have a stronger moral responsibility to engage with a fuller range of participants needs when the relationship is deeper conversely when the relationship is more distant this can mitigate the need to return results this certainly could apply in the case of a healthy volunteers data in a population biobank being used by a secondary researcher defined as those researchers who are not involved in the original project but are …accessing the data through managed data access mechanisms the relationship between a secondary researcher and a participant can be seen to be physically distant if the research is taking place in another institution perhaps in another country furthermore the secondary research may take place long in the future creating a gap between the time of joining the biobank and the time of the discovery a balance must also be struck between using resources to further the research and the costs associated with maintaining the option of recontact with individual participants in the event of a significant discovery emerging biobanks are expensive enterprises and some have argued that it is a mistake to stray from the goal of knowledge for the public good to that of benefiting individuals also with early outcomes of uncertain value initial findings need to be confirmed by further research to avoid premature conclusions and prevent unnecessary alarm and invasive followup testing concern about the use of associations between observed changes in the genome and predictions about the consequent risks of common disease by companies selling genetic tests direct to the public has been raised by the uk human genetics commission resulting in the production of a code of conduct and by the us secretarys advisory committee on genetics health and society in addition california and new york have ordered directtoconsumer genetic testing companies to stop soliciting business from state residents the downstream work to validate suspected findings has not been within the remit of the population studies themselves but that of the researchers accessing the resource commentators are also considering whether agreeing to return results might impose fiduciary duties on biobank administrators therapeutic misconception is another concern studies have shown that in the context of clinical trials research participants do not always appreciate and understand the important differences between research and treatment if clinicallyrelevant results are given to them this may enhance any confusion however many commentators now consider this position of not returning individuals results as untenable based on arguments of autonomy and the rejection of paternalism on the part of researchers they argue that participants should be able to access their results moreover the desire of individuals to receive their results when participating in research studies appears to be on the rise the factors driving this change in attitude are varied however clues may be found in the parallel progression of changes in society together with the increase of genetics knowledge as a result of the completion of the human genome project these changes are forcing population biobanks to reconsider their stance on returning results new drivers the first drafts of the human genome sequence were published in 2001 and the finished sequence in 2004 the improvements in sequencing technology have been monumental while the hgp used essentially the same techniques introduced by fred sanger in 1977 since its completion t he perbase cost of dna sequencing has plummeted by ˜100000fold over the past decade far outpacing moores law of technological advance in the semiconductor industry the current generation of sequencing machines can read ˜250 billion bases in a week compared to ˜25000 in 1990 and ˜5 million in 2000 the ability to sequence a large number of base pairs at a relatively low cost is one of the drivers behind personalised medicine and personal genomics individuals such as james watson codiscoverer of the chemical structure of dna have had their genomes completely sequenced and the ability to sequence a persons genome raises the question of what to do with that information and how to communicate it whole genome sequencing produces an enormous amount of data about an individual at this point in time much of it cannot be interpreted however the evidence base is growing and clinical applications are becoming more readily available personal genomics companies now provide customers with a genotype profile based on a selected number of single nucleotide polymorphisms that indicate a potential predisposition towards conditions and tendencies for example 23andme will provide genetic analysis information on personal traits cancer status drug response and disease risk while commentators debate the efficacy and worthiness of such personal genomic profiles 23andme believes they are …democratizing personal genetics and expanding the opportunity for more people to benefit from the genetic revolution claims of the predictive power of these dnabased diagnostics may now be contributing to a climate of expectation about the utility of biobankderived information thus private practice appears to be driving public policy this desire for ones personal genome is one reflection of societal shifts over the last few decades on one hand genetics and genomics knowledge is increasing and becoming part of everyday language as well as more and more significant in medical practice in parallel society has been changing from a position where a paternalistic view of life was accepted to one where people are taking greater individual control in their daytoday lives the rise of personal computing and social networking has changed the way in which individuals live their lives internet use has increased dramatically over the last decade and internetbased social networks such as facebook and twitter are now used extensively for casual as well as business uses they are also used extensively as a part of social activism as shown in the early2011 uprisings in egypt in medicine patient activists are becoming more and more a part of the health care and drug development process patientdriven medicine is on the rise patient groups in online communities are sharing their experiences with each other and clinicians through social media sites … p atients suffering from a variety of diseases and chronic conditions are overcoming what formerly was a stigma of discussing with others the progression of their illnesses and how they respond to different treatments people are realizing more and more the incredible value of sharing medical information benjamin heywood president of patients like me said with an increased knowledge of genetics together with the growing ability to personally control ones environment and the ability to contribute directly to the progress of medicine research it is not surprising that people are actively seeking personal health data this includes participants in large scale population biobank studies public perceptions about the application of genetics in non clinical contexts although biobanks are established for the purposes of facilitating research by others into the genetic components of health and disease and because of this they generally benefit from high levels of public support and legitimation this cannot be taken for granted by those responsible for their establishment and future maintenance the application of genetics in nonmedical contexts is also on the increase and this inevitably colours the perceptions of citizens policy makers and regulators as to the potential risks and benefits associated with this technology the depiction of forensic science on television the use of forensic databases for the detection of crime and the rise in dnabased paternity testing have created a perception of certainty about the dependability of genetic information the csi effect defined as …the phenomenon in which jurors hold unrealistic expectations of forensic evidence and investigation techniques has been demonstrated to be real and is influencing not only jurors but the way in which judges and law enforcement officials act as well in the uk public consultations do not focus on whether or not there should be a uk dna database but rather how it should be constituted used and governed the american association of blood banks reported that relationship testing in its accredited laboratories has risen steadily from 1988 with 77000 reported cases to almost 415000 cases in 2008 recreational uses such as ancestry tracing are also growing in popularity the success of television shows such as who do you think you are have encouraged people to seek out their ancestors many websites now exist that will provide information on your ethnic origins for a fee although there is some dispute whether these services are accurate genealogical tourism to trace ones family history is a growing business with people taking trips to visit ancestral lands as well as to visit genealogical libraries for research purposes santos and yan postulate that …by fashioning group distinctiveness and drawing on ancestry one is able to rescue ones individuality a commodity that is being eroded in modern society this sense of individuality goes one step further with the introduction of genetic testing vendors are now providing the dna test the subsequent ancestral data analysis and the appropriate travel arrangements to visit the land of ones ancestors in one complete package the search for ones genetic roots can have unsuspected and sometimes unwelcome ramifications the consequences of the revelation that ones biological father is not the same as ones social father can be devastating for a family as well there is continued speculation about the potential for insurers to use genetic information to exclude people at risk from cover this has led to restrictions on access by insurers based on either voluntary codes such as the concordat and moratorium between the uk government and the association of british insurers recently extended until 2017 or on statutory prohibition such as the genetic information nondiscrimination act in the us despite these measures suspicion of insurers intentions remains widespread and this is reflected in often inconsistent attitudes to the use of genetic information by public and private bodies on the part of individuals and groups guidance for returning results outside of population biobanks many organisations have considered the implications and processes related to returning individual research results especially genetic results as far as the process is concerned it is recommended that researchers …should have a clearly articulated policy on feedback and the nature of the feedback if any that will be provided to participants common if not unanimous agreement can be found on the conditions and processes that might make up this policy the irb the researcher and other appropriate experts are responsible to make the determination about disclosure research subjects need to be given an opportunity to decide whether they want to receive the research results informed consent process and document should indicate if disclosure is planned or likely and describe the risks associated with disclosure only professionals capable of providing genetic counseling should give genetic or genomic research results counseling of patients before and after receiving research result is required oversight of the disclosure process is required if there is an agreed plan for disclosure it needs to be approved by an ethics review board and made clear to potential participants in addition any results should be determined to be analytically and clinically valid some commentators believe that there should also be some form of medical intervention to offer the individual others believe that this is not a requirement especially when there are no known or no effective interventions regardless the participant needs to have been told whether there is a possibility of results being returned and asked for their consent if they decide they do not wish to know this should be respected if the decision is taken to not return results to individuals this too must be made clear to potential participants examples from biobanks and other largescale genetic research studies these guidelines are of general use to a population biobank however they are not completely appropriate as they do not fit with the structure and mission of a biobank and thus create potential difficulties as mentioned biobanks are not designed to be concerned with the healthcare needs of individuals and will generally not have the resources such as the services of genetic counsellors available to them but if they wish to address this issue population biobanks need to consider how to include the potential for immediate individual benefit into the structure of a populationbased resource being created for future unknown research with no specific guidance to draw from population biobanks are looking at old and new practices being used by other biobanks and longitudinal studies from which they can tailor their own policies a returning results through a general practitioner lifelines hosted by the university of groningen netherlands is a cohort study to investigate universal risk factors and their modifiers for multifactorial diseases participants are recruited for the most part through their general practitioner and it is through this relationship that the results process is managed the lifelines researchers worked with the recruiting gps to define cutoff levels for assessment information if one of these assessment levels causes concern the participant will receive a letter telling them that they should contact their gp to discuss it while their gp receives a letter with the actual results specific genetic information is not returned so that the individual can say that they have not had genetic testing as this has implications related to insurance if lifelines researchers discover validated and clinically significant information that will have an influence on a participants health it is reported to their gp who will then discuss it with them this model provides a bridge between the biobank and the participant recruited through the gp and relies on the strength of the gppatient relationship that exists in many parts of the world to provide an avenue for returning of results it would certainly seem logical that primary care settings where the relationship between the gp and individual is clear and may be longstanding would be the appropriate setting for receiving and discussing clinically significant and perhaps lifealtering health information however this depends on the healthcare system having an emphasis on continuity between a gp and a patient a situation that might not exist in all countries b returning results directly to individuals after consideration by an oversight committee researchers look to their ethics review board for assistance in deciding how to handle questions of ethical conduct in research however these boards are responsible for approving and in some cases monitoring hundreds of research projects they may not have the time or expertise to deal with the specifics of returning results in one specific study especially if that is a largescale populationbased study with thousands of participants therefore some projects create internal committees similar to data monitoring or data access committees that work together with the executive committee of the biobank and the responsible ethics review bodies kohane and colleagues have suggested the model of an informed cohort oversight body an independent body responsible for returning results to participants this body would be composed of various experts including ethicists geneticists and patients who would make decisions regarding which results would be returned and how it would be done this model is now being put into practice the coriell personalized medicine collaboration is …an evidencebased research study designed to determine the utility of using personal genome information in health management and clinical decisionmaking it is not a population biobank but a longitudinal study using the icob model to oversee the return of results the study aims to recruit 100000 adults from in and around the delaware valley in the northeastern part of the us study researchers are investigating the impact of personalised genetic information on peoples health and whether it can indeed be used to improve outcomes with consent saliva is collected from volunteers an online account is created for each participant where that person completes health questionnaires the saliva sample is genotyped to determine genetic variations and a personalised genetic report is made available online to the participant this report will contain risk information on various conditions as well as how the individual may react to certain medications participants are then able to discuss their reports with their gp family member or a genetic counsellor and make healthcare decisions accordingly they can also allow secondary researchers access to their coded data the cpmc has formed an icob to review the stateofthescience only those druggene pairs and genetic variants for health conditions approved by the icob will be given out their criteria for approving which conditions and gene variants it will return are the association between the variation and the condition and the actionability of the variant and the interventions available approved conditions include agerelated macular degeneration coronary heart disease and melanoma study researchers will follow participants over the course of a minimum of five years asking for updated medical information and how they have used their personal genetic information a consortium of biobanks is also using an oversight committee in its work also related to electronic medical records the emerge network is a usbased …national consortium formed to develop disseminate and apply approaches to research that combine dna biorepositories with electronic medical record systems for largescale highthroughput genetic research emerge brings together five projects each of which study the relationship between genomewide genetic variation and a common diseasetrait as part of their study they have established several working groups one of which is the return of results oversight committee as this committee is new and has not as yet published policies the processes it will choose to suggest to its member biorepositories are unknown at this time however rather than not return results as it had done in the past its proposed informed consent language clearly states that contact may be made with participants you should not expect to get individual results from research done through the biobank researchers must study samples and information from many people over many years before they can know if the results have meaning we will not give the results to your doctor we will not put them in your medical record there is a small chance that researchers could discover something that might be very important to your health or medical care right now if this happens we will contact you to see if you want to learn more c returning all information to participants the previous two models reflect the position that healthcare and other related professionals are necessary to act as gatekeepers between the science and the individual and make decisions as to what information that individual should receive the personal genome project takes an alternative position on this subject while not strictly a largescale population biobank this cohort study is recruiting participants …to contribute genomic sequence data tissues and extensive environmental trait and other information to a publicly accessible and identifiable research database their aim is to enroll 100000 participants who will openly share their genomic and healthrelated information as well as their experiences as a participant pgp researchers give participants a preliminary research report that includes the genetic variants that have some likelihood of clinical relevance and instructs them to confirm anything potentially significant with their gp or care provider in this process the intermediary is removed and the participant has control of the information although there is still an acknowledgement that a health professional is necessary for interpreting the data however when it comes to the work of secondary researchers the pgp states in its consent form that generally the pgp will not provide you with the results of any analysis development or other work performed by third parties with access to your tissues or cell lines however because such results may be made publicly available and may be identified as deriving from your tissues or cell lines you may become aware even without your consent of the results of such activities therefore the pgp can be seen as akin to the traditional biobank in that it gives its members results of an assessment but does not return results from secondary researchers d returning no results longitudinal biobanks that have been recruiting for several years according to an agreed epidemiological strategy and consent procedures may decide not to or may not be able to change their long standing position regarding returning results for example uk biobank which completed its recruitment of 500000 participants in late 2010 has had a noreturns policy since its beginning it states on its website that while individuals will be given results from the assessment if they choose they will not receive results from future research 1what will i get out of attending an appointment you will be helping in a research study aimed at improving the health of future generations we will at the end of the visit give you a report of the results of some of the measurement undertaken this will include your blood pressure lung function body mass index body fat weight and height 2will you tell me if you find something wrong with me we will tell you if your blood pressure is particularly high or low or if your lung function is significantly reduced during the next 2030 years samples will gradually be analysed as the biobank resource becomes available for medical research of all kinds both in britain and around the world as this may be far in the future and researchers will be analysing anonymised samples we will be unable to inform you of any findings whether this policy will change in the future for this or any other longstanding biobank is unknown if a biobank does choose to revise its policy and address return of results it will need to consider whether original consent materials allow for recontact of participants recontact is one provision longitudinal biobanks typically include in their consent materials as this allows the biobank to ask participants for additional data from health records or if they wish to participate in specific research studies the future for population biobanks this is a new issue for population biobanks and few details have been published this paper has used examples from other largescale longitudinal studies as well as biobanks to show how study organisers are beginning to integrate returning results into their practice some studies are creating committees to consider queries from researchers who may be wondering whether certain information should be returned to a biobank participant oversight boards are being used to assist researchers in decisions regarding which variant information should be given to participants however the evidence is limited at this stage and biobanks need to carefully plan how they will deal with this issue and have any procedures reviewed and approved by their ethics review board consent materials should make clear whether any results will be returned to participants and if so how it will be done recontact measures will need to be discussed regardless returning results should not be used as an incentive to join a study as this is inconsistent with the nature of these kinds of studies and it may introduce confusion amongst participants biobank administrators must be aware that even the best laid plans need some flexibility time should be dedicated to anticipating future contingencies longterm population studies will necessarily not produce results in the short term but one cannot know when a discovery will be made that will impact the lives and health of individuals in addition anecdotal evidence has shown that participants may demand results even if the policy of the project was not to disclose them especially if researchers find a mutation that might respond to a therapy or develop an intervention that might be beneficial researchers agree that there is a moral imperative to return results that may significantly impact an individuals life how this will be done needs careful consideration conclusions historical policies regarding the issue of whether or not results should be returned to research subjects by biobanks or by the researchers using biobank samples and data have been deliberately cautious in part this has been due to justifiable concerns regarding the validity and the significance of such results and the need for further validation before they can be used as a basis for action by research participants andor clinicians in part this has been for ethical concerns about the release of information to individuals who have not asked for it and may not want it and in part it has been for practical reasons arising from the cost and the logistical difficulty of organising an appropriate procedure these assumptions are increasingly being challenged public perceptions regarding ownership of genetic information its my genome and i am entitled to have the information in it and professional anxieties about the ability of sample donors to handle complex information of uncertain value are shifting novel communication possibilities are opening up cost effective ways of disseminating information to individuals groups or populations advances in genetics and genomics are increasing the probability of unanticipated information being revealed and practices in the private sector regarding genetic predisposition testing are influencing public expectations with regard to the outputs from public sector biobanks it is clear that the historical dam behind which the flow of genetic and genomic data was held until it could be released in a carefully controlled manner to a few licensed recipients will come under increasing pressure and may well prove to be unsustainable even if society deems it desirable to do so policies for the return of findings to research participants must be subjected to regular review and where appropriate and necessary amended to reflect changing circumstances and possibilities in so doing researchers can consistently demonstrate fitness for purpose securing public trust in the operation of biobanks and hence contribute to the sustainability of these valuable yet expensive resources

historically largescale longitudinal genomic research studies have not returned individual research results to their participants as these studies are not intended to find clinically significant information for individuals but to produce generalisable knowledge for future research however this stance is now changing commentators now argue that there is an ethical imperative to return clinically significant results and individuals are now expressing a desire to have them this shift reflects societal changes such as the rise of social networking and an increased desire to participate in medical decisionmaking as well as a greater awareness of genetic information and the increasing ability of clinicians to use this information in healthcare treatment this paper will discuss the changes that have prompted genomic research studies to reconsider their position and presents examples of projects that are actively engaged in returning individual research results

introduction recently the national institute of educational evaluation of mexico released a study entitled aprendizaje y desigualdad social en méxico which documented systematic disparities in spanish and mathematics performance among mexican students associated with the sociocultural conditions of the students examining childrens school performance in light of families academic cultural capital the authors found students from higher sociocultural levels outperformed their less advantaged peers in all areas taking greater advantage of the learning opportunities offered by the schools revisiting the concept of cultural capital the concept of cultural capital as proposed by bourdieu over three decades ago as part of a theory of practice consists mainly of linguistic and cultural competence and that relationship of familiarity with culture which can only be produced by family upbringing when it transmits the dominant culture in the home the sets of dispositions which incline agents to act in particular ways are inculcated cultural capital is typically acquired quite unconsciously during the whole period of socialization and includes the expected behaviors language competencies values attitudes to and relationships with academic culture that are associated with bourgeois culture bourdieu posited that it is through the institution of the school that dominant culture and the dispositions attitudes and linguistic codes associated with it are legitimized thus contributing to the reproduction of the unequal distribution of societal advantages across social classes highly critical of the simplistic way in which his work had been presented to englishspeaking audiences he contended that the schools contribute to but do not reproduce in deterministic fashion the distribution of cultural capital because schools primarily reflect the knowledge and values of economically and culturally dominant groups in society they validate and reinforce the cultural capital that students from such group already bring from home thus possession of cultural capital and validation of that capital represent the process through which a familys socioeconomic status influences the childrens eventual educational attainment and performance over the years researchers have sought to apply and test the cultural capital concept sullivans study with students in their final year of compulsory schooling in england found that cultural capital was indeed transmitted in the home from parents to children but that it provided only a partial explanation of class differentials in educational attainment dumais also found that cultural capital affected educational outcomes in a limited way whereas habitus proved to be more predictive of students grades in their study comparing white and african american secondary school students roscigno and ainsworthdarnell concluded that cultural capital and educational resources did vary by racial group and only moderately predicted racial and social class gaps in performance they described teachers as gatekeepers who rewarded the more affluent students with more attention and higher expectations concluding that african american and lowses students received a lower educational return based in part on the micropolitical evaluative processes at the school and classroom level in a complementary study lareau and horvat closely examined interactions between parents and teachers theorizing that the families cultural and social resources became capital when they served to facilitate parents interactions with dominant standards in school interactions within individual interactions they identified moments of inclusion when families were able to activate and draw on their cultural capital and moments of exclusion when families were not able to activate the cultural capital that they might possess reproduction theory which is concerned with determination of the contributions of the educational system to the reproduction of the structure of power relationships in society has been criticized for its overly deterministic nature and for its presentation of schools as monolithic entities with the teachers serving as gatekeepers to students differential academic success however sullivan noted the enormous decline in the status of the teaching profession in great britain and questioned portrayals of teachers as a cultural elite who are prejudiced against nonelite pupils in their description of schooling for indigenous children in rural communities in argentina borzone de manrique and rosemberg found that although the indigenous colla children participated in an oral culture and entered school without experience with reading and writing this did not disadvantage them in school because of the low level of literacy development and the few text materials provided by the school they concluded that the fact that a fracture is not created between the schools in the colla communities and the home itself has severe consequences for the childrens access to the literate culture these studies suggest that variation in the contexts of schooling and in particular in the connections between home and school may contribute to differential performance outcomes for children associated with social class status parental involvement in their childrens schooling a number of scholars and researchers in education have pointed out the importance of the relation between school and families in different countries in latin america school reform has shown concern for parent involvement with schools for the benefit of childrens education however for parents as well as teachers it is not clear what this relationship involves and the expectations of the role that each holds for the other are multiple and different in most schools in latin america parent participation focuses on organizing and participating in fund raising activities to acquire materials and equipment for classrooms or for the improvement of the physical conditions of the school schools also conduct informational meetings for parents however the literature on education points to the importance of a different kind of involvement martiniello described the variety of functions and roles that parents perform in their interaction with school and the different results in terms of learning opportunities for their children she summarized four types of parental involvement parents viewed as responsible for child rearing and the school in charge of formal education parents as educators supporting and helping children at home with homework parents as agents providing support to the school and helping the school to improve services and material conditions and parents empowered with agency for educational decisions that is as part of committees affecting school and educational policies these types although different in the quality degree and extent of parental involvement in schools all seem to a certain extent unidirectional parents are involved with the school but not necessarily the school with parents a different approach developed by gonzalez moll and amanti known as funds of knowledge is one that they distinguish from the more typical parent participation programs in this approach the goal is for teachers and schools to recognize parents strengths resources and experiences in defining pedagogical characteristics their emphasis is on giving voice representation and authenticity to families in ways that can help teachers and children make learning more meaningful providing a bridge that facilitates childrens knowledge construction in other words they propose a change in perspective of the role of teachers not as conveyers of educational information but as educators with a theoretical perspective that seeks to understand the ways in which people make sense of their everyday lives the present study uses data collected in two very different sociocultural environments in a large metropolis in mexico to examine the relationships among the literacy practices engaged in by children at home and the ways in which these practices are communicated shaped and fostered by teachers and administrators in the first year of elementary school we view literacy practices in which families engage as including not only the observable literacy events or activities involving use of text but also the cultural values attitudes feelings and relationships that shape and give meaning to those events of particular interest in this study is the role of the school in the production of cultural capital in the home through its shaping of at least some of the literacy practices that children and families undertake particularly those associated with literacy instruction and development the study addresses the following research questions 1 what characterizes the relationships between parents and teachers around literacy instruction in the two communities 2 what literacy practices particularly instructional literacy practices are carried out in homes in the two communities and how are these informed by parents attitudes and values methods the present study is part of a longitudinal study of literacy and oral language development among 360 children in grades 1 through 3 in four public schools in a large metropolis in mexico the authors form part of an international team carrying out the study reese a former bilingual teacher in the us and teacher of english in south america has conducted studies of homeschool connections among immigrant latino families in the us mejía arauz focuses her research on cognitive development in social contexts with an emphasis on informal and peerfocused learning opportunities both within and outside of school she has worked with children attending josé morelos school on studies of situated learning ray bazán is the former coordinator of a universitysponsored learning center in the community of one of the studys other participating schools the analyses in this paper focus on the experiences of first grade students in two of the schools which were selected to represent contrasting socioeconomic conditions in the surrounding communities both schools are public following the national curriculum and utilizing the approved national textbooks however the socioeconomic status of the two communities is markedly different josé morelos school is located in a predominantly working class area on the outskirts of the city it is a recently refurbished school located in a community with historic roots in the precolumbian past where the local catholic church building dates from the eighteenth century and where the inhabitants still refer to their community as a pueblito or small town on the edge of the community several americanbased assembly plants are located providing employment for local families including unprecedented workplace opportunities for women these plants require their employees to have at least a secondary school education thus promoting changes in families with respect to the level of schooling they would like their children to achieve formerly an isolated indigenous town this community has been incorporated into the metropolitan area through the rapid urban expansion of the past few decades josefa ortiz de dominguez school is in a predominantly middle class colonia of the city the residential areas are quiet comprising primarily twostory singlefamily homes with enclosed gardens and carports in front the colonia is transversed by several major commercial thoroughfares where businesses range from small shops to larger banks and minisupermarts cyber cafés internet services computer stores and stationary stores are common as are private academies offering classes in dance drawing and gymnastics for the present study the coauthors carried out community observations together noting uses and availability of textual materials both formal and informal in the different settings mejía arauz and ray bazán also carried out over 40 hours of classroom observation documenting instructional strategies and student participation during spanish language and reading instruction currently in mexico finishing secundaria is the mandatory level of schooling although there is no form of control nor legal consequences if this is not accomplished in the complete sample of families from all four participating schools the average number of years of schooling for mothers was 959 and for fathers was 968 however there were striking and significant differences in the level of parent education by neighborhood and school parents in the predominantly middle class neighborhood averaged 134 years of schooling while parents in the working class community averaged 67 years participating teachers who comprised all of the grade 1 through 3 teachers at each school completed two surveys a written survey was completed individually and collected data regarding teachers academic and professional preparation years of experience use of official instructional materials from the secretaría de educación pública and their attitudes regarding the usefulness of a variety of instructional strategies a second survey administered facetoface at school during the nutrition break included questions on use of classroom libraries use of instructional materials homeschool communication and possible causes of problems associated with teaching and learning the director of josé morelos school and the assistant director of josefa ortiz de dominguez school participated in an openended audiotaped interview of approximately 90 minutes in length with one of the mexican coprincipal investigators the interview protocol covered topics such as school goals literacy instruction and assessment school resources homeschool communication and parent involvement perceptions of the community and families and professional development parents were asked to complete a 46question survey including questions about family demographics and the frequency that family members engage in a variety of literacy practices parents were invited to come to the school where the surveys were administered in person by projecttrained research assistants in year 1 of the study a total of 344 parents of children in grades 13 completed the survey three families per classroom at each school were selected for more indepth home visits that each included a parent interview a child interview and an observational field note the interviews carried out by projecttrained research assistants focused on family literacy practices attitudes and materials on parents participation in church and other community organizations and detailed data about the childrens daily activities outside of school and the opportunities that these offered for literacy use research assistants all mexican and most natives of the city transcribed the interviews which were then verified to ensure that the transcription accurately reflected parents responses and wording for the present analyses narrative data from the two openended parent interviews per family conducted when the children were in first grade were reviewed and coded according to themes of interest these themes included both those derived from past research and theory as well as those that emerged through review of the data coding themes derived from previous research with latino immigrant families in the us included home literacy practices parentteacher communication and parent perceptions of teachersschool and community initial codes developed for the current study included literacy instructional methods and parent beliefs regarding teacher perceptions of familiescommunity transgenerational literacyschooling emerged as a theme in the early stages of coding and was added to the list of formal codes the practice of constant comparison originally proposed by glaser and strauss was used to examine similarities and differences across participants as well as between community settings analytic induction was used to systematically seek negative as well as confirmatory cases coded material was reduced using data matrices for purposes of summarizing and identifying patterns in the data these themes serve to organize the findings below home literacy environment and continuity of experiences children in both communities participate in some common print experiences associated with their lives in an urban environment and all parents describe their childrens interactions with environmental print as children begin to decode the labels on products and signs on store windows as one mother described when wed go somewhere shed notice the signs from the time she was little and first started talking shed see a sign and she knew what it said both communities are rich in a variety of signage ranging from informal and handwritten notices and advertisements to professionally printed signs and banners these signs advertise products services community meetings classes and political candidates comparable numbers of families in both communities report attending church where the children are reported to peruse the hoja parroquial or attend catechism class all families report literacy practices associated with childrens schoolwork help with homework reviewing childrens notebooks receiving messages from the childs teacher and purchasing or constructing materials requested by the teacher such as flash cards in addition within each community families present a wide range of literacy practices from families who engage in a variety of activities involving use of text on a daily basis to families for whom literacy use outside of childrens schoolwork and environmental print is rare however although there are commonalities in the experiences of children in the two communities there are also overall differences in the quantity of literacy observed and engaged in by children in the home in each context many of the nine josefa ortiz de dominguez parents describe themselves as addicted to or accustomed to reading and they described multiple ways in which their children experienced reading and writing at home several children were reported to write letters to niño dios at christmas time and others wrote cards to family members one mother described writing shopping lists with her preschool aged daughters ever since they were little they did them if for example i said eggs they drew eggs if i said carrot they drew a carrot now they can definitely do them lists with me another mother described how her husband perused the ads that arrived from the local supermarket and her daughter loved to keep the ads and play with them another parent described her sons initiation of literacy use sometimes he asks permission for something and he makes me little cards he puts boxes for yes and no i have to mark them according to whether or not i give him permission in the josefa ortiz de dominguez community all of the case study parents reported reading stories to their children in the early years although in two cases the parents no longer did this with their first grade children because the children were now reading on their own all of the parents reported that their children had the opportunity to observe them reading and writing for example in one home the mother explained since i am a catechist i have to prepare the theme and they see me preparing the theme getting information from here and getting information from there my children my two boys are present when im teaching the catechism class and they also participate and they do know a little more because theyve seen me getting the information on the other hand descriptions of the ways that families engaged children in literacy use at home in the working class josé morelos community were quite different all of the families reported reading to children and storybook reading was reported in over half of the homes the others reported reading the childrens school books homework prayers and environmental print in one home the older sister read a prayer before meals its her habit to read when were getting ready to eat or something to read from a booklet that i have with readings for the month five minute prayers but he doesnt like it at the same time however most of the mothers reported that their children did not observe them reading andor writing at home this is not to say that reading and writing were not occurring in the homes parents did report reading the newspaper or the bible and older siblings often reported internet use however descriptions of parents engaging with their children in tasks like making lists or writing stories and cards did not emerge in the interviews with josé morelos parents for example a father who brought home calculations for a carpentry job he was working on was reported to tell his daughter no leave that alone because youre going to lose the paper that i wrote on rather parents descriptions of childrens reading and writing and their own involvement with their children around reading and writing were largely centered around completing the school homework these findings mirror those of paratore melzi and krolsinclair working with latino immigrant families in the us who also found that the most common literacy activities where those deliberately and explicitly intended to advance their childrens learning in other words a common practice in the homes were instructional literacy practices understood as formal school practices to be replicated in the home and not as activities associated with informal learning in everyday settings in the parent interviews we found evidence of a continuity of experiences between what parents experienced as children in and out of school and the kinds of experiences that they provided for their children in the josefa ortiz de dominguez community as compared with the josé morelos community more parents were read to as children more were told stories as children and more parents read stories to their children during or prior to first grade one of the josefa ortiz de dominguez mothers said of her own family growing up that reading was our daily bread and another stated proudly that she was in the cuadro de honor in elementary school when i was little i can also tell you that i was a good student because i have good retention i never really had any difficulty and i believe that my children are the same way the confidence with which many of the josefa ortiz de dominguez parents talked about their own school experiences was not mirrored in the josé morelos community half of the parents had themselves grown up in the josé morelos community and attended the same school that their children attended one mother said that she did not like school and cried when she was taken one of the fathers described his wife as an analfabestia because her family took her out of school in grade 2 she herself said of the local school the little that i learned was learned there another father reported his attempts to motivate his daughter to try her best in school by drawing on his own experience were all like this we were all children once and it was hard work for us to learn and they also criticized us because we didnt know anything and so you need to stop being afraid of writing like the youth and adult literacy program students in brazil described by bartlett parents reported shaming episodes in school in which they were made to feel inferior due to their speech patterns and literacy proficiency parent reports revealed not only a continuity of schooling and learning experiences between parent and child generations but also transgenerational communication of attitudes and assumptions regarding literacy and schooling attitudes that were associated with parents own school experiences our results mirror those of del valle in his work with puerto rican immigrant families in the us in which differences in home literacy environments were associated with differences in the mothers experiences as either the teachers pet in a catholic school in puerto rico or as a selfdescribed troublemaker and school dropout our findings also complement those of scheuer et al in argentina who collected elementary school students perspectives on their own writing development comparing experiences of middle class children with those from the marginalized sector they found that all students stated that writing began at home for them and involved family members however while families in the marginalized sector wrote letters to communicate with family members or wrote notes to school their use of literacy was primarily realized andor directed outside of the home the families in the middle class sector experienced literacy as an inherent activity of family life up to this point our findings are consistent with a traditional cultural capital explanation that is middle class parents are creating home environments that are saturated with literacy storybook reading and conversations surrounding stories and uses of print this greater familiarity with text transmitted in the home would be expected to serve as an advantage for these children when they enter school however as we explore below home is not alone as a source of cultural capital nor is it the sole contributor to inequalities in educational outcomes contrasting community settings families reside in communities that differ with respect to socioeconomic status contributing to different perceptions by the teachers of the families the colonia in which josefa ortiz de dominguez school is located is described by parents teachers and the school director as tranquila parents describe it as a place where one can leave ones door open and where the neighbors are friendly although the director stated that many of the students come from homes in which parents are separated or divorced or where the children live with their grandparents because their parents work she said that in this lower middle class community the majority are attentive to school needs teachers also found the community to be tranquil friendly and a good cultural and economic level another teachers description of the students families underscores the perceived connection between the families socioeconomic and cultural levels the parents help since their economic level is upper middle and this means that the parents are better educated and more involved with their families a different community image emerges as parents and teachers describe the pueblito or the community surrounding josé morelos school originally an indigenous community dating to the preconquest period the pueblito retains its saints day celebrations dances and customs infused with precolumbian traditions it is a community that until recently was characterized by adobe houses and unpaved streets some residents express pride in their pueblo im a native from here so i say its the best one mother stated however parents also describe their community as plagued with conflicts fights and drugs several parents described how the weekends and the community celebrations are the time when many of these fights break out with one mother lamenting that the police from the nearby municipality will not step in when this happens and that taxis from the city refuse to enter their community at night an isolated community for centuries the pueblo now receives migrants from other states in mexico many of whom speak indigenous languages some of the residents claim that these newer residents are the ones selling drugs and causing problems one mother stated as soon as they say where are you from from san josé oh they say thats where they steal and kill people and thats not true a lot of those killed are from oaxaca from veracruz from other places and theyre not from here the media are also described as contributing to this negative image of the community sometimes in the newspaper it says that soandso was beaten up or soandso was injured for the most part the teachers descriptions of the josé morelos community reflect the negative aspects mentioned by parents without a corresponding pride in the communitys cultural past or in its recent improvements one teacher described the community as like a red light of violence and drug addiction added to maltreatment in the family other teachers mention the poverty marginalization delinquency gangs and violence in the community these characteristics are associated with values such as lack of respect scarce family values and lack of interest in school one teacher summed up the community as multicultural violent and barely tolerable there are badmouthed and disrespectful children teacher perceptions of literacy instruction students and families the teacher survey results revealed few differences between teachers in the two communities with respect to their use and evaluation of the literacy instructional materials provided by the government 1 teachers in both settings reported finding the teachers guides helpful appropriate for the level of their students and useful in meeting the program objectives teachers in both schools rated fluency intonation diction comprehension spelling and handwriting as important or very important aspects of literacy development with teachers at both schools rating reading comprehension most highly in addition teachers at both schools rated the importance of sharing academic goals with the parents as very important and both groups stated that they did communicate these to parents with respect to use of books other than textbooks in the classrooms practices at the two sites differed teachers in both schools reported having classroom libraries and close to 90 of the teachers in each group reported presenting the books to the children in class however the classrooms in josefa ortiz de dominguez school contained on average double the number of books as the classrooms in josé morelos school and josefa ortiz de dominguez teachers reported that children in their classes used the books somewhat more frequently than did students in josé morelos school it was in josé morelos that unopened packages of new books were observed or books were reported to be stored in the locked teacher cabinets in most of the classrooms therefore bookshelves were empty and or used for storage of other things although teachers at the two schools had similar levels of preparation and reported similar attitudes and experiences with respect to the national curriculum teachers attitudes regarding the communities in which they work and the families of their students varied greatly as we saw above teachers perceived the community surrounding josefa ortiz de dominguez school as a tranquil middle class community that provides residents with the services and resources necessary to support schooling teachers did not describe their students as uniformly high achieving rather they noted a range of performance in their classrooms some children were described by their teachers as restless and one teacher added that as first graders they arent very disciplined yet but overall the teachers descriptions of students and parents were positive when parents were not involved in school 80 of the teachers said that this was because of demands of work teachers descriptions of the josé morelos school community stand in stark comparison to the positive perceptions described above for the middle class community teachers negative perceptions and descriptions of the community characterize their views of parents and children as well one of the nine teachers surveyed described her students as hardworking and responsible the remaining 89 of the teachers described their students in negative terms disorganized lazy apathetic as one teacher said of her class the group presents grave problems with conduct and bad habits brought from home in this community lack of parent support for schooling is attributed by 55 of the teachers to parents lack of interest and apathy one teacher connected this as well to parents lack of culture in this working class community teachers comments revealed a tendency on the teachers part to devalue work as a legitimate contributor to lack of parent support of schooling as one teacher put it the pretext is that they dont have time because they work and another teacher echoed the sentiment others work and claim that they dont have time evaluations of the local community in cultural and moral terms shape not only how teachers view students and families but also how they interact with them to this point the study has demonstrated that the kinds of classrelated teacher perceptions and expectations of students documented in the us over the past three decades are also patterns in mexico and that classbased expectations on the part of teachers continue to be prevalent in mexico in the sections that follow we document ways in which these expectations shape communications and interactions with parents with home practices emerging as coconstructions based on both parent and teacher input parent perceptions of the school and teachers our study has enabled us to gather both parent and teacher perspectives and it is interesting to note that parents perceptions and evaluations of their childrens schools and teachers mirror to a large extent those of the teachers parents of students at josefa ortiz de dominguez school described the school in largely positive terms one mother stated that it is like a private school parents proudly described the resources that the school has such as its three ample play areas english classes and computers extras such as the english instruction are made possible by the yearly fee that parents pay parents descriptions of the childrens curriculum included mention of lessons on environmental issues and community studies as well as artistic and cultural activities a school like this is needed everywhere one mother contended just as josefa ortiz de dominguez teachers described the parents as profesionistas who exhibit family values and support for education the parents described the teachers atenciones or care with the children parents saw the teachers as trained and well prepared who not only complete the learning objectives but also are not absent parents at this school did not report being involved in academic decisions at the site however they described the ways in which teachers involved them on an individual level as collaborative partnerships for example veronicas mother rated the teachers efforts to involve the parents in childrens learning as good stating that she just comments to us that veronica is doing poorly in spanish you have to help her a little like in putting words together right away i look for what i can do to help her form words and to find ways for her to understand things one parent mentioned that the teacher sent home temarios or sheets with the topics listed that the children were studying in school and another contended that the teacher was always available when i need to talk with the teacher i can find her one of the few criticisms that emerged in onethird of the interviews was from the parents of children who were higher achievers those children who had entered first grade already knowing how to read one quoted the teacher as saying that the more advanced children got bored because of the large class size and the differences in performance among the children in class the contrast with the perspectives of the josé morelos parents is vivid although onethird of the parents described the josé morelos teachers as doing a good job of teaching another third described teachers as lacking in interest as well as in professional preparation over half of the parents were dissatisfied with the teachers interactions with their children stating that teachers were abusive and unjust in their discipline and that they complain a lot close to half described the classrooms as overcrowded and one mother characterized the classroom as a shouting match parents also complained that teachers were often absent project observers documented multiple instances of teachers being called away from their rooms and of classes left unsupervised or classes of absent teachers being watched by the next door teacher another common complaint was that josé morelos school was closed to parents as one mother stated it seems like a prison for example a mother described how the teacher wanted her to help with preparations for a class project but the mother was not allowed through the school gate and could not provide the help the teacher asked for the closed door policy was confirmed by the director who explained her rationale entonces la enfermedad del alcoholismo y todos esos males o sea de la drogadicción y todo entonces por eso es que yo tengo la puerta cerrada no porque no quiero comunicarme con los padres de familia yo quiero que la escuela sea una escuela abierta pero es cerrada a la vez si dejo entrar a una señora pues tengo que dejar entrar a todas y como son muchas pues no vamos a poder dedicarnos a lo que es el trabajo con los niños a que los niños construyan sus aprendizajes nada mas tienen permiso de entrar de las 12 todos los viernes de las 12 a las 1230 media hora y así ya se que hablan lo concreto a lo que vienen no estar plática y so with the sickness of alcoholism and all those problems like drug addiction and everything so that is why i have the gate closed not because i dont want to communicate with the parents i do want the school to be open but it is still closed if i let in one woman then i have to let in everyone and since there are a lot then we wouldnt be able to dedicate ourselves to our work with children so that children construct their own learning they only have permission to enter every friday from 12 to 1230 just a half hour so that they talk concretely and not just come her to chat and chat and that the school becomes an unsafe place plática entonces la escuela se convertiría en un lugar inseguro our data suggest that teacher perceptions of parents also shape the manner in which they interact with parents in both her formal interview and in more informal encounters the director of josé morelos school proudly described interactions with parents in which she appeared to be frank and jokingly aggressive in her dealings with parents demonstrating the qualities of frank treatment that farr contended were typical of the ranchero identity she talked about how she would chide the parents for not coming to meetings or not supporting the teachers and laughingly added i complain to the parents and i dont care sometimes i tell them how can you expect your children to be calm if you yourselves are badly behaved if there isnt unity then the children dont do well how can you expect your children to be little apples if you yourselves are lemons she felt that the parents responded to her franqueza in a similar joking fashion for example when parents complained that the school was too crowded the director reported answering back i do say this to the ladies dont have so many children what are you rabbits i say that to them and they get mad no teacher were not rabbits were tlacuaches a trickster animal character from precolombian folklore there were descriptions in some of the parent interviews of teachers interactions with children and parents that were characterized by a brutal directness for example one mother described how her daughter was pulled out of the classroom by her hair by the teacher in the parent conference following the event the teacher asked the mother if there was drinking and violence in the home because she had observed tendencies toward violent behavior in the child this type of frank and accusatory interaction was simply not reported in the interviews of parents in the more upscale josefa ortiz de dominguez community in the section above we have seen that in part parent perceptions of teachers reflect the teachers perceptions of parents that is parents who are seen by teachers as attentive and supportive in turn perceive the teachers as attentive and effective parents who are perceived as lacking in interest and positive values by their childrens teachers in turn perceive the teachers as lacking in interest and preparation and abusive in their treatment of children the teachers and administrators perceptions of the parents contribute to policies such as the closed campus policy as well as shaping interaction patterns such as the bullying and joking engaged in by the josé morelos director and some of the teachers at the same time some of the conditions that contribute to a richer teaching and learning environment at josefa ortiz de dominguez are possible due to the material extras that parents in that middle class environment are able to provide parent pay cuotas or supplemental fees for additional teachers for english and art for cleaning the school and for computer instruction at all grade levels in addition parents are reported to fill in occasionally when a teacher is absent apparently this strategy is possible in a community where the majority of parents are professionals but would not be possible in josé morelos where the average number of years of schooling is 67 in that community children are left without english classes with a computer lab that is not operational and with high rates of teacher absenteeism these findings are consistent with willms and somers analysis of factors associated with educational outcomes for the latin american region as a whole namely that all of the school resources variables with the exception of pupil teacher ratio were positively correlated with the socioeconomic level of the school instruction and coconstruction finally in seeking to understand how home literacy practices might be influenced by the expectations of and interactions with teachers as well as by the parents own experiences and attitudes we move to the area of school instruction for it is in this area that we also observe differences between the two settings differences between the community settings of josefa ortiz de dominguez and josé morelos go beyond the perceptions attitudes and stereotypes held by parents and teachers and also beyond differences in what parents and children are doing at home the original notion of cultural capital these differences extend to the way in which literacy is being instructed at school at least in part and thus to the associated parent understandings of what their role in assisting their childrens literacy development is josefa ortiz de dominguez and josé morelos schools are similar in some key aspects both have large class sizes of 50 students per classroom both follow the national curriculum and survey findings reveal that teachers in both groups describe themselves on average as in agreement with the majority of the aspects of the program teachers at both schools rate themselves as adequately prepared to teach reading the main goal of the mexican national program for teaching reading and writing in elementary school is to teach the different functions and forms of the language for communicative purposes it focuses on promoting the development of childrens communicative abilities that is that children learn to use oral and written language for an efficient communication both in the school as well as in different social contexts the program consists of four components oral expression reading writing and reflections about the language although as a didactic strategy these components are taught separately in a lesson they are considered parts of a whole system for teaching it is expected that by means of working on the four components in the lesson children will understand the alphabetic principle and develop reading and writing skills according to their school grade thus letter names letter sounds and syllables are not taught in isolation but rather as part of a holistic communicative approach literacy instruction this program is compulsory for all mexican schools public and private and it is supported with specific books and activity books prepared by the sep all first grade children are provided with a book for reading an activity book and a figures book although teachers are expected to follow the guidelines and sequence of lessons and activities indicated in the teachers manuals they are also allowed to make changes and enrich lessons according to childrens needs and interests however although receiving similar preparation to teach the national curriculum and reporting similar ideologies with respect to its implementation teachers at the two schools reported engaging in somewhat different teaching practices using the national materials teachers at josefa ortiz de dominguez school had on average 174 years of experience teaching compared with 106 years of experience for teachers at josé morelos school these more experienced josefa ortiz de dominguez teachers reported that they used the national curriculum almost exclusively with only two reporting that they augmented this program with other methods on the other hand in josé morelos school a majority of the teachers reported using other methods along with the national curriculum two reported using the syllabic method as one teacher explained because there are 53 children and with this method they learn to read faster and i can tell easily the ones who are falling behind others reported using the global method an eclectic method and a sight word method parents descriptions of the way in which their children were being taught to read also differed from school to school the majority of josefa ortiz de dominguez parents described how the children were taught to blend letter sounds this is the method they use here the sound of the letter another mother explained they dont work on separate syllables anymore like carro now they started to work on whole words so they dont read letter by letter anymore by contrast in the josé morelos community twothirds of the parents described the way that their children are being taught as following a syllabic method one of the mothers described the teacher as beginning with the vowels and the alphabet and then they joined the letters like m with a ma m with e me and thats how they learned them another mother described how the teacher maestra virginia had given the children a laminated alphabet card and with it they did join s a and it says sa join the l and the a sala the method described by these parents in the josé morelos community follows the traditional reading method in mexico brought from spain in the colonial period the method of the cartilla y deletreo or primer and spelling in this method dating from the sixteenth century the pupil was given a pamphlet with the vowels the alphabet and then over 300 isolated syllables followed by sentences embodying catholic doctrine tanck de estrada explained how children were taught to read el alumno al ver tra ba jo diría te ere a tra be a ba jota o jo trabajo in other words pupil would name the letters for the syllables in isolation followed by a final reading of the word separating the word syllablebysyllable an advance in method by the nineteenth century was to substitute the letterbyletter reading for the direct reading of the syllables with blended letter sounds according to parent descriptions vestiges of both the deletreo and the silabeo are still practiced in josé morelos and at least some of the teachers state that they rely on syllabic instruction to support the initial reading development of nonreading first graders according to the director of josé morelos school this situation is explained by the fact that the teachers are following the national curriculum and the parents simply do not understand this por ejemplo hace días tuve como un problema con unas señoras que vinieron enojadas maestra es que esa maestra no está trabajando los niños no saben la e no saben las letras ¿cómo que no saben sí saben esos niños la maestra está trabajando con el método global de análisis estructural y el proceso de construcción de la lectoescritura es más o sea tarda más pero ustedes se van a dar cuenta como es mejor que el de las sílabas o el onomatopéyico eso es del tiempo de la canica ay dios mío por eso a veces es trabajoso hacer que la gente entienda for example several days ago i had a problem with some ladies who came and were angry teacher that teacher isnt working the children dont know the letter e they dont know the letters what do you mean they dont know the children do know the teacher is using the global method of structural analysis and the process of construction of literacy is one that takes longer but youll realize that this method is better than the syllabic or the onomatopeic those are from olden times oh lord this is why it is so hard sometimes to get people to understand however our data indicate that the perceptions of the parents of how reading is taught to their children are not simply the result of lack of understanding of the method the teacher is using or of parents own preference for antiquated methods as the director claimed rather parents understandings are coconstructed with the teachers the teachers at josé morelos school themselves make more use of the traditional methods and they send home materials such as the laminated alphabet cards that reinforce these older methods through the materials being sent home and the recommendations made by teachers for how they should help at home parents understandings of literacy development are reinforced understandings characterized by the directora as oldfashioned and not in line with modern standards bourdieu makes the distinction between cultural capital in the embodied state or longterm dispositions attitudes linguistic usages and understandings and cultural capital in the objectified state or in the form of cultural goods such as books pictures instruments etc our analyses have yielded differences in the cultural capital of children and families in the two communities in both the embodied and the objectified states at the same time differences in both states are observed not only in the homes of the children but also in the points of connection between home and school discussion the notion of cultural capital as originally proposed by bourdieu has proven to be extremely fruitful in uncovering social inequalities and by implication how these may be transformed however his work has also been the subject of critique in response to perceptions that the concept reflects a deficit view of nondominant class families some researchers have proposed alternative definitions of cultural capital reflecting a view in line with a funds of knowledge orientation garcia states a persons entire set of cultural relationships not just in the family but across all the social spheres has been called his or her cultural capital in effect it is the cultural fund that the individual draws upon to support all the activities of life not only does it help protect and nurture the individual in family or familylike settings it also plays a similar role in nonfamilylike institutions especially the school cushner mcclelland and safford put a different spin on cultural capital stating that much of the cultural capital of human societies emerges from philosophical literary musical and artistic attempts to answer fundamentally religious questions however in extending the definition of cultural capital to include all people and groups regardless of class status the value of the concept in providing at least a partial explanation for persistent classassociated variation in students academic performance is lost the 2007 inee study cited at the beginning of the article also makes somewhat misleading use of cultural capital concept in that study academic cultural capital was operationalized as the parents level of education their expectations regarding their childrens educational attainment frequency of movie attendance number of books in the home and home access to the internet these were variables that loaded onto a single factor that was associated with student achievement however other variables such as frequency of going to a museum or to a theatre production equally predicted to form part of the cultural capital concept from a theoretical standpoint were not included because they were not found to predict student outcomes ultimately the report found variation in both achievement outcomes as well as in academic cultural capital at the school level to be greater than variation at the individual level a condition that they found to represent una alta segregación educativa en los centros escolares con base en el nivel sociocultural de sus estudiantes the authors note that this relationship can also be related to families with higher levels of academic cultural capital choosing schools with more and better resources than those available to families with lower levels of academic cultural capital what the findings of our study point to are also clear differences in both families cultural capital as evidenced in the varied literacy practices involving firstgrade children as well as in schoollevel student performance however differences in cultural capital appear to provide only a partial explanation for the performance outcomes differences in the literacy experiences of children are not exclusive to the home environment differences are apparent in the communities in which they live and in the resources and opportunities available at the schools where they study differences in the ways in which teachers communicate with parents and involve them in their childrens schooling were documented as well as differences in the ways in which early literacy instruction was implemented by teachers who were presumably using the same national curriculum finally school treatment and expectations experienced by parents formed part of the legacy of experience and understandings that shaped their interactions and practices with their own children a year and a half after the data collection for this firstyear study the parents at josé morelos school went on strike picketing outside the school and closing the school for a day parents complained of the same conditions that have been described above high rates of teacher absenteeism and lack of respect for parents the placards held by parents as they blocked the school gate read if all children have the right to an education why do ours not have a teacher we demand that each class has its own teacher we demand a school thats dignified and clean and that they respect us as parents their slogans indicate a lack of conformity with the structural inequalities in the educational system that result in a crowded and inadequately staffed school campus and they also reveal resistance to the treatment that they and their children receive at the hands of school personnel the parent strike resulted in the removal of the director from josé morelos school during the third year of our study however at the time of writing it is still too soon to determine if the strike had an effect on the conditions that the parents were struggling to improve the willingness of parents in both communities to help children with homework and follow through on requests from teachers as well as the organization of the strike in the working class community indicate a level of parent engagement in their childrens schooling that is at odds with stereotypes and assumptions of many mexican educators as well as us educators who work with mexican families in the us teachers beliefs about the potential involvement of working class and latino parents in their childrens education are often reinforced in the textbooks that they read in their professional preparation classes for example that middle and upper class parents are more involved in their childrens schooling or that cultural attitudes such as depreciating education after high school and emphasis of family over the achievement and life goals of children may hinder classroom success for mexicanamerican students instead the findings reported here help to illuminate the role of schools and teachers in contributing to the understandings and experiences that the children are perceived to be bringing from home with this understanding can come efforts to modify connections between school and home for the benefit of childrens academic performance and experience cultural diversity in learning and development specifically on processes of social interaction participation and communication in formal and informal learning and in sociocultural and cognitive development antonio ray is professor at the instituto tecnológico y de estudios superiores de occidente in the graduate and postgraduate programs of the school of education his research interests include cognitive development as a result of formal educational processes and literacy development in elementary school children and children with learning disabilities

this article examines the relationships among the literacy practices engaged in by firstgrade children and parents at home and the ways in which these practices are communicated shaped and fostered by teachers and administrators in two different sociocultural environments in urban mexico the differences observed between the home literacy experiences of children in a working class and a middle class community included transgenerational communication of assumptions regarding literacy and schooling as well as attitudes associated with the parents own school experiences classbased expectations on the part of teachers not only shaped interactions with parents but were also reflected in the way the national curriculum was delivered with a greater emphasis on rote skills and traditional reading instruction in the working class community the authors argue that the school plays a role in the coproduction of cultural capital in the home through its shaping of some of the literacy practices that children and families undertake

introduction favelas have been referred to as urban slums viewed as undesirable dangerous and crimeridden areas of high risk to visitors beyond these negative imaginations they are thriving communities amid a dense urban living environment from a tourism policy and urban transformation perspective there has been appeal and the desire among tourists to stay and consume everyday living environments that differ from what people are used to visiting transforming spaces to cater to tourist interests is resulting in new forms of inclusion and exclusion these appeals are primarily driven by authentic experiences that tourists today demand in rio de janeiro an authentic experience is increasingly seen through life in the favela away from the hotels and areas of mass consumerism that line copacabana and ipanema beaches rio is wellknown for its landscape of favelas and these residential areas have widely been publicised and romanticised through popular culture aiding a new consumer culture frenzel and freiremedeiros highlight how new semblances of power are established by allowing tourists to regularly visit favelas on scheduled and private tours people entering or touring can arguably alter daily activities by causing disruptions or distractions in these everyday living environments impacts can be positive and negative from one standpoint it allows people to earn an income from tourism nevertheless we also need to question if they are commodifying their surroundings so that tourists can experience life in these notorious areas soft power can play a role in commodifying culture because a particular image is exported to tourists thus soft power relates to this work and is explored to assess appeal and attraction and is an important conceptual consideration when critically exploring the impact of tourism in urban areas from an urban policy standpoint it is also important to consider the urban transformation literature to explore alterations to the living environment to get a sense and perception of what is unfolding in rio specifically promotional activities and the desire to gain a particular experience can create symbolic value the communication of value here is important where we consider soft power as this will influence local residents the tourists and plannerspolicy makers differently as each can shape impacts on how some may be included and others may be excluded urban transformation in this case is about how tourism is shaping memories and awareness it is not transformation in the infrastructural sense but transformation in the form of a service industry leading to socioeconomic change that can result in inclusion and exclusion and impacts on an everyday living environment we can learn a lot from and interpret usergenerated content with critical meanings embedded in reviews posted by tourists who visit a particular destination in this paper the impact on policy and the living environment is aligned with ongoing spatial transformations occurring in cities such as rio where vulnerable populations are interacting with tourists with differing social and socioeconomic consequences tours offeredled by local residents is an opportunity for individuals to earn some regular or supplemental income however a critical argument is tourism can disrupt everyday living environments as these are vulnerable communities tourism also can result in consequences that lead to disruptive powerdynamics among residents based on those who are involved or based along the tourist path or able to afford to offer a tourism product while these people come from the favela a successful business could see them improving their economic situation and moving to a more affluent area and only coming back to the favela to use its presence as a commodity this can cause a domino effect whereby other families begin doing the same resulting in increased tourism and even unwelcomed behaviour among tourists and locals disrupting the living environment of the favela and thus reducing the authentic appeal that tourists seek this dynamic may also create mechanisms of competition and genderbased power hierarchies in vulnerable communities that make the very meaning of the term community lose its importance again from an urban geography standpoint this is a form of tourismled urban change whereby transformation is driven by the desire to consume how people reside in a certain living environment thus leading to locals commodifying spaces and places to make money off the desires of tourists wanting to gaze upon and experience favela life this paper contributes new insight to the notion of soft power by looking at the impacts of slum tourism on authenticity opportunity and urban change using standpoints from users to assess and critique practice and policy this paper begins by exploring the range of literature concerning these areas to merge these different areas of research starting with the link between slum tourism and authenticity and then considers the literature on how tourism is creating power dilemmas aligned with urban transformations we then explain the approach and method of evaluating content from tripadvisor to frame critical insight that challenges the practice of offering tours of a favela a review of the findings leads into a discussion of policy and planning implications where we speak back to findings from recent related studies that explore the impact of tourism on local communities slum tourism and authenticity the concept of slum tourism is a subfield of reality tourism offering social tours that sell an authentic and participatory experience when visiting infamous poverty stricken destinations such as delhi in india soweto in south africa or the rocinha favela in rio discussed in this paper these tours originally gained traction as a legitimate strategy to develop areas of poverty in the 1990s where the financial benefits of tourism were to be redistributed back to support those living in identified areas of poverty over the 25 year period of research regarding slum tourism also known as pity tourism the link between the benefits of such tourism and the reduction of poverty remains divisive and inconclusive tourism for example can improve short and mediumterm outcomes for the poor through the generation of income and tax on services offered however tourism expansion and an over reliance on tourism for income have also been linked to further poverty in the poorest of households who remain excluded from the benefits of tourism brazil in particular has been one location used as a focus point for the development and consequences of slum tourism for example freiremedeiros examined how the favelas and in particular rocinha offer tourists the opportunity to contribute to local economic development by paying to visit to the community this is also seen as a sense of adventure an outcome of popular images and media constructing an anticipated experiencethat becomes the tourist product freiremedeiros conclude that rocinha is just one of hundreds of tourist destinations that do not benefit from tourists primarily as they actually do not spend money while in the favela and any capital generated by tour operators is minimally reinvested in the favela and often by way of a token charitable gesture now with the gig or sharing economy the opportunity to reverse the way tourists can experience authentic favela life through the renting of rooms through platforms such as airbnb could offer a way to return capital into the citizens pocket this however requires access to the internet writtendigital literacy and online baking capabilities all of which remain poor in the favelas across brazil as connectivity and communication is essential to push a soft power agenda and involve people in service industries such as tourism even before the gig economy existed freiremedeiros noted that one ironic consequence to those able to offer tourists authentic opportunities by running their own citizen led tours is that tours might end up being more staged than had they travelled with external agencies still in some respects tours through brazils favelas offer a staging of lived experiences and this emerges in reviews on tripadvisor however this communication is for future visitors and tourists and isolate those who do not have internet and digital literacy skills despite all the ethical debates around slum tourism in brazils favelassuch tours and tourism opportunities can perhaps be seen as a way to improve the visibility of the favelas in rio authenticity is an essential debate in tourism that is not often discussed alongside the notion of soft power while soft power concerns relationships bonded through economic and cultural influence favelas have become distinct attractions because of cultural appeal which can persuade travellers to visit a place online and social media platforms for more than a decade now have played an important role today in projecting images and promoting authentic experiences based on userperceptions while favelas are active living environments tourism researchers argue that such places can also be sanitized to manifest placesattractions in this way places as attractions can become recreated or staged because some tourists seek altered realities others argue we are moving beyond staged manifestations as the focus on reality is part of contemporary consumer demands where tourists seek everyday experiences by focusing on tripadvisor posts as a form of ugc this paper argues that perceptions of a placeattraction as consumed expressions as user experiences are based solely on their encounters and then align with their desired outcomes the link back to soft power is then the ability of platforms such as tripadvisor to persuade future travellers based on the influence of the user and how they communicate their experience those who live in the favela are in many respects excluded from sharing their story as the power of persuasion lies with the one who has visited as a tourist wang argued feelings of authenticity are not guided by the fact that tourists see the object as authentic because they are engaging in activities free from the constraints of their everyday life however and what remains contested is there can be no regard to the fact that the attraction gazed upon is an active living environment however there can be a certain ignorance as people visit popularized and romanticized attractions and more contested challenges arise when a place or attraction is transformed into a tourism product urban change hénaff challenges us to better understand the act of building and changing the urban environment especially as sectors such as tourism are having a major impact on local living environments moreover it is important to consider the changing influences of tourism on local living environments as this is a decisive factor when we consider social and economic change amid inclusion and exclusion based on where and how opportunities are directed and how locals perceive visitors entering their everyday living domain despite increasingly innovative approaches to placemaking as a pathway to economic development and social sustainability issues of inclusion and exclusion persist in destinationsattractions alongside the question of who the beneficiaries of neighbourhood and wider urban change will be existing pressures from urban change fall disproportionately on already struggling urban areas particularly those where the social and economic fabric of an area are already underpinned while investments and new touristic activity can increase consumption in many cases it has also resulted in greater economic disparities and increased levels of social exclusion recent research on urban transformation has an essential role to play developing our conceptual understanding of how people place and policy interact offering a critical perspective on social and economic change locally this is also where insight from critical scholars including lefebvre or harvey challenge us to expose the social construction of space to articulate and address inequitable power relations learyowhins recent examination of the contribution of community actors and collective political action in the creation of public space offers a counterstrike against neoliberal provoked fatalistic pessimism when it comes to future consumption likewise the potential as well as the challenge of urban transformation has been illuminated by recent critical examinations of the trend of leveraging culture heritage and increasing tourism consumption as part of urban change against this backdrop of neoliberalism consumptiontourismled urban renewal more recent development strategies have extended to more creative or innovative investments in areas such as tourism leisure culture or heritage for instance clarks edited collection examines how the leisure industries are driving change in urban areas location and experience concerning the case of rio here are what is driving favela tourism and is resulting in homeowners transforming their spaces into places for tourism consumption however whether for traditional investment projects or those aligned with tourism are specific to the budgets and ability of the private individual to commodify their local living environment attracting people to what are deemedperceived as troubled places creates new power divisions especially in brazil where nationwide projects include some whilst excluding many this transformation speaking back to points made above is altering consumption patterns for both inhabitants and newcomers alikelikewise observed in recent studies urban and community change leads to questions over territory territory is how we determine and recognise spaces boundaries belongings and associations scholars have taken this notion further to conceptualise territoriality or territorialisation to refer to organisation or social cultural or political agents at play to distinguish places based on power or representation often referring to various degrees and scales of community and identity nofre et al are very critical of this concept as tourism is resulting in social change and is disrupting local everyday life among residents as more tourists enter an area and extends beyond its sustainable carrying capacity then we enter discussion and debates concerning overtourism which is grounded in debates over local territory and territorialisation approach to identifying and reviewing content increasingly ugc informs our understandings and perceptions of the world but must be challenged due to the communicated disparities that emerge despite the widespread acceptance of online content its ubiquity can lead to concerns and subjectivity can result in falsehoods tripadvisor is aware of this and clearly notes that reviews are subjective opinions made by the user qualitative content analyses challenge researchers to seek meanings and determine themes extracted from texts andor relate content to new conceptual understandings qualitative content analyses are thus about highlighting issues and narratives embedded in the texts interpretations of user experiences and practices are present through interactive online and media discourses moreover expressions presented through various outlets create ground and shape our perceptions as such this study utilises content analysis to evaluate meanings presented through tripadvisor to understand the dominant narrative of how users perceive interact and share their experiences of visiting favelas in riospecifically the rocinha favela in this paper tripadvisor posts were interpreted and organized into three themes emerged and interpreted from ugc to analyse discussions and representations concerning favela tourism in rios rocinha favela this work starts by assessing content from the tripadvisor page titled rocinha favela tour to assess tourist experiences through ugc this page includes 91 reviews in ten languages english spanish portuguese french german italian russian traditional chinese dutch and hebrew of the 91 posts 15 posts were deemed irrelevant for this analysis because they did not speak to the destination or were interpreted as just advertising for a business while many of the posts are repetitive the authors identified specific quotes from the content to include in each section extracts from the posts are presented to support the development and interpretation of each theme posts not in english were translated to english using google translation linked to each post this paper is not concerned with the score that participants post on tripadvisor but the qualitative comments they leave as this can help researchers identify themes that emerge to critically interpret narratives this approach was used for translations because this is what consumers and future travellers will view as it is embedded in tripadvisor with each post for posts included in this paper we only include the translated version as translated from google translate which is an option in each nonenglish post in tripadvisor results and analysis to link the focus on soft power to the interpretations in this paper favelas are part of the urban cultural fabric of rio and tourism is an important economic influence favelas and this focus on slum tourism is also controversial as there are numerous insights suggesting people simply seek to gaze upon everyday life in a real community again soft power as a form of appeal and persuasion and is communicated to us through userperceptions tripadvisor posts are based on the users interactions and awareness despite the semblances of power being onesided and the experiences described are subjective on the tripadvisor page for the rocinha favela tour the about page mentions dont just look come experience rios most unique favela tour come see and experience rocinha through the eyes of real locals while also emphasising this is not just a favela tour but immersion into the community not a slumming tour but a personal sincere experience real sustainable tourism three interconnected themes emerged when evaluating tripadvisor posts of rios rocinha favela tour in many respects the notion of commodification and even authenticity runs through each theme but the analysis below begins with the consideration of how the living environment becomes a product or a tourism attraction the rocinha favela tour is widely publicised and is often highlighted as a chance to see a living and working favela given this has become a popular tourism attraction this leads to the second theme of opportunity or awareness opportunities do exist for people in the community to now be involved in tourism for the sake of local economic impact but with having a tourism product in such a vulnerable living environment is ensuring awareness is maintained the third theme builds on and relates to the previous two but focuses more on the semblances of authenticity that emerge from the tripadvisor content analysed in this paper more specifically getting us to challenge and critique userperceptions living environment or a product commodification one concern about gazing at a poorer living environment was bluntly expressed by one user you really need to look at the poor people like animals in the zoo another user captioned their post a shocking experience signifying that this was something different from what they were used to seeing on holiday however another user suggests that doing a favela tour gives you the opportunity to explore a part of the city that otherwise would be unaccessable to the tourist after reading the reviews we begin to question is this a community or a commodity for the purpose of showcasing people living in a poorer living environment several users frame the stark reality of rocinha as an attraction to realy get a view of social oppression lack of resources life in the slums of rio our viatour guide gave us a good insight into the history and challenges of life in a slum and how theyve become a large part of the culture of rio this tour opened our eyes to a lot of rios stark realities this was a view into the real brazil and how people in the favella are just leading their lives working shopping kids playing out it was busy noisy but we didnt feel unsafe we walked through the favella from the top to the bottom we took pictures always remember when doing this tour it is a favella some people dont like photos being taken at all i cant call this wonderful exciting or any of these terms that makes you think that this is your average vacation tour its not but it is a view of how over 90 of people in rio live its a chance to see the real rio see the other side of rio the tour description itself reveals that the rocinha experience is not a slumming tour but a personal sincere experience real sustainable tourism this can seem reassuring to any tourist who might feel guilty about spending time in a precariousvulnerable space it is not the residents of the favela but the individuals experience in a favela it is like an experience of redemption and gratitude to some who as the comment below puts it relativizes the existing privilege of certain tourists while at the same time softening the awareness of the favela tour as the tour values would be used to improve the favela heartbreaking to see how the people here live and really grateful about what i have some of the money we paid for this tour would go to this community to help the people here another rio it is clear that no one will show you the real life in favels but what you see is also impressive while we are introduced to what people frame as real life as they gaze upon it as an attraction a commodity an emphasis on rocinha as a living environment is not completely forgotten it was an amazing experience that our guide showed us his neighborhood and discussed the daily lives of the community there they are friendly and real there is nothing to worry about the visit as long as you use common sense and dress and behave appropriately rocinha is a nice lively and busy community where a lot of local working class lives and works there due to their circumstances when we visit a country we tend to enjoy the experience and local culture by feeling understanding listening and tasting the culture rather than visiting top tourist attractions and scenic points walking around and seeing the organisation and architecture of the favela illustrates how poverty has been able to concentrate its afflicted onto an inhospitable hillside whilst conveniently segregating them from the suburbs some of the free facilities available to residents are appealing such as electricity and wifi but i doubt would make up for living in what is essentially a modernday concentration camp for the poor i have to highly recomend this tour for anybody who wants to look around a real rio favela and see the everyday peoples way of life what people seek is an experience and while those who post realise that they are walking through an active living environment they put themselves at the centre to highlight how they feel about touring a favela and offer insight on how to dress how to act and what to expect when visiting or what you can do to assist people we recommend not taking pictures of people it is advisable to go with clothes comfortable and slippers because you walk a lot to know every corner of the place leading us to discover the world of favela that none of us knew and was curious to discover lucy accurately told us the history of the places and the people who live in the favela made us taste local products and another thing that filled our hearts in rocinha was the afterschool program for the para ti association dedicated to children of the favela if you decide to go offer colored pencils crayons like we did the children will be very happy it is the best gift for them in addition tourism helps clarify images and remove myths and fears that are popularised and communicated in the media as some users note i watched films in which favels were shown i wanted so much to find out what they were inside there everywhere the police gangsters gopnik and drug addicts were not noticed the streets are dirty but not polluted each shack is equipped with air conditioning as they say not the poorest residents of the city live there under the guidance of a guide a walking tour through the favela rochina a bit skeptical in advance but never felt unsafe is one of the better favelas fascinating tour in the favelas … it allowed us to understand that the favelas are not only synonymous with drug trafficking but also and above all honest people who try with all their strength to improve their condition with an enviable spirit of life during this tour we also had the opportunity to walk inside the very narrow villages and to observe the daily life of these people i strongly recommend this experience that with the modest sum of € 25 allows you to see an important phenomenon of this country and to understand how the brazilian state does everything to not improve the situation of these people to some this came at some discontent by locals they know in rio as some put more emphasis on the element of consumption a brazilian friend was not quite pleased with my joining the tour thinking that i joined to gawk at the poverty and poor living conditions inside favelas that was not at all my intention the experience was rewarding and at the same time physically draining it involved a lot of walking up and down narrow alleys that just got narrower as we went deeper inside this city within a city the tour takes you to quiet areas of the favela not that you see people with guns listen to gunshots or that stuff it is a safe tour there is nothing to fear the only bad thing is that it is very commercial they take you to areas for consumption go prepared for a good walk its the best way to get to know every detail of this amazing community however despite the fact that touring through a local living environment can present its challenges something that ugc allows is for people to commend what is happening and encourage more visitors some view tourism as helping local people i think these visits serve them as economic help and us to see life from another side but recent research notes that this is disrupting everyday life as tourism is not always sustained and therefore the impact on the local economy can have negative consequences what we do not get is the local voice and their satisfaction of visitors making their way through their streets and looking at how they live but it is summed up visitor experiences that entice other or future travellers an experience to know the reality of brazil i recommend doing a tour with a local guide of the favela because it will allow you to go into places and meet people that otherwise would be impossible and all in a safe way personally i think it has been an enriching experience to see the other side of rio and on the other hand the reality of the country it is very interesting to visit this place where you enter a house you have an impressive view from above to the whole favela to be able to walk the streets and people are very kind to everyone you can take pictures and there is no risk almost every house has a gorgeous view of rio from the window consistent was how users discussed how safe the community was there was much excitement about the chance to wonder around a vulnerable living environment and while much was reported about the safety there are still concerns as tourists can create unwelcome attention but the positivity is also a chance to create new local economic opportunities this is also where we encounter challenges with authenticity because overtourism as we see recently is threatening communities but at the same time people need to service so it will be some time until tourism managers can strike that balance surrounding economic opportunitypotential and impacts on local communities with this point to conclude this section a user mentioned there is great hope for this city and we hope to see more development each time we return but the challenge here then becomes if the favela develops does that take away from the element of attraction on one side it will improve the living environment for residents but it could take away the earning potential of rocinha tourists visit here because they seek something different and gaze upon favela life but development brings a new awareness and opportunity for people as improvements are made to the local living environment the challenge then is what opportunities would exist for the local tourism economy if the favela develops in a manner similar to other parts of rio main tourism areas not only that but what impact would that have on the local residents would opportunities exist or would be forced to leave their local area opportunity or awareness understanding a places history helps change perceptions and overcome stereotypes common posts about rocinha were its an eye opener fantastic and informative tour … we learnt a lot of things about brazils history and how the favela started and helps to give a greater understanding of rio for those who reside in rocinha life is a struggle and for those who can tourism is an option where they can use their local knowledge to earn a living by promoting tourism it is a way to shape or create awareness and offering a tour that seeks to bring people into an area and educate them about it can also alter imaginations and popularwidespread stereotypes as noted above images and imagination of favelas are romanticised and popularised visàvis movies and news media and people are drawn to this as a way to shape their awareness by experiencing a favela firsthand tripadvisor is about creating awareness through ugc and in this section users post on how tourism has opened up the favela and created a new local economy and comments on the history of the rocinha adds narrative insight there is another side to rio away from the beaches and bars and its well worth a look we headed to the favela da rocinha with a local guide as part of a sustainable initiative that puts money back into the local community we had a chance to meet local people in their own home and they had a chance to tell us their story which had very little connection with the media stereotypes youve probably heard about the favelas this was really the highlight of my visit to rio this tour was very insightful with regards to how people live in the favela rocinha the tour guide lives there and so he was able to provide information about its history family life and how the government have supported past projects within the favela this tour was amazing and a must and is a huge part of brazilian culture there were beautiful views of the favela and sense of community within the favela it is also safe with the tour this tour is very informative it gives you a great insight into what daily life in the favelas looks like you get an opportunity to buy some artwork and some food on the way and meet many friendly locals as well as amazing views over the city the guide gives you heaps of information and seems to know a tonne of people there these were comment posts as there was much unaminity about how the tour is an education experience offering more scope beyond this as a tourist gaze there is an emphasis on the guides as they help shape an awareness we went on a tour with a very well respected local guide of the community while feeling safe with the guide we would not recommend going into the favela without a guide the guide was very informative and gave us a real feel of what living inside the favela is like it was like a maze inside with all the ally ways and streets a must do tour but get a good guide go with local guide of course it is a place to see the other side of rio the tour is recommended with a local guide who has lived there it is an incredible walk where you see the reality of the favelas our guide was very clear in all the details explaining how they came to be built while many focused on the positives that tours through rocinha offer there were also some users that framed different pictures highlighting the two sides of rio my guide lives there and therefore he is well known in the community they dont like the word favela anymore and prefer comunidade rocinha is a city within a city with a population of 150000 it is only 15 minutes away from ipanema but that is irrelevant as it is another world … there are people everywhere and there is a strong sense of pride in their community they like you taking an interest in their world one man i met said welcome to rocinha senhor rocinha is yours i highly recommend a tour with a guide particularly one who lives there because of the political and criminal unrest in rio right now you are very limited where you can go i did not have concern for safety but the tour was very limited you do get some good info from the tour guide beyond copacabana and ipanema the tour covered the worlds largest favela rocinho in rio de janeiro it was an eyeopening experience seeing and walking deep inside rocinho and learning the rich history of how favelas started and how favelas add to the rich culture of brazil eye openerthe history about the favela was most interesting the walk to the bottom was lengthy and my feet got wet and dirty hides nice seeing the locals would recommend it any day never ever go alone we saw a man with a machine gun pretty sure he was ready to use it if we didnt have a guide lol visiting a favela was a different experience obviously we travel very quiet sectors during the hour and a half that lasted our visit but one comes out with an idea of how millions of brazilians live who are far from what one lives daily as a tourist and the reality of many millions more of brazilians something different to understand the contrasts of rio which helps to understand in depth the contrasts of rio demystifying that in the favelas there are only criminals tourism and touring is about communication and awareness and this is where again we see people taking the opportunity to include themselves in the industry as a way of overcoming socioeconomic exclusion a lot of comments focus on passing through the favela but staying and spending locally brings new money into the community as one user encourages having lunch in rocinha would already make the community benefit from the effects of tourism there however we still need to question who benefits from tourism opportunities as guides can set specific routes and stop in places where they can get a commission which then can limit the impact of tourism in the community one user picked up on this critical point the only ones who really have something to contribute are the guides who enrich themselves with the poverty of the people sociogeographically favelas are a part of the urban periphery but as tourism increased in brazil there was a need to diversify the offering and because favelas have been romanticized and widely popularised as one user posted having read the book the spectacular favela it really was special for me to visit rocinha and bring the book to life through these powerful mediums tourism opportunities can arise taking people into what is deemed the real or authentic rio semblances of authenticity you can immerse yourself directly in the life of the people living there the challenge with connecting this theme to the above section is first we see a living environment transformed into a tourism product for which then residents seek an opportunity to shape consumer awareness and when we analyse visitor reviews because those who generate the content speak about what the view as real based on their gaze the path they walked and the people they encountered we get a sense of how people feel about the rocinha as people look to authenticate the experience by suggesting it is without any staged attractions and adding to this the element of experience another user suggests this tour is a full sensory experience where you can fully use your senses and feel your emotions another user embedded the word authenticity to explain how they felt and they address the possibility of something happening but that is what they enjoyed no zero risk also shootings possiblebut what a precious experience i loved it i loved the people the authenticity the landscape the street art another user also noted the term in their post samba and sipping caprinha in rocinha whats the best thing about the tour you may ask our tour guide gave us the best authentic experience of rocinha a trip never to be missed when in rio authenticity as noted is highly contentious in the tourism literature but is nonetheless important to assess when reviewing ugc because this is a starting point where future travellers increasing seek information building on this wise and farzin argue that people look to social media for advice to help authenticate future experiences one user posted that the rocinha experience is sanitised noting you visited a home of one of the residents but you could see that it was set up for tourists but others highlight that you havent seen rio without seeing the favela and a chance to explore the daily routine of residents in rios slums as a way of authenticating the experience several commented that being with a local helps make the tour feel authentic because you are gaining that first had experience different from the comment in the previous paragraph that the home visit is sanitised but in some ways helping with explaining the experience and promoting the attraction is explaining how safe they felt very interesting and safe went on this with my family of three to see the other side of rio good tour felt quite safe friendly people great eye opening experience was somewhat wary about the safety of this but my husband was keen to do this guided tour booked via the hotel and this was an intimate well informed tour by 3 guides the lead one of which had 25 years experience turned out to be one of my best experiences in rio felt very safe amazing pics fascinating eye opening opportunity to see how the locals live makes you very appreciative of what you have included dance by 3 locals who encouraged me and my husband to dance with them great for those who want a lot of culture on holiday and to broaden themselves an interesting overview of one of the more popular favelas in rio always use a guide for this and our guide made us feel safe at all times we visited the rochina favela with our guide patrick from be a local we were collected from our hostel and driven less than 15mins to the top of the favela we then walked for a couple of hours through the passage ways stopping on the way to view an art gallery musicians a bakery and a crèche the tour was informative we felt completely safe and very interesting to see firsthand the cultural and economic differences in rio our tour guide gave a great overview of how the tour would work and history of the favela in rio he showed us how luxurious the areas we drove through were but made it clear that we would notice immediately when it endsand it did we were then given a break background of rocinha…socially economically and historically everyone was standing there kindof looking around like are we going to be robbed is this safe the guide explained that this is one of the many misconceptions of the favela unique experience very cool this tour i felt safe despite all the risks that this tour might have mixed with sadness and joy the tour is walking through the alleys and alleys of the favela we know locals who sell products that they make themselves and they welcome us very well including trying to communicate with foreigners we get the sense from some of these posts that this is an opportunity because people might not go here unless there was a tour option favelas are sometimes regarded as places where locals police themselves as negative publicity will deter visitors but some people are attracted to favelas because they feel they are taking a risk because of how they are popularised in film as dangerous places as one user posts the reality of the attraction was it was nothing like i expected going on to comment the favelas are nothing like majority of people describe them to be these days theyre all built from brick have electricity plumbing cable and shops rosinha favelas is definitely safe to visit on a tour adding that additional insight on safety as well while safety here helps with altering more popularised perceptions of favelas another key focus on the content interested in this section was confirming what users posted as real or how they viewed reality for instance a visit to understand the real brazil a different and very real view of rio after the initial excitement subsided it was clear that we were visiting a neighborhood that was in ways similar to any other we passed houses stores bars restaurants and schools we werent in kansas anymore but the microcosm was familiar it was a fascinating experience brazil from the other side if you want to know the other part of brazil i think its worth it good visit another reality of rio it has very good bars at affordable prices and local food for very few places where you eat very well it is very cheap clothes and things that sell there so it is a good option if you want to buy summer clothes purses or flip flops the most advisable go without anything of value as simple as possible so they go unnoticed among the crowd it is a good option that if you take the precautions it is advisable to go reality to some was further detailed as an authentic learning experience building on insight from the above section and we see how users try and comment on points that they felt were authentic in this local living environment discussion and concluding remarks policy and planning implications tourism is a form of soft power in that governments use it to persuade people to visit but through the use of ugc and people sharing experiences goes beyond foreign policy and offers new insight into international relations using tourism as a medium social media is increasingly used as a powerful medium to display semblances of a destination soft power communicated via social media and online ugc platforms such as tripadvisor based on what was presented in this paper is thus another way of connecting people and places and framing creating or confirming popular imaginations it influences people by using and disseminating culture and local values these can be both positive and negative and while there was a lot of overwhelmingly positive comments seen in the analysis above there was one particularly negative post warning people not to go do not gotoo dangerous recent unrest in rocinha has been serious and about six weeks ago tourist shot dead on guided tour unrest not yet resolved we have seen this in past work as well where some negative connotation can cause panic and unease after times of tragedy or violence in contrast this post seems to unite the three themes outlined from the content it is not a shame to expose the poverty of a country in a tour there is no shame in being poor but there are precarities but this is a social aspect consistent with the reality that we should not avoid seeing and so i think i think the favela tour is a sort of sample tour because the route goes through places where the route is allowed and safe and could not be otherwise wise and clark argue processes of urban change are defined and understood differently across and within different geographies while a lot of literature considers more widespread urban change initiatives this paper is more concerned with change that is targeted in favelas as this transforms everyday living environments this is a response to shifting economic conditions demographic composition and social pressures challenge how change is planned for and even understood by and among locals the process of urbanisation is accompanied by multiple political economic and social drivers and in brazil connecting stakeholders can be a challenge as local government officials urban planners and private investors who can promote and implement change in our cities in the most exemplary cases of the rocinha slums among the 756 existing favelas in rio which inhabit 22 of the citys population the local government strategies with the assistance of economic agents are seeking to induce modernization plans in these spaces this is arguably leading to reductions of the feelings of insecurity and the contradictory recognition of the favela as a historical cultural and spatial heritage of brazil seeing these spaces as increasingly suitable for tourist commercialization the violence associated with widespread actions of the police and the national army that seek to impose this socalled modernity includes among many aspects what can be commodified and sold to tourists and corroborates with the historical attempt to disseminate a more positive image both nationally and internationally although critical scholars note this leads to further inequalities where even in poverty stricken areas it can now be possible to extract positive aspects although tourists are not to be blamed for the potential predatory effects of the soft power produced by tourism agencies that tries to show the other side of rio it is not possible to ignore the complex and violent social relations based on the discrimination of gender race and social class operating in brazil this also must be considered when we relates discussions to soft power as this produces fertile ground for the intensification of inequalities and worse the maintenance of poverty as a way of preserving slum tourism as a unique experience as indicated by neri and silva the modernization shock introduced by the state police force in the last decade has resulted in a transformation of the real estate markets in rocinha and alemão favelas this includes an increase in rent values and imposed restrictions for community residents to circulate through the territory and has resulted in an increase in the sharing economy and people staying planning in favelas especially has numerous challenges and there are limits on what levels of controlling are possible as these communities often grow and are controlled organically this calls for more grassroots movements and policies that enable people to voice a decision while we cannot compare rio to places such as barcelona directly what we can learn is how local residents are responding to an influx of tourists into local areas that can have an impact on quality of life in some respects as seen in paris is new interactions are creating new economic opportunities however this results in a staging of culture and thus threatens authenticity and the lived realities that portray an authentic experience of seeing how the underprivileged livewhich is what the slum tourists seeks while we see comments about experiencing the real rio or brazil we need to question how does this threaten the local living environment shovals edited collection address how overtourism is threatening liveability and while tourism brings economic benefits are these at the disposal or commodification or local culture and those who reside there these are the questions that are pressing among tourism scholars but while we highlight these issues planners and policy makers struggle to control change and tourism expansions because there can be limitations on who gains and who does not tourism is increasingly becoming part of urban change narratives as communities struggle and individuals seek to earn new and supplemental incomes concerning the leisure and service industries there are two choices change and attempt to keep up with the pace of global demand or to resist change and stagnate wise and clark address this as creative change but as they argue creative does not necessarily imply a beneficial outcome for all concerned creative change can be perceived as tangible or conceptual however this can threaten the very authenticity of the community and the everyday living environment changing urban space and amenities can change perceptions of the area for local stakeholders visitors and most importantly for the people who live there in times of oftenrapid change sustaining community and social identities can be problematic

urban transformations help shape new opportunities and createrecreate awareness in everyday living environments it is not transformation in the infrastructural sense but transformation in the form of a service industry producing socioeconomic change that can result in inclusion and exclusion of people in the communitythus affecting the everyday living environment within this we need to consider the tourist gaze and how users who visittour vulnerable living environments report perceptions of their experiences on forums such as tripadvisor which helps researchers frame understandings of commodification opportunitiesawareness and even authenticity each addressed in this paper this paper evaluates tripadvisor posts of rios rocinha favela tour in many respects the notion of commodification and even authenticity runs through each theme but the analysis and data posted to tripadvisor challenges us to consider how a favela becomes a consumer product or a tourist attraction the rocinha favela tour is widely publicised to prospective visitors as a chance to experience a living and working favela given rocinha has become a popular attraction in rio this leads to the second theme opportunity or awareness opportunities do exist for people in the community to get involved in tourism and turning the favela into a product helps shape and maintain awareness the third theme builds on and relates to the previous two but focuses more on the semblances of authenticity that emerges to link the points highlighted in this paper a discussion of soft power concerns relationships bonded through economic and cultural influence because favelas have become distinct attractions it is cultural appeal and a different residential side of the city that persuades travellers to visit online and social media platforms for more than a decade now have played an important role today in projecting images and promoting authentic experiences based on userperceptions and this paper looks at how the users communicate their experiences

introduction topic models have become a common tool for unsupervised analysis of large text corpora mining a corpus for latent topics expressed as distributions over words while at the same time inferring how documents are distributed among these topics in essence a topic model decomposes the sparse worddocument matrix into a product of wordtopic and topicdocument matrices this idea was first fleshed out in probabilistic latent semantic analysis 15 and now the topic model of choice is latent dirichlet allocation which is a bayesian version of plsa with dirichlet priors assigned to wordtopic and topicdocument distributions 914 over the years lda has received tremendous attention with many extensions developed for many different purposes but each of them has been a separate research project with a new version of one of the two basic inference algorithms for lda either a variational approximation for the new posterior distribution or a new gibbs sampling scheme hence it is hardly practical to expect a researcher especially in social sciences to develop new lda extensions for each new problem even slight modifications of an existing extension may be hard both to develop and to implement in software hence we use a recently developed approach called additive regularization for topic modeling 31 and the corresponding opensource implementation bigartm 32 artm extends the basic plsa model with a general regularization mechanism that can directly express desired properties in the objective function and the inference algorithm results automatically as a special case artm with smoothing regularizers can mimic the lda model 34 although such regularization results in the same model stability as already noted for lda itself 2434 note that recent studies uncover deep problems with the basic lda model specifically its instability stemming from numerous local maxima of the objective function 11819 flexibility is a big advantage of artm in practice especially for digital humanities where one often has but a feeling of what one is looking for having trained a trial model in the form of regular lda or artm without regularizers a researcher can formulate what is lacking and what is desired of the resulting topic model in most cases bigartm lets a researcher combine regularizers from a builtin library in order to meet a set of requirements to the model quickly and efficiently to achieve all these results a social scientist has only to learn how to create regularizes and set their parameters this can be done easily by editing a few lines of code with no mathematical inference and no coding having trained a trial model in the form of regular lda or artm without regularizers a researcher can formulate what is lacking and what is desired of the resulting topic model the bigartm framework also lets one quickly develop and test new regularizers tailored specifically for ones problem in most cases bigartm lets a researcher combine regularizers from a builtin library in order to meet a set of requirements to the model quickly and efficiently in this work we show one such application of the artm approach for the problem of mining a large corpusstream of usergenerated texts for specific topics of discourse defined with a fixed dictionary of subject terms to achieve a good topic model we split the entire set of topics into subjectrelated and background topics develop a new regularizer that deals with this predefined dictionary of subject terms and build a combination of regularizers to make topics more interpretable sparse and diversified the artm framework lets us do all of these things seamlessly without complicated inference and developing new algorithms we present an extensive evaluation of our results concentrating on interpretability evaluation produced by a team of human assessors this is both needed in our case study and generally represents a gold standard for the quality of a topic model experimental results suggest that while the basic artm model is no better than regular lda new regularizers significantly improve both number and quality of relevant topics the paper is organized as follows in section 2 we introduce the basic plsa model its bayesian counterpart lda and the general setting of the artm approach in section 3 we review regularizers used in this work and comment on their effect on the resulting topic model section 4 lists the specific models we have trained and covers the results of our case study in finding ethnicrelated texts in a large dataset of blog posts section 5 concludes the paper a preliminary version of this work has appeared in the proceedings of the 15th mexican international conference on artificial intelligence 4 compared to the conference version we have conducted a novel study of topic modeling on a reduced collection filtered with respect to the top words of relevant topics and extended the survey part of the paper topic modeling and related work let d denote a finite set of documents and let w denote a finite set of all terms from these documents each term can represent a single word or a key phrase following the bag of words model we represent each document d from d as a subset of terms from the vocabulary w assume that each term occurrence in each document refers to some latent p t∈t p p t∈t φ wt θ td this mixture also directly corresponds to the generative process for a document d for each term position i sample topic index t i from distribution p and then sample the word w i from distribution p parameters of a probabilistic topic model are usually represented as matrices φ φ wt w ×t θ θ td t ×d with nonnegative and normalized columns φ t and θ d representing multinomial wordtopic and topicdocument distributions respectively plsa in probabilistic latent semantic analysis 1516 the topic model is trained by loglikelihood maximization with linear constraints of nonnegativity and normalization l d∈d w∈d n dw ln t∈t φ wt θ td → max φθ under constraints w∈w φ wt 1 φ wt ≥ 0 t∈t θ td 1 θ td ≥ 0 where n dw is the number of occurrences of the term w in the document d the solution of this optimization problem satisfies the following karushkuhntucker conditions with auxiliary variables p tdw n wt n td p tdw norm t∈t φ wt θ td φ wt norm w∈w θ td norm t∈t where n wt d∈d n dw p tdw n td w∈d n dw p tdw and the norm operator transforms a vector t∈t into t∈t representing a discrete distribution xt norm t∈t max x t 0 s∈t max x s 0 this system follows from and can be solved numerically the simpleiteration method for this system of equations is equivalent to the em algorithm and is typically used in practice it repeats two steps in a loop according to the equations above the estep can be understood as the bayes rule for the probability distribution of topics p tdw p for each term w in each document d auxiliary variable n wt estimates how many times the term w is associated with the topic t over all documents n td estimates how many terms from document d are associated with the topic t the mstep can be interpreted as frequency estimation for conditional probabilities φ wt and θ td the iterative process begins with a random initialization of φ and θ lda the latent dirichlet allocation model 914 introduces prior dirichlet distributions for the vectors of term probabilities in topics φ t ∼ dir as well as for the vectors of topic probabilities in documents θ d ∼ dir with vector parameters β w∈w and α t∈t correspondingly inference in lda is usually done via either variational approximations or gibbs sampling in the basic lda model with the latter reducing to the socalled collapsed gibbs sampling where θ and φ variables are integrated out and topic t i for each word position is iteratively resampled from p distribution estimated according to the same formula similar to plsa but with smoothed bayesian estimates of conditional probabilities φ wt norm w∈w θ td norm t∈t where n wt is the number of times term w has been generated from topic t and n td is the number of terms in document d generated from topic t except the current triple over the recent years the basic lda model has been subject to many extensions each presenting either a variational of a gibbs sampling algorithm for a model that extends lda to incorporate some additional information or presumed dependencies extensions that add new dependencies include correlated topic models that exploit the fact that some topics are more or less similar to each other and may share words with each other using logistic normal distribution instead of dirichlet to model correlations between topics 6 markov topic models use markov random fields to model the interactions between topics in different parts of the dataset connecting a number of different hyperparameters β i in a markov random field expressing prior constraints 20 relational topic models construct a hierarchical model reflecting the structure of a document network as a graph 11 and so on extensions that use additional external information include various timerelated extensions such as topics over time 36 or dynamic topic models 735 that apply when documents have timestamps and represent topic evolution in time supervised lda that assigns each document with an additional observed response variable 8 an approach that can be extended further to eg recommender systems 23 sentimentrelated extensions add sentiment variables to the basic topic model and train both topics and sentiment variables in various contexts 213038 and so on in particular a lot of work has been done on nonparametric lda variants based on dirichlet processes that can determine the optimal number of topics automatically 132837 for our present purpose of mining and analyzing documents related to a specific userdefined topic the lda extensions that appear to be most relevant are the topicinset knowledge model and its extension with dirichlet forest priors 2 3 where words are assigned with zlabels a zlabel represents the topic this specific word should fall into and the interval semisupervised lda model 1024 where specific words are assigned to specific topics and sampling distributions are projected onto that subset artm topic modeling can be viewed as a special case of matrix factorization where the problem is to find a lowrank approximation φθ of a given sparse matrix of termdocument occurrences note however that the product φθ is defined only up to a linear transformation since φθ for any nondegenerate matrix s therefore our problem is illposed and generally has an infinite set of solutions previous experiments on simulated data 34 and real social media data 10 show that neither plsa nor lda can ensure a stable solution to make the solution more appropriate one must introduce additional optimization criteria usually called regularizers 29 the dirichlet prior can be considered as a weak smoothing regularizer therefore our starting point will be the plsa model completely free of regularizers rather than the lda model although the latter is more popular in recent research works in additive regularization of topic models 31 a topic model is trained by maximizing a linear combination of the loglikelihood l and r regularizers r i i 1 r with regularization coefficients τ i mining ethnic content online with additively regularized topic models 391 restrictions necessary conditions for the local maximum 34 r r i1 τ i r i l r → max p tdw norm t∈t φ wt θ td φ wt norm w∈w n wt φ wt ∂r ∂φ wt θ td norm t∈t n td θ td ∂r ∂θ td where n wt d∈d n dw p tdw and n td w∈d n dw p tdw again this system of equations can be solved with the em algorithm the strength of artm is that each additive regularization term r i yields a simple additive modification of the mstep many models previously developed within the bayesian framework can be easier reinterpreted trained and combined in the artm framework 3334 eg plsa does not use regularization at all r 0 and lda with dirichlet priors φ t ∼ dir and θ d ∼ dir and maximum a posteriori estimation of φ θ corresponds to the smoothing regularizer 5 the regularizer can be interpreted as a minimizer of kldivergences between the columns of φ θ and fixed distributions β α respectively additive regularization general approach in this section we consider an exploratory search problem of discovering all ethnicrelated topics in a large corpus of blog posts given a set of ethnonyms as a query q ⊂ w we would like to get a list of ethnically relevant topics we use a semisupervised topic model with lexical prior to solve this problem similar models have appeared for news clustering tasks 17 discovering health topics in social media 25 and ethnicrelated topics in blog posts 1024 in all these studies researchers specify for each predefined topic a certain set of seed words usually very small eg a news category or ethnicity this means that we must know in advance how many topics we would like to find and what each topic should be generally about the interval semisupervised lda model allows to specify more than one topic per ethnicity 10 but it is difficult to guess how many topics are associated with each ethnicity and if an expert does not anticipate a certain subset of seed words it will be impossible to learn in the model moreover and in 1024 where the case study was similar to our present work islda was used to look for ethnicrelated topics but since seed words related to different ethnicities were separated into different topics so no multiethnic topics could appear in our present approach the topic model has more freedom to decide the composition of subject topics in s moreover all cases above include a large amount of preliminary work involved in associating seed words with predefined topics we address the above problems by providing a lexical prior determined by a set of ethnonyms q common for all ethnically relevant topics the model itself determines which ethnicity or combination of ethnicities make up each relevant topic we use an additive combination of regularizers for smoothing sparsing and decorrelation in order to make topics more interpretable sparse and diversified 34 the artm framework lets us do all of these things seamlessly without complicated inference and developing new algorithms all these regularizers have been implemented as part of the bigartm opensource topic modeling toolbox we show that the combination of regularizers significantly increases the number of retrieved wellinterpretable ethnical topics first of all we split the entire set of topics t into two subsets domainspecific subject topics s and background topics b regularizers will treat s and b differently the relative size of s and b depends on the domain and has to be set in advance by the user the idea of background topics that gather uninteresting words goes back to the special words with background topic model 12 but unlike swb we define not one but many background topics in order to model irrelevant nonethnicrelated topics better thereby improving the overall quality of the model smoothing and sparsing a straightforward way to integrate lexical priors is to use smoothing and sparsing regularizers with uniform β distribution restricted to a set of ethnonyms q β w 1 q w ∈ q we introduce a smoothing regularizer that encourages ethnonyms w ∈ q to appear in ethnicrelated topics s together with a sparsing regularizer that prevents ethnonyms from appearing in background topics b r τ 1 t∈s w∈q ln φ wt τ 2 t∈b w∈q ln φ wt in the exploratory search task relevant content usually constitutes a very small part of the collection in our case the entire ethnicity discourse in a large dataset of blog posts is unlikely to add up to more than one percent of the total volume our goal is to mine finegrained thematic structure of relevant content with many small but diverse and interpretable subject topics s but also to describe a much larger volume of content with a smaller number of background topics b formally we introduce a smoothing regularizer for background topics b in θ and a sparsing regularizer that uniformly supresses ethnicrelated topics s r τ 3 d∈d t∈b ln θ td τ 4 d∈d t∈s ln θ td the idea is to make background topics b smooth so that they will contain irrelevant words and subject topics s sparse so that they will be as distinct as possible with each topic concentrating on a different and meaningful subject decorrelation diversifying the term distributions of topics is known to make the resulting topics more interpretable 27 in order to make the topics as different as possible we introduce a regularizer that minimizes the sum of covariances between φ t vectors over all specific topics t r τ 5 t∈s s∈st w∈w φ wt φ ws τ 6 t∈b w∈w ln φ wt the decorrelation regularizer also stimulates sparsity and tends to group stopwords and common words into separate topics 27 to move these topics from s to b we add a second regularizer that uniformly smoothes background topics modality of seed words another possible way to use lexical priors is to distinguish ethnonyms into a separate modality generally modality is a kind of tokens in a document examples of modalities include a separate class of tokens each modality has its own vocabulary and its own φ matrix normalized independently a multimodal extension of artm has been proposed in 32 and implemented in bigartm we introduce two modalities words and ethnonyms the latter is defined by a seed vocabulary q and matrix φ of size q × t in artm the loglikelihood of a modality is treated as a regularizer r τ 7 d∈d w∈q n dw ln t∈t φwt θ td where regularization coefficient τ 7 is in fact a multiplier for worddocument counters n dw of the second modality in order to make ethnicrelated topics more diverse in their ethnonyms we introduce an additional decorrelation regularizer for the modality of ethnonyms r τ 8 t∈s s∈st w∈q φwt φws note that we introduce decorrelation for subject topics s separately for words modality with φ matrix and for ethnonyms modality with φ matrix mining ethnic content online with additively regularized topic models 393 putting it all together the bigartm library 1 lets users build topic models for various applications simply by choosing a suitable combination of predefined regularizers all of the regularizers listed above can be used in any combination by using different mixtures one can achieve different properties for the resulting topic model in one of the models we combined all regularizers described above note that while the resulting models have relatively many hyperparameters and optimal tuning of them may incur prohibitive computational costs in practice it suffices to set the hyperparameters to some reasonable values found in previous experiments in all results shown below hyperparameters were tuned with a greedy procedure one by one evaluation datasets and settings from the sociological point of view the goal of our project is to mine and monitor ethnicrelated discourse in social networks eg find how popular topics are related to various ethnic groups perhaps in specific regions and identify worrying rising trends that might lead to ethnicrelated outbursts or violence while multimodal analysis that would account for topic evolution in time and their geospatial distribution remains a subject for further work we evaluate our models on a real life dataset mined from the most popular russian blog platform livejournal the dataset contains ≈ 158 million lemmatized posts from the top 2000 livejournal bloggers embracing an entire year from mid2013 to mid2014 data were mined weekly according to the livejournals rating that was quite volatile which is why the number of bloggers in the collection comprized several dozens of thousands the complete vocabulary amounted to 860k words but after preprocessing it was reduced to 90k words in ≈ 138 million nonempty documents to choose the number of topics we have trained plsa models with 100 300 and 400 topics evaluated that the best result was at 400 topics and hence chose to use 400 topics in all experiments this corresponds to our earlier experiments with the number of topics in relation to mining ethnic discourse 1024 the collection was divided into batches of 10000 documents each all artmbased models were trained by an online algorithm with a single pass over the collection and 25 passes over each document updates are made after processing every batch for the semisupervised regularizer we have composed a set of several hundreds ethnonyms nouns denoting various ethnic groups based on literature review russian census and un data expert advice and other sources 249 of those words occurred in the collection ethnonyms were considered the best candidates for improving mining topics that correspond to the sociological notion of ethnicity and interethnic relations the latter are understood as interpersonal or intergroup interactions and attitudes caused or justified by the ethnic status of participants they should be differentiated from international relations where the main actors are countries including nationstates and their governments or individual official representatives and the subject is not always related to the ethnic status of individuals or groups international and interethnic relations are closely connected and in some situations inseparable however intuitively it is clear that for preventing internal ethnic conflict monitoring attitudes to migrants expressed by bloggers is more relevant than mining news on world summits or international trade treaties we therefore assumed that topics on ethnicity per se should be dominated by ethnonyms while ethnic adjectives and country names would more probably refer to international relations in the russian language these three categories are almost always different words which in our mind could contribute to easier differentiation between topics on ethnicity and on international relations models in our bigartm experiments we have trained a series of topic models in all models with hyperparameters we have tuned these hyperparameters to obtain the best models available for a specific model with a greedy procedure start from reasonable default values optimize the first parameter fix it and optimize the second parameter and so on in total we have evaluated eight models with t 400 topics each for all models we have chosen regularization coefficients manually based on the results of several test experiments in all additively regularized models with lexical priors we divided topics into s 250 subject topics and b 150 background topics next we list the different models compared in the experiments below and provide the motivation behind introducing and comparing these specific topics plsa reference plsa model with no regularizers lda lda model implemented in bigartm with smoothness regularizers on φ and θ with uniform α and β and hyperparameters α 0 β 0 10 4 smooth artmbased model with smoothing and sparsing by the lexical prior with regularization coefficients τ 1 10 5 and τ 2 100 besides in this and all subsequent regularized models we used the smoothing regularizer for the θ matrix with coefficients τ 3 005 and τ 4 1 decorrelated artmbased model that extends with decorrelation with coefficients τ 5 5 × 10 4 and τ 6 10 8 the smoothing coefficient for ethnically relevant subject topics was τ 1 10 6 restricted dictionary artmbased model that extends by adding a modality of ethnonyms with coefficients τ 7 100 and τ 8 2 × 10 4 the decorrelation coefficients was τ 5 15 × 10 6 and τ 6 10 7 subject words were smoothed with coefficient τ 1 11 × 10 4 for this model we used a dictionary with q 249 ethnonyms extended dictionary same as but with dictionary extended by adjectives and country names if respective ethnonyms did not occur the positive outcome here would be that more relevant topics can be found with an extended dictionary while the negative outcome is that ethnic topics could instead get lost within topics on international relations recursive the basic plsa model trained on a special subset of documents namely documents retrieved from topics that were considered ethnicrelevant by assessors in model 5 with a threshold of 10 6 in the θ matrix for all subject topics here the hypothesis was that a collection with a higher concentration of relevant documents could yield better topics keyword documents plsa model identical to but trained on a subset of only those documents that contained at least one word from the dictionary models 7 and 8 were introduced to test two different ways of enriching the initial collection model 8 was used as reference for model 7 it was to check if enriching the collection through a preliminary cycle of topic modeling would yield better results than retrieving texts via a simple keyword search figure 1 shows several sample topics from some of the models it appears that later models 6 and 7 yield topics that are better suited for the ethnic purpose of our study in what follows we will expand and quantify this observation assessment in the rest of this section we discuss the qualitative and quantitative results of our study starting from the assessment methodology and then discussing the results of our human coding experiments however results coming from the assessors were supplemented with values of the tfidf coherence quality metric introduced earlier in 1024 it has been shown that tfidf coherence better matches the human judgment of topic quality than the traditional coherence metric 22 results on average coherence and tfidf coherence for all topics in every model are shown in table 2 we show two versions of coherencebased metrics computed with top 10 words in a topic and computed with top 20 words the distributions of all four metrics are also shown in more detail on fig 1 which shows the sorted metrics for each model so a graph that goes above the other represents the better model table 2 and fig 1 show that while models 5 and 6 win in all four cases all models have comparable values with respect to the topic quality metrics except for models 3 and 4 this was supported by preliminary human evaluation so we decided to drop these two sets of results from further consideration choosing to use limited human assessment resources on the better models for all other models assessors were asked to interpret the topics based on 20 most probable words in every topic of each model except models 3 and 4 that demonstrated much lower quality as measured with coherence and tfidf coherence 24 and thus were excluded from assessment for each topic two assessors answered the following questions related both to the overall quality and to the ethnic nature of our study do you understand why these words are collected together in this topic absolutely not partially yes if you answered partially or yes to question 1 do you understand which event or phenomenon can be discussed in texts related to this topic absolutely not partially yes is there an ethnonym among the topwords of this topic specify the total number of ethnonyms if you answered partially or yes to question 2 is this event or phenomenon related to ethnic issues not at all partially or unclear yes if you answered partially or yes to question 2 is this event or phenomenon related to international relations not at all partially or unclear yes if you answered partially or yes to question 2 is this event or phenomenon related to some other category of topics not related to ethnicity not at all partially or unclear yes assessors were clearly instructed on all matters including the differences between ethnicity and international relations we have asked assessors about both of these issues because from our previous experience with semisupervised approaches 1024 we know that the international relations topics are often retrieved instead of ethnicrelated topics or tend to blend with them this ultimately produces high probabilities for documents devoted to global political conflictsrelations or just travel abroad and fails to bring up texts related to internal ethnic conflict everyday interethnic communication including hate speech or national policies on ethnicity issues everything that was considered important in this case study we therefore wanted to discriminate between the algorithms good at retrieving international relations topics and those able to retrieve exactly what we want ethnic discourse we have collected the answers of seven assessors table 3 summarizes total intercoder agreement values showing the share of differing answers for every question in general these results show good convergence between the assessors on the level of our previous experiments with similar evaluation 26 when the assessors disagreed in assigning a topic to a category rather than averaging their results we produced two sets of scores in the first set we assigned each topic a maximum from the assessors scores in the second set we did the opposite that is assigned a topic the minimal score we thus obtained the upper and the lower bounds of the human judgment and compared the models for every model table 4 also shows the average tfidf coherence metric note that although our results match previous experiments regarding the comparison between coherence and tfidf coherence well still in this study human judgments correlate with tfidf coherence only at the level of approximately 05 so there is still a long way ahead to develop better quality measures since the models we test here all attempt to extract a certain number of highquality topics while filtering out trash topics into a specially created ghetto it makes little sense to compare the models by the overall quality of all topics it is much more important to look at the coherence of those topics that were found either good or relevant by the assessors relevance and coherence scores table 4 summarizes the most important results on quality understood as interpretability and its relation to tfidf coherence in this table partially interpretable topics are those that were scored 1 by at least one of the assessors answering question 2 highly interpretable are those that were scored 2 respectively the two leaders are models 5 and 6 we can see in table 4 that model 6 outperforms all the rest by the overall quality that is by coherence and tfidf coherence calculated over all topics model 5 does produce higher values of coherences and tfidf coherences in the groups of interpretable topics but note that the number of interpretable topics is lower this means that model 5 finds fewer topics but the topics it finds are on average better table 5 summarizes our most important findings regarding how relevant the topics are to our goal partially relevant topics are those that were scored 1 by at least one of the assessors answering questions 5 and 6 highly relevant are respectively those that were scored 2 by at least one assessor all relevant topics in table 5 include topics that are either partially or highly relevant to either ethnicity or international relations average interpretability was calculated as the mean evaluation scores given to the respective topics by assessors answering question 2 here we again see the same two leaders models 5 and 6 and the former outperforms the latter in terms of tfidf coherence of relevant topics while the latter outperforms the former in terms of the number of topics considered relevant by the assessors this is true both for ethnic and international relations topics and for both levels of relevance this means that our extension of the seed dictionary brings more topics found by assessors both generally interpretable and relevant to both international relations and ethnicity although average coherence of these topics becomes somewhat lower ethnic topics thus do not get substituted by or lost among topics on international relations table 6 shows humanevaluated interpretability of the topics it shows the average score given by the assessors to topics from each subset and for the two general questions eg the top left corner shows that on average assessors scored 180 on question 1 for topics that are highly relevant to ethnic issues note that interestingly now model 6 outperforms model 5 in terms of interpretability according to this measure in model 6 relevant topics are not only more numerous but also slightly more interpretable than in model 5 however fewer of them are clearly related to specific events for sociologists a larger number of relevant topics is an advantage since they are not very numerous anyway and can be doublechecked for relevance and interpretability manually while had they been filtered out automatically they may never be brought to the experts attention so model 6 looks preferable at the same time the dictionary of model 6 has been situational it substituted the missing ethnonyms with adjectives and country names while the ethnic groups whose ethnonyms were present in the collection were not supplemented by adjectives or country names this principle of dictionary construction means that different adjectives and country names should be excluded each time even if some of them are present in the collection it also may have lead to some overfitting in our best model to make this model more practical and the quality assessment more reliable in the future we suggest to rerun it with the full dictionary of ethnonyms adjectives and country names that will be made universal interesting results are produced by models 7 and 8 by evaluating both the number of relevant topics and coherence the recursive model looks similar to model 5 with restricted dictionary keywordbased model is similar to model 6 it thus means that reiteration of topic modeling on a subset of texts extracted during the first iteration does not bring improvement or even brings deterioration and therefore is excessive and useless in terms of numerical results singleiteration modeling on a collection selected by keyword produces the results similar to or not dramatically worse than the best model but the sets of ethnicityrelated topics found by these two approaches are significantly different so to get the best possible coverage one should probably use a combination of these techniques one possible direction for further work prefiltering and twostage topic modeling in the final series of computational experiments we tested a natural extension of the ideas expressed in previous models to filter the original collection with respect to the resulting subject topics and try topic modeling again to test this idea we have chosen documents from the original collection that contained top words from subject topics discovered on the previous step then the much reduced collection was again subject to topic modeling in this experiment we have compared several variations of artm models the reduced collection contained approximately 320k documents with the same set of ethnonyms as the large models the reduced collection has allowed us to perform a largescale comparison of artm models with different parameters in the paper we show a sample of nine models with characteristic parameters that may result in different behaviour table 7 shows their parameters note that model 9 has the same parameters as model 8 but has been trained for three epochs over the entire dataset compared to a single pass in model 8 to make the results comparable with full models we have trained all models with the same number of topics 250 subject topics and 150 general topics and computed coherence scores on the entire dataset rather than the reduced one table 8 shows coherence results for new models the top nine rows show average coherence scores for all topics and can be directly compared with table 2 we see that the best secondstage models models 4 and 5 have better coherence scores than the best firststage models from table 2 comparing models 8 and 9 we also see that additional passes over the corpus do indeed improve the topics but only very slightly so in case of a large corpus when it is costly to double or triple the training time one pass should be sufficient table 8 also provides separate average estimates for coherences and tfidf coherences of subject and background topics note an interesting effect background topics have consistently better scores than subject topics across all models this is due mainly to the fact that we have chosen a far larger number of ethnic topics than necessary since we need to make sure all ethnic topics are captured by the model and a false positive is not a problem we show some sample topics from one of the best second stage models in table 9 while ethnic topics do indeed have plenty of good ethnicor nationalityrelated topics they also have a lot of uninterpretable junk topics at the same time background topics are not ethnicrelated but are indeed more coherent on average conclusion in this work we have shown that additive regularization of topic models can provide social scientists with an effective tool for mining specific topics in large collections of usergenerated content our best model has outperformed basic lda both in terms of the number of relevant topics found and in terms of their quality as it was found in experiments with topics related to ethnicity what is especially important for digital humanities additive regularization allows one to easily construct nontrivial extensions of topic models without mathematical research or software development by combining builtin regularizers from the bigartm library one can get topic models with desired properties in this work we have combined eight regularizers and constructed a topic model for exploratory search that can take a long list of keywords as a query and output a set of topics that encompass the entire relevant content this model can be used to explore narrow subject domains in large text collections in general this study shows that artm provides unprecedented flexibility in constructing topic models with given properties outperforms existing lda implementations in terms of training speed and provides more control over the resulting topics both specific regularizers introduced here and the general artm approach can be used in further topical studies of text corpora concentrating on different subjects andor desired properties of the topics however further experiments are needed to make our comparisons more precise first it would be interesting to compare our best model with semisupervised noninterval lda where instead of ascribing small bunches of words to multiple small ranges of topics the entire dictionary would be ascribed to a large range of topics second as has been mentioned above it would be interesting to experiment with the universal dictionary of ethnonyms adjectives and country names finally the results should be tested for stability via multiple runs of each model stability of topic models is an interesting problem in its own right 18 in general semisupervised learning approaches exhibit a good potential for mining not only ethnicityrelated topics but also other types of specific topics of which the endusers may have incomplete prior knowledge

social studies of the internet have adopted largescale text mining for unsupervised discovery of topics related to specific subjects a recently developed approach to topic modeling additive regularization of topic models artm provides fast inference and more control over the topics with a wide variety of possible regularizers than developing lda extensions we apply artm to mining ethnicrelated content from russianlanguage blogosphere introduce a new combined regularizer and compare models derived from artm with lda we show with human evaluations that artm is better for mining topics on specific subjects finding more relevant topics of higher or comparable quality

introduction the conventional approach of defining immigration the intensity of immigration is generally repeated to be very low in india the two major sources of data on immigration in india the census and the national sample survey cover only permanent or semipermanent immigration with seasonal immigration partly over lapping with the category of short duration immigration 10 however immigration adopted in the census and the nss do not consider long term immigrants without changing the place of residence as migrant as a result the coverage of these report show declining trends of out migration over the years 7 contrary to this the national commission on rural labour 9 finds increasing trends of seasonal and temporary migration over the years besides this many of the micro studies dealing with the issue of migration in the theoretical context as well report much higher incidence of out migration particularly in the case of under developed regions besides there is a considerable change in the nature and cause of migration in recent years proportionately more migration is taking place among the labour force in search of their livelihoods which is mainly for relatively longer terms besides this one of the general objectives of this study is to examine the socioeconomic factors behind labour immigration from rural areas of rajasthan and its impact on the individual migrants their families and also on the village society and economy as a whole considering the importance of human intervention to avoid over concentration of population in some nodal centres and urbanward migration and its related issues becomes an important theme to probe urbanward migration is a response to the change taking place in the spacial economic system the major issues that emerge are can migration be independent of socioeconomic and political structure if not why does geographical homogeneity manifests into similar mobility patterns does migration helps in generating functional regions through change in the space content and space relations if so what are the possible changes in space content and space relations that induce migration and influenced by migration processes to answer such issues the relevance of rural to urban migration becomes more pertinent rather than studying rural to rural migration which is oriented more towards development of kinship system the urban to rural migration is very weak in india the urban to urban migration reflects the various steps in the migration process and is governed more by economic process rather than social thus the two components rural to urban and urban to urban constitute the universe of migration rajasthan is the largest state in the country its geographical area is 342 lacs sq km and it is situated in the northwestern part of the country which is surrounded by the state of punjab haryana and uttar pradesh in the northeast madhya pradesh in the southeast and gujarat in the southwest the state has a long international border with pakistan human settlement in the state is scattered low density of population vast area and segmented pattern of human settlement are some of the constraints adversely affecting the development of the states economy rajasthan with its meager water resources and perilous dependence on scanty low and uncertain rainfall is most vulnerable to drought and famine conditions agriculture plays a vital role in the economic development of the state and continues to be back bone of the economy as state is predominantly agrarian where 75 of the population is living in rural areas and about 70 depends upon agriculture and allied activities the agriculture scenario in the state is characterized by its dependence on the monsoon which is highly inadequate and erratic in nature at present less than one fourth of the agricultural area in the state is under irrigation due to low agricultural productivity and heavy population growth in rural area problem like poverty malnutrition inadequate employment arises so in order to earn livelihood people from rural area move from one place to another in search of work statement of the problem the study of such above discussed special mobility may be helpful in highlighting some of the unexplored and changing relationship so the purpose of present study was to find out socioeconomic aspects of rural migration in rajasthan hypothesis discussions in the various studies on internal migration highlights the following hypothesis is to be tested in the course of present study 1 there shall be high incidence of out migration from the low agricultural developed region male selectivly increases in rural to urban migration stream with increasing distances 3 there is higher intensity of migration from the village attached to district headquarters 4 the varying class of rural area shall have significantly different types of migration however lower class migration shall be from rural to rural and upper class migration shall be from rural to urban 5 the socioeconomic and demographic characteristics differ significantly between migrants and nonmigrants 6 the asset position of household effect the intensity of migration among the households where asset position is better the tendency to migrate will be less 7 poor employment opportunities at the native place and expectations to get more remunerative employment at destination will keep the migrants workers tied to the place of destination 8 upper caste youth shall be migrating in large numbers objective of the study is 1 to know who migrate and why migration 2 to identify the patterns of migration to cities from rural areas of rajasthan during 3 to examine the socioeconomic factors behind rural migration 4 to find consequences of migration on family village and economy as a whole 5 to know the changing nature and magnitude of migration and to establish the relationship between structural changes in the economy of states and resulting pattern of population mobility toward urban areas 6 to find that the low economic development in general and inequality in the development of the villages and adjoining areas are the most important reasons of high incidence of migration 7 to identify the urbanward migration regions on the basis of various characteristics of migrants significance of the study the significance of the study is that through this research socioeconomic aspect of rural migration in the rajasthan can be known which will help in understanding who migrates why migration change in pattern and intensity of migration what are the reason behind these changes adverse affect of migration on the development of the rural economy this study will help in adopting such measures as will help in transformation of rural economy which is a step higher than development which is a step above growth both the quantities and qualitative aspect will be taken into account for transformation of the rural areas it will also suggest what policy should be followed by government institutions ngos or other big business houses for the rural development which may help in reversing the migration delimitation 1 study was delimited to northern region of india ie rajasthan 2 study was confined only to rural folk 3 married female migration were not be taken into account for the purpose of the study 4 the study was based on secondary datas though every care will be taken to include the results from the studies that had utilized primary data study was undertaken only in 2 district of northern rajasthan which are developed from agricultural point of view 6 in the present study only out migration of rural people was taken into account there is an increase in urban to urban migration rate for short and medium distances the inter state migration has slowed down the interstate inequality in various socioeconomic dimensions of development is noted to be on the rise the decreasing mobility of both rural and urban population poses the major challenge for the development strategy being followed in india the review of the available studies indicates several gaps which have not either filled or left unnoticed and hardly any work on such gaps is worth mentioning the economy of rajasthan is termed as under developed backward the study of migration patterns in an out migrating state will help in generating the literature on migration at macro level for core out migrating regions review of literature methodology the purpose of the study is to examine the socioeconomic aspect of rural migration in northern rajasthan the present study is entirely based on the data available in various secondary sources the secondary data were obtained from records books and reports of the various committees and commissions appointed at the central and state level statistical data were helpful in enumeration of various facts for the purpose of analysis and interpretation of data manual processing was done present study was empirical exercise which revolves around the inductive approach of scientific enquiry the inductive approach defines its path from particular to general the data were collected processed tabulated and analysed to establish certain existing unknown relationships on urbanward migration in the selected regions so far how far such interrelations were nearer to reality and superior to each other is a separate debate an attempt here was to interpret the results close to progressive ideology so in order to properly understand the problem and to arrive at certain conclusion investigator has decided to choose northern rajasthan the northern rajasthan is agriculturally more developed as compared to the other region of the state from the northern region 2 districts were chosen according to their development from agriculture per capita income education point of view and from each district villages were chosen on the following basis  the one which has highest population  the one which has the lowest population  the village attached to the district head quarters the study was arranged in five sections after presenting introduction in the first section the second section deal with the socioeconomic background of the study area in general and of the migrants and nonmigrants in particular the section is based on the census survey conducted in the villages of the 2 districts of rajasthan and briefly present an account of socioeconomic factors responsible for out migration in the third section changing nature and magnitude of migration presented in the fourth section other details of the current migration and likely impact of out migration on the household studied and in the last section major conclusions and policy recommendation presented conclusions it was found that the pattern and intensity of rural out migration mainly depends on the agriculture production in the region male dominantly migrating from rural to urban it was proved that there is higher intensity of migration from the village attached to district headquarters the proportion of daily migrants as compared to other migrants is greater ie shorter the distance more the daily migrants the one set of migrants migrates to specific areas and other is different which are subjected to move under the structural compulsions the mobile population is more sensitive to economic opportunities and tries to acquire more knowledge and skill to compete with nonmigrants the asset of household effect the intensity of migration among the households where asset position is better the tendency to migrate is less the most prone to migration household is those whose head of the households are either nonagricultural labourer or are involved in some private service poor employment opportunities at the native place and expectations to get more remunerative employment is the main reason of migration upper caste youth is migrating in large numbers to far distance urban area to get the better employment upper caste people do not do any manual wage work in their villages because of caste taboos in case of lower caste also migrating for better opportunities the education has filled the gap of caste and migration is largly for the better employment and high income group also migrating toward urban area for better facilities education and services the migration largely effecting there social structure and also emotional needs

human settlement in the rajasthan state is scattered low density of population vast area and segmented pattern of human settlement are some of the constraints adversely affecting the development of the states economy due to low agricultural productivity and heavy population growth in rural area problem like poverty malnutrition inadequate employment arises so in order to earn livelihood people from rural area move from one place to another in search of work the study may be helpful in highlighting some of the unexplored and changing relationship so the purpose of present study was to find out socioeconomic aspects of rural migration in rajasthan the northern rajasthan is agriculturally more developed as compared to the other region of the state from the northern region 2 districts were chosen the study is based on the census survey conducted in the villages of the 2 districts of rajasthan and briefly present an account of socioeconomic factors responsible for out migration it was proved that there is higher intensity of migration from the village attached to district headquarters the proportion of daily migrants as compared to other migrants is greater ie shorter the distance more the daily migrants the asset of household effect the intensity of migration among the households where asset position is better the tendency to migrate is less poor employment opportunities at the native place and expectations to get more remunerative employment is the main reason of migration upper caste youth is migrating in large numbers to far distance urban area to get the better employment the high income group also migrating toward urban area for better facilities education and services the migration largely effecting there social structure and also emotional needs

researching the study objective pubmed and cinhal was searched using keywords on data science techniques and ltc the screeningand selection process was carried out by two authors and not limited by research design or publication date a narrative synthesis was conducted based on the two aims the search strategy yielded 1277 studies 18 were included machine learning modelsalgorithms were the most used techniques and were primarily used for researching specific adverse outcomes including the identification of risk factors for falls and the prediction of frailty this review reveals the limited use of data science techniques on data from ltc facilities the low number of articles indicates the need for strategies aimed at the effective utilization of data science techniques and evidence of their practical benefits there is a need for a wider adoption of these techniques in order to exploit data to their full potential and improve the quality of care in ltc by making datainformed decisions to evaluate populationlevel evidence for and strength of an association of lbp with lss in older adults data source medicare part b carrier and outpatient claims data 5 standard analytical file for 2017 methods unadjusted and adjusted analysis of crosssectional data combined with condition process analysis results several hundred thousand older adults met criteria for inclusion in this study lumbar spinal stenosis was common in both older adult males and females but slightly more commonly diagnosed in females low back pain was prevalent in older adults but more so in females a majority of older adults with lss were diagnosed with lbp unadjusted and adjusted analyses demonstrated that lbp was present at increased rates in older adults with lss conclusions low back pain is diagnosed in the majority of older adults diagnosed with lumbar spinal stenosis it is important to recognize that the symptom profile of older adults with spinal stenosis includes low back pain and treatment should be adjusted to respond to this management need

evidence suggests that goal setting and care partner support help aging adults improve their health less is known about how aging adults and care partners collaboratively participate in goal setting the purpose of the current review was to describe the scope of the literature on this topic a search was conducted in pubmed cinahl socindex and pscyinfo reviewers screened 1231 articles for the following inclusion criteria 1 participants included aging adults 50 years and care partners 2 goal setting was conducted and 3 articles were in english of the twentynine articles that were included most n21 assessed goal setting for care partners and aging adults separately goal setting was primarily directed toward patient care with only a few studies prompting care partner specific goals n4 common goals reported by aging adults were independence improving or maintaining functioning addressing symptoms and remaining socially active care partners listed similar goals but also identified accessing services and supports as important this review is the first to describe goal setting with aging adults and their care partners revealing concordant and discordant prioritization of goals within dyads these findings illustrate the importance and potential complexity of including care partners in the goal setting process we also found that collaborative goal setting and care partner directed goals are scarce indicating the need for additional work in this area collaborative goal setting aligns with patient and familycentered care approaches and can contribute to better care plans that meet the needs of aging adults and their care partners

first let me backtrack for a moment and try to articulate what is meant by research culture what is a research culture according to one definition research culture encompasses the behaviours values expectations attitudes and norms of our research communities it influences researchers career paths and determines the way that research is conducted communicated and used for social development a research culture is a culture that looks towards new knowledge and new research for addressing problems identified by the research community industry social activists the policy makers and the public at large also it incorporates a tradition of interrogating existing knowledge and exploring alternative ways of understanding issues from different perspectives i see this as a key feature of liberal arts education and the social science mindset that should guide knowledge production and application of the knowledge so produced for addressing human problems knowledge production in the global periphery knowledge production in the contemporary world is by and large determined by inequalities in knowledge production originating from the colonial era for instance an article on research culture in the caribbean universities stated the following we contend that research culture in the caribbean comes up against the strictures of postcolonial dependence university education in the region being largely a oneway traffic of ideas from metropolitan centers to island peripheries the structural inequality in scientific knowledge production in the contemporary world and the resulting dependency syndrome in knowledge production are increasingly recognized as key challenges all sciences are facing this should however not be seen as a deterrent for developing a research culture in countries in the global south on the contrary a proactive research culture is one way in which researchers in the global south can collectively seek to redirect and reorient as an analytical framework grounded in the global south the postcolonial turn in social analysis is just one such effort to critically engage with social analysis from the viewpoint of global south subaltern perspective emanating from india is a specific application of postcolonial theory with its own research culture tied up with indian social reality its specific aim is to liberate social analysis from coloniality grounded in metropolitan interests june 2023 sri lanka journal of social sciences 46 a brief overview of the evolution of social sciences in sri lanka sri lanka is one of the earliest asian countries to introduce social sciences after india and the philippines this indicates that not only there are many higher education institutions engaged in social science teaching but there is also a diversity of organizations engaged in social science research on a regular basis gaps in research culture in social science practice in sri lanka a proactive social science research culture encompassing these different institutions is yet to be evolved this is reflected in a number of deficiencies in knowledge production in relation to social issues affecting the country first there is no open discussion about pressing social issues affecting the country from a diversity of viewpoints for instance the current economic crisis affecting the country is approached by different analysts using a strictly neoliberal angle a political economy perspective and dependency theory however there is no debate among them or an adequate questioning of these perspectives to provide a balanced analysis that can guide policy makers second the research process is by and large handled by established individual researchers rather than groups of researchers with a common understanding of the issues at hand also ensuring continuity of research when the lead researcher retires or takes on some other responsibilities one empirical indicator of this is that many of the publications are single authored unlike in natural sciences where the pattern is different and many of the publications are authored by many contributors there are however some signs that this pattern is changing for instance in the current issue of sri lanka journal of social sciences the number of multiauthored articles is 6 as compared to 2 single authored articles third cross cutting research networks actively engaged on vital issues like gender environment social inequality urbanization demographic trends migration and identity politics are largely nonexistent or nonactive for the most part sri lanka journal of social sciences 46 june 2023 fourth there is inadequate interaction between research and policy development in sri lanka in an ideal setting research should inform policy formulation and policy dialogue should generate new ideas for research on the contrary policy formulation and social science research have tended to ignore each other in ways that is harmful to each other and created a hiatus between the process of economic and social development and knowledge production in the country fifth as a longestablished social science journal sri lanka journal of social sciences experience many difficulties in identifying reviewers getting manuscript reviews on time and a shortage of quality submissions from within sri lanka on a regular basis this is despite the substantial expansion of social science higher education in the country as reported earlier in this editorial while the real problems the academic community is encountering in the light of the current economic crisis may be partly responsible for this situation this also indicates the fact that the absence of a satisfactory research culture where society as a whole is eagerly waiting for new knowledge and the application of limited social science knowledge available is largely absent in sri lanka at present more importantly neither the researchers nor the policy makers consider it necessary to consult each other and develop a feedback mechanism whereby research can contribute to practice and viceversa this is an ultimate indicator of an absence of a proactive research culture in social sciences in sri lanka

this editorial points to the need for developing a positive research culture for advancing social science research in sri lanka this is not to say that a positive attitude towards research is absent among social scientists and the scientific community in general in sri lanka on the contrary there is an emerging recognition that social science inputs are necessary for tackling the various challenging problems facing the country today however what is lacking is a firm faith in building a local social science knowledge base for exploring various approaches for understanding critical issues facing the country constant debates about relevant issues and a critical engagement with the social economic and political environment in which we find ourselves this is what i call a proactive research culture where we constantly turn to new research for generating new knowledge and finding answers to serious problems affecting the current and future generations

introduction the high burden of obesity among adults in countries like the united states and australia poses daunting costs associated with cardiometabolic diseases like type 2 diabetes mellitus 1 2 3 4 5 though management of some cardiometabolic diseases can be effective 6 preventionespecially of obesity as a key determinantought to be the imperative for health policy a recent us report highlighted the need for better evidence on potential obesogenic risk factors operating at the neighborhood scale 7 despite many scientific investigations published in this area 8 the identification of neighborhood effects is well known to have many methodological challenges partially due to the reliance upon crosssectional data 9 a key strength of using longitudinal data is that change in body mass index among participants living in more socioeconomically advantaged compared with disadvantaged neighborhoods can be potentially analyzed however not many longitudinal studies have been conducted in this regard and those which have report mixed findings 10 11 12 13 some have shown differential increases in bmi among participants living in more disadvantaged neighborhoods 1011 but others found no statistical evidence for this association 1213 moreover we are aware of no study that has examined trajectories in bmi as people age in relation to neighborhood disadvantage and to what extent these differ by gender within the same analysis this is an important gap in the scientific literature since bmi is not consistent across the adult lifecourse and gender differences are widely recognized 81415 but identifying when socioeconomic trajectories in bmi diverge during adulthood is policyrelevant data for informing and enhancing prevention initiatives 16 two mainstream hypotheses support an overall theory of socioeconomic divergence in bmi across the lifecourse importantly both of these hypotheses indicate that divergence occurs as a result of a more rapid weight gain among residents of socioeconomically disadvantaged neighborhoods relative to their counterparts in more affluent surroundings the first hypothesis is deprivation amplification 17 wherein socioeconomically disadvantaged neighborhoods are suggested to contain types of built environment that constrain healthy lifestyle choices and make less healthy options easier repeated exposure to these socioeconomically disadvantaged circumstances may result in more rapid weight gain as people age the second hypothesis is weathering 18 a psychosocial pathway that fits the classic accumulation hypothesis in lifecourse epidemiology 19 this is a process of wear and tear attributable to the clustering of negative experiences that accumulate differentially within disadvantaged neighborhoods including discrimination relative deprivation 21 violent crime 22 and disorder 23 this psychosocial pathway is suggested to result in the overstimulation of allostatic systems and an increased propensity to gain weight 24 25 26 these deprivation amplification and weathering hypotheses are probably very closely entwined but it is not the aim of this paper to distinguish one from the other rather the purpose of this paper is to investigate the broader hypothesis that residents of socioeconomically disadvantaged neighborhoods will not only be heavier than their counterparts in more affluent surroundings as younger adults but that this inequity will widen as men and women age potentially to differing degrees of magnitude by gender methods design no cohort data on weight status by age gender and neighborhood socioeconomic circumstances was available for people across their entire adult lives as an alternative a growth curve methodology via an accelerated longitudinal design was employed which involved pooling groups of people of different ages repeatedly followedup 27 this design enabled the use of highly detailed panel data from the household income and labour dynamics in australia 28 approval for the use of deidentified hilda data was provided by the government department of social services data we extracted 100394 personyears of data from the 2006 to 2012 waves of hilda access to hilda was provided by the melbourne institute of applied economic and social research with funding for data collection from the australian government through the department of social services hilda is an annual nationally representative panel survey that collects data on selfreported height and weight from which body mass index can be derived approximately 84164 person years of data had valid bmi measures and a subset were residentially stable for at least 12 months prior to the survey we focused on the residentiallystable subsample of personyears which were from 18341 participants aged 15 years and older nested within 5626 census collection districts the rationale for focusing upon the subsample of residentially stable participants was our interest in neighborhood disadvantage as a predictor of bmi the impact of one on the other is unlikely to occur within one year with contextual influences on health status like bmi generally hypothesized to occur over a longer period 29 the mean number of personyear observations per participant was 29 with 3759 of 21403 participants observed in one year only the gender distribution of personyears was 29104 for men and 32454 for women bmi averaged at 267 with a standard deviation of 56 the main outcome variable was bmi which was normally distributed in continuous format the ccd of residence for every participant was linked by the data provider to the arealevel measure of socioeconomic circumstances the socio economic index for areas index we used the index of relative advantagedisadvantage which summarizes multiple census variables that describe positive and negative aspects of socioeconomic circumstances 30 a range of variables were identified to help address probable sources of confounding based upon a synthesis of previous literature 82931 these included gender age demographic and personlevel socioeconomic factors demographic factors consisted of whether a participant was living on their own or as part of a couple the number of children in the household and if somebody in the household had been pregnant in the last 12 months socioeconomic confounders included the highest level of education achieved average household gross income and the percentage of time in the last year spent unemployed statistical analysis a multilevel framework was used to model annually repeated measures of bmi at level 1 within participants at level 2 nested within ccds at level 3 this multilevel linear regression was estimated in mlwin 230 32 with the variance partition coefficient used to describe the relative contributions of phenomena operating at each level to the overall variation in bmi among the sample in model 1 genderspecific growth curves were fitted with gender and age linear and square variables and 2way interaction terms model 2 introduced dummy variables for neighborhood socioeconomic quintiles socioeconomic and other demographic confounders were added in model 3 finally model 4 introduced a threeway interaction term to investigate bmi trajectories by age and gender across different quintiles of neighborhood disadvantage predicted mean adjusted growth curves were illustrated to afford interpretation of the 3way interaction term results of the 61558 personyears 397 were within the normal range 348 were overweight 229 classified as obese and 26 considered underweight the average age was 466 with a standard deviation of 185 a minimum of 18 and a maximum of 100 a total of 647 were living as part of a couple 328 had less than high school education and 879 reported zero time spent unemployed in the last 12 months the average household gross income was au 106490 with a standard deviation of au 102690 a total of 47 of the sample reported a pregnancy within the household in the last 12 months and 625 had no children the ageand genderadjusted multilevel model showed that approximately 73 of the variation in bmi was observed between participants around 178 over time and 96 between ccds males tended to have higher bmi than females on average particularly at younger ages higher bmi was associated with higher levels of neighborhood socioeconomic disadvantage adjustment for confounding variables made negligible impact on the association between bmi and neighborhood socioeconomic disadvantage bmi was higher among participants living as part of a couple those who spent 75 or longer of the last 12 months unemployed those with a midlevel of education and those with a pregnancy in the household in the last 12 months no significant associations were observed for household gross income or the number of children in the household fig 1 illustrates the adjusted bmi growth curves predicted from an extension of model 3 using a threeway interaction between age gender and neighborhood socioeconomic disadvantage at age 1524y socioeconomic inequity in bmi was already evident among men and especially women for men this gap remained reasonably constant throughout adulthood until a socioeconomic convergence from 75 years and older among women the socioeconomic gap widened from 28 kgm 2 at age 1524y to 32 kgm 2 by age 3544y within the most affluent areas the gender gap narrowed by age with males 17 kgm 2 higher than women at age 1524y converging to just 06 kgm 2 by age 6574y in contrast there was marginal gender difference at age 1524y between men and women in the most disadvantaged areas but this rose to 07 kgm 2 higher among women by age 4554y discussion many studies report higher bmi among the residents of socioeconomically disadvantaged areas 81415 though not all 33 this study provides support for the mainstream finding more importantly it also reports new evidence that reveals an inconsistency in the degree of association between bmi and neighborhood socioeconomic circumstances by age and gender for men and especially women socioeconomic inequity in bmi observed among younger adults widens as people age this is due to a faster gain in bmi among people living in more disadvantaged neighborhoods relative to their counterparts in more affluent areas to illustrate this pattern the mean bmi among men and women in the most disadvantaged neighborhoods at age 1524y was 254 kgm 2 men in the most affluent areas only reached this bmi level by age 2534y while women in the most advantaged surroundings similarly only achieved a comparable bmi by age 4554y this indicates that above and beyond demographic and personal socioeconomic circumstances people living in more disadvantaged areas not only experience higher bmi from younger adulthood but for women in particular this inequity also widens across the adult lifecourse this is not to say that neighborhood disadvantage is the definitive causal agent of the widening socioeconomic inequity in bmi across the lifecourse potentially the level of neighborhood disadvantage is a proxy for other spatially manifesting factors that influence bmi via deprivation amplification andor weathering pathways distinguishing between these pathways was not the aim of this study but it should be noted that our results are nonetheless based upon observational longitudinal data that is prone to a range of methodological problems notably but not limited to confounding we controlled for several individuallevel characteristics in order to adjust for systematic differences between people living in neighborhoods of contrasting socioeconomic circumstances but there may be other unmeasured factors that influence both where people live and their weight early life experiences and prior health could be potentially important factors since it is well known that neighborhood relocation is health selective 34 35 36 37 an important part of the identification challenge is that people do not choose their neighborhoods of residence by flip of a coin and for some commentators once all individuallevel confounders are taken into account there may be little variation in neighborhood socioeconomic circumstances left to explain 9 this daunting prospect is likely to depend upon context however with recent evidence from a study of hilda showing significant offdiagonal residential mobility in australia 38 the offdiagonal aspect refers to the extent that people move to a new area that is substantively different in some shape or form to the previous neighborhood of residencesocioeconomic disadvantage in the case of the previous australian study the identification of causal neighborhood effects will also depend upon time with factors that influence where people live and potential weight gain unlikely to be consistent across the lifecourse nor across generations and furthermore unlikely to result in instantaneous impacts on bmi the bleak outlook for distinguishing between ageperiodcohort effects is increasingly appreciated 39 40 41 and the question of how to conceptualize and measure the temporal dynamics of neighborhood effects on health remains a work in progress for the discipline of social epidemiology more generally the issue of outcome misclassification due to longknown differences in the selfreporting of height and weight between genders and age groups is another limitation that needs to be acknowledged 42 these challenges apply to the pooled longitudinal design that we have used though the availability of a cohort study tracking people fully across their lives at regular time intervals and with consistently measured indicators would still be subject to ageperiodcohort limitations in conclusion the observations in this study indicate that women living in socioeconomically disadvantaged neighborhoods not only have heavier bmis in young adulthood but the rate of weight gain appears to be potentially higher as they age this means that socioeconomic inequity in bmi among women tends to widen across adulthood this pattern was not as obvious for men future work needs to focus on the identification of causal effects of neighborhood socioeconomic circumstances on weight gain second it would be operative for that work to attempt to differentiate between factors attributable to deprivation amplification and weathering hypotheses given the likelihood that these studies will continue to rely upon observational data inferences must remain conservative but relatively new techniques such as causal mediation models could provide new insights 4344 further steps may also include studies that attempt to imitate randomized trials by focusing upon withinperson change in bmi across different age groups and by gender with the putative interventions mimicked either by a change in contextual exposure due to neighborhood relocation 363745 or as a result of the surroundings changing while the study participants remain within the same places 46 data was accessed under a licence the result of a peerreviewed application data is otherwise confidential and cannot be released by the authors those interested in accessing the data must contact the melbourne

do socioeconomic inequities in body mass index bmi widen across the adult lifecourse bmi data for 29104 male and 32454 female personyears aged 15 years and older 21403 persons in total were extracted from the household income and labour dynamics in australia between 2006 and 2012 multilevel linear regression was used to examine age and gender specific trajectories in bmi by quintiles of neighborhood socioeconomic circumstance models were adjusted for probable sources of confounding including couple status number of children resident if somebody in the household had been pregnant in the last 12 months the highest level of education achieved the average household gross income and the percentage of time in the last year spent unemployed approximately 96 of bmi variation was observed between neighborhoods high neighborhood disadvantage was associated with 209 kgm 2 heavier bmi 95 ci 182 236 at age 1524y socioeconomic inequity in bmi was already evident among men and women especially 226 kgm 2 among women in the most affluent areas compared with 254 kgm 2 among the most disadvantaged among women only the socioeconomic gap widened from 28 kgm 2 at age 1524y to 32 kgm 2 by age 3544y geographical factors may contribute to more rapid weight gain among women living in disadvantaged neighborhoods

this study seeks to provide a better understanding of child wellbeing among children living with married parents who are of different racesethnicities in this paper the term interethnic is used to describe marriages in which partners differ in their racial or ethnic identification and sameethnic is used to describe couples who share their racial or ethnic identification similar to hohmannmarriott and amato who note that the term interethnic can include both interracial and interethnic marriages this study considers marriages between major us racialethnic groups including whites blacks hispanics asians and native americans the first aim of this study is to examine whether child wellbeing differs between children living with interethnic and sameethnic parents to go beyond some of the limitations of much existing work we use nationally representative data from the first wave of the national survey of families and households we focus on a broad age range of children from 5 to 18 years old and consider four different indicators of child wellbeing including global wellbeing positive affect negative affect and behavioral problems a second aim of this study is to assess whether other family characteristics and processes that differ by interethnic status explain any differences that are found in child wellbeing in addition to controlling for demographic and family characteristics two potential explanatory factors are considered level of parents relationship stressors and parenting quality both relationship stressors and poor parenting practices negatively influence child wellbeing and some prior research suggests differences exist between interethnic and sameethnic couples on these factors but prior studies have not tested the extent to which differences in relationship stressors or parenting quality can account for differences in child outcomes between interethnic and sameethnic families we consider several indicators of relationship stressors and parenting quality a strength of the current study is that it includes the selfreported racial and ethnic identification of both spouses this is an improvement over studies that rely on one spouse reporting for both people because an individuals racialethnic classification of a spouse may not always match up with that spouses selfidentification it should be noted however that children growing up in a family with parents who selfidentify as members of two different racial groups or alternatively with parents who identify with the same racial group may or may not hold a consistent selfidentification for example some children who identify as multiracial may have two parents who identify with the same racial group and other children who identify with a single race may live with parents who identify with different racial groups our study therefore addresses the question of whether children who are growing up in a family with parents who selfidentify as members of two different racialethnic groups experience more negative outcomes than those who are growing up in a family with two parents who identify with the same racialethnic group our findings may not correspond directly with differences in wellbeing between children who selfidentify as multiracial and those who identify with a single race although there is likely to be substantial overlap between parent and child selfidentification although having data from both parents and their children would be ideal to better address some of this complexity having parental reports does allow us to examine the implications of differences in their racialethnic selfidentification for their children further the parents selfidentification is particularly relevant for many of the important mechanisms examined in this study including relationship stressors such as marital conflict and parenting quality background a few early scholars suggested that children in interethnic families were at greater risk of negative outcomes than children in sameethnic families but provided little empirical evidence to support their conclusions results were often based on nonrepresentative samples and interethnic families were not always directly compared to sameethnic families in particular it was suggested that children in interethnic families were at greater risk for lower levels of selfesteem trust and feelings of acceptance and exhibited greater levels of anxiety restlessness aggressiveness and withdrawal even some of these early studies however provided mixed findings or suggested no differences for example one study using data from the hawaii family study of cognition found that offspring in interethnic families did not appear to be at greater risk of developing internal or social adjustment problems than offspring in sameethnic families and few differences in personality traits existed between the two groups more recent research has focused on adolescent wellbeing and multiracial offspring in particular with a few studies based on nationally representative data from the national longitudinal survey of adolescent health findings from these studies provide some limited evidence for a negative relationship between interethnic status and some adolescent outcomes specifically these studies found some evidence that multiracial adolescents had greater involvement in risky and antisocial behavior and higher rates of depression counseling and academic problems than monoracial adolescents a study of middle school students in seattle found that multiracial students exhibited greater levels of physical violence and were more likely to try cigarettes or alcohol than monoracial students one study of university students however found no difference between mixed heritage students and same heritage students on levels of self esteem feelings of alienation or stress these studies also suggest however that the relationship between interethnic status and youth outcomes depends on several factors including the way multiracial identification was measured the specific multiracial and monoracial groups included for comparison and the wellbeing outcomes examined for example stephan and stephan defined mixed heritage as any combination of white asian and hispanic ancestry and did not find multiracial offspring to be at greater risk for negative outcomes than monoracial offspring fryer and colleagues compared blackwhite biracial youth to black monoracial and white monoracial youth and found blackwhite youth were involved in more risky and antisocial behavior than both monoracial groups but their levels of academic achievement fell in between them cheng and lively compared six different multiracial groups with their associated monoracial counterparts across 13 adolescent outcomes results varied by the specific subgroups compared and the outcome examined they found evidence that multiracial adolescents fared less well than monoracial adolescents on some outcomes but they were comparable on other outcomes in a recent review of the literature on multiracial individuals and psychological wellbeing shih and sanchez concluded that the evidence for poorer adjustment among multiracial individuals was decidedly mixed overall the limited and mixed findings of previous research provide no clear or strong pattern regarding whether children in interethnic families are generally fairing more poorly than their peers living in sameethnic families the ambiguity of existing studies suggest a need for more research to understand how child wellbeing may differ or not differ between children in interethnic families and children in sameethnic families as well as the family characteristics and processes that may account for any differences in wellbeing that exist conceptual model in this study the effect of parents ethnic heterogamy on child wellbeing is tested as a mediation model based on the spillover hypothesis empirical research has shown support for the spillover hypothesis which suggests that tensions from the marital relationship can carry over into the parentchild relationship interethnic couples may experience greater relationship stressors which stem from experiencing more marital conflict having fewer shared values and receiving less social support from others than sameethnic couples these negative factors that affect the couples relationship may lead to poorer quality parenting and weaker parentchild ties problematic parenting in turn could negatively affect childrens wellbeing and development a simple conceptual model would take the form parents interethnic status → parents relationship stressors → quality of parenting → child wellbeing prior research provides some support for the link between interethnic status and relationship stressors greater marital heterogamy particularly age and racial heterogamy is associated with reports of lower marital quality and lower marital happiness a recent study found that the lower relationship quality reported by partners in interethnic unions stemmed from these couples receiving less social support having fewer shared values and more complex relationship histories than sameethnic couples one study focusing on adolescents in married twoparent households however found no differences in parental reports of marital quality by whether the adolescent identified as multiracial the presence of relationship stressors has been linked to poorer quality parenting marital conflict is associated with harsh and less favorable discipline techniques greater parental withdrawal and less emotional support to children and tenser parentchild relations parents who lack supportive social networks have been found to be less warm and responsive toward their children and report feeling less effective as parents greater relationship stressors in parents lives have also been linked with negative outcomes for children marital conflict has been associated with childrens greater externalizing problems internalizing problems and overall poorer adjustment holding fewer shared values between partners has been associated with childrens withdrawal and mild depression parents lack of social support has been associated with children having more frequent accidents and injuries as well as more behavior problems and less competence in social situations prior research has also demonstrated an association between poor quality parenting and negative child outcomes some research has further suggested that poor quality parenting is a mediator in the link between parents relationship stressors and child internalizing and externalizing problems with regard to a direct link between interethnic status and parenting quality there is some suggestion that parenting quality may be lower in interethnic families but the evidence is more limited and mixed one study using nationally representative data from add health found no differences in adolescent reports of relationship quality with mothers or fathers by the adolescents interethnic status despite some research suggesting that differences exist between interethnic and sameethnic couples in levels of relationship stressors and parenting quality and the large body of research linking relationship stressors and parenting quality to child wellbeing prior research has not tested the extent to which differences in relationship stressors or parenting quality can account for differences in child outcomes between interethnic and sameethnic families in addition to considering the role of relationship stressors and parenting quality we also control for several background and family characteristics that may be associated with interethnic status and child wellbeing controls include the parent respondents gender raceethnicity and education the childs gender and age the couples income length of the parental marriage the number of children in the household and the presence of any blended children in the household for example compared to sameethnic couples interethnic couples are more likely to be in marriages of shorter duration have children from prior relationships in their household and have less education and income higher levels of parental education and income tend to be associated with higher levels of child wellbeing whereas child wellbeing may be compromised in families with a large number of children or for children living in blended families younger and older children often exhibit different levels of wellbeing with problem behaviors tending to increase during adolescence girls are more likely to exhibit internalizing problems and boys are more likely to exhibit externalizing problems parents gender is also included because it may be related to their reports of family processes and child outcomes the parent respondents raceethnicity is included in the analyses to estimate the effects of being in an interethnic family on child wellbeing separately from the effects of the parents own raceethnicity on reports of child wellbeing method data data come from the first wave of the national survey of families and households a nationally representative probability sample of 13007 adults in us households in 19871988 the response rate was approximately 74 the sampling design oversampled several groups including minorities recently married persons single parents and cohabiters a selfadministered questionnaire was also given to the spouse or cohabiting partner of the primary respondent descriptive results will be presented using the sample weight to allow for national representativeness regression results will be presented with unweighted data some have argued that using weights in multiple regression analysis is unnecessary or can lead to inaccurate results if independent variables in the models are similar to variables used to create the sample weight nevertheless we tested the regression models with and without sample weights and the results did not yield substantively different conclusions since the focus of the present study is on married couples with children we selected only married respondents reducing the original sample of main respondents to 6877 given that most of the child outcome measures were only available for children five or older only married couples with a focal child ages five to 18 were included reducing the sample to 2446 next we eliminated respondents who did not have a completed spousal questionnaire reducing the sample to 1986 the spousal questionnaire was crucial for measuring nonshared values and determining the spouses raceethnicity cases where either the main respondent or spouse did not answer the racialethnic identification questions were also excluded resulting in a final analysis sample of 1936 families of the 1936 main respondents 102 were in interethnic marriages measures parents interethnic statuseach parent was asked which of nine categories best described their racialethnic identity white black mexican american puerto rican cuban other hispanic asian american indian or other we combined responses of mexican american puerto rican cuban and other hispanic into a single hispanic category reducing the number of categories to six parents were defined as being in an interethnic marriage if each partner reported a different racialethnic identification based on this final six category identification the most common interethnic pairing is whitehispanic followed by whiteamerican indian all other combinations have less than fifteen couples we realize that broad identifications can mask important subgroup differences but data limitations and small sample sizes for some subgroups precluded a more detailed analysis of ethnic categories or specific interethnic pairings child wellbeingfour measures of child wellbeing are examined global wellbeing positive affect negative affect and behavior problems all items in these measures come from the main respondent and are in reference to a focal child in the household global wellbeing is a singleitem measure rating how well the focal childs life has been going overall standardized scales were created through factor analyses to signify positive and negative child affect positive affect is a sixitem scale rating how often the focal child is willing to try new thing keeps self busy is cheerful and happy does what the parent asks gets along well with others and carries out responsibilities on own negative affect is a fouritem scale rating how often the focal child is unhappy sad or depressed bullies or is cruel or mean to others is fearful or anxious and loses temper easily responses for each question ranged from 1 not true to 3 often true and were coded so that the scales measure a high level of positive affect and a high level of negative affect behavior problems is the final measure of child wellbeing respondents were asked if they had to meet with a teacher or principal in the past year due to the childs behavior problems if the child has ever been suspended or expelled from school if the child has ever run away from home for one or more nights if the child has ever been involved with the police if the child has seen a doctor or therapist about any emotional or behavioral problems and if the child was particularly difficult to raise the two questions regarding suspensionexpulsion from school and meeting with a teacherprincipal were not applicable for the few children who were not attending school so we based the behavior problems measure on only the remaining four questions for this subgroup of children we took the average of the four or six items to make an overall measure of behavior problems with scores ranging from 0 did not experience any of the four or six behavior problems to 1 experienced all four or six of the problems relationship stressorsthree distinct measures were used to reflect stressors that may negatively impact the couples relationship quality the first measure is a three item standardized scale created through a factor analysis that assesses marital conflict the first item comes from a question asked of the main respondent taking all things together how would you describe your marriage the second item comes from a question regarding what the respondent thinks the chances are that they will eventually separate or divorce level of disagreement is the third item represented as a scale created from seven questions asked of main respondents regarding how often in the last year they had arguments with their spouse about household tasks money spending time together sex having another child inlaws and the current children the second measure of relationship stressors is a constructed variable tapping the extent to which the couple has nonshared values both the main respondent and spouse were asked to rate the extent to which they agreed or disagreed with ten statements it is better for everyone if the man earns the main living it is better for a person to get married than to go through life being single parents ought to help their children with college expenses marriage should never be ended except under extreme circumstances preschool children are likely to suffer if their mother is employed parents should provide financial help to their adult children when they are having difficulty it is alright for an unmarried couple to live together even if they have no interest in considering marriage parents should encourage just as much independence in their daughters as in their sons children ought to let aging parents live with them and in successful marriages partners must have freedom to do what they want individually we computed the absolute difference between the main respondents and spouses responses to each item and then computed the mean absolute difference as an overall measure of nonshared values a higher score indicates a greater discrepancy between the main respondent and their spouse the third measure of relationship stressors is low social support main respondents were asked whether or not they had received help from friendsneighbors sonsdaughters parents brotherssisters other relatives or no one in the past month with regard to five different sources of support babysitting transportation repairs work around the house and advice emotional support we assigned a score of 1 for each situation that the respondent reported having received help from no one by adding across the five items this measure is a count of the number of domains in which the main respondent received no help from anyone quality of parentingquality of parenting taps three general domains parental monitoring quality of the parentchild relationship and warmthharsh discipline parental monitoring is assessed with a single item measure regarding whether the main respondent knows whom the focal child is with when away from home the second domain reflects the quality of the parentchild relationship and is assessed with two measures both measures come from single items one regarding how often the main respondent had enjoyable times with the focal child in the past month and the second regarding how often the main respondent had difficulty dealing with the focal child in the past month the last aspect of parenting quality consists of two measures a measure of warmth and a measure of harsh discipline unlike previous questions that are asked in reference to the focal child items used in these measures are asked in reference to all children in the household and therefore reflect parenting quality at a more general level warmth and harsh discipline are both twoitem scales main respondents were asked how often they praise hug yell at and spank or slap their children praise and hug were used to measure warmth yell and spankslap were used to measure harsh discipline controlsmain respondent gender and focal child gender are both dichotomous variables raceethnicity of the main respondent when used as a control is measured as a set of dummy variables white black hispanic and all others education of the main respondent is measured as a set of dummy variables less than high school completion of high school or ged some college but less than a bachelors degree and received a bachelors degree or beyond income reflects the couples combined income in thousands of dollars the log of income is used in the regression analysis to minimize skewness age of the focal child is a continuous variable ranging from five to 18 years the number of children in the household under 19 years of age was created from information contained in the household roster length of the marriage was constructed by subtracting the date of the marriage from the date of when the interview took place and is represented in years the presence of any blended children in the household is a dichotomous variable 1factor analysis demonstrated that all scales were unidimensional correlations between control variables were all below 42 except for the correlation between length of marriage and the presence of any blended children correlations between the relationship stressor measures and correlations between the parenting quality measures were all below 34 fewer than 2 of the cases were missing on the child wellbeing measures for the parenting quality measures fewer than 5 of the cases were missing low social support nonshared values and marital conflict had approximately 6 11 and 16 missing respectively all control variables had 2 or less missing cases except for income where approximately 11 of the cases were missing to deal with missing data multiple imputation was conducted using the ice program in stata analytic strategy we begin by comparing differences between interethnic and sameethnic families on all of the study variables mean levels are reported for continuous measures with tests of statistical significance based on ttests percentages are reported for categorical measures and tests of significance are based on the chisquare test then we examine the relationship between parents interethnic status and child wellbeing in a bivariate and multivariate ordinary least squares regression framework we present two models for each of the four child outcomes the bivariate relationship between parents interethnic status and child wellbeing is estimated in the first model the second model is the full multivariate model that includes parents interethnic status along with all controls for background and family characteristics the three measures of relationship stressors and the five measures of parenting quality 2 results the interethnic families in our study differed significantly from sameethnic families on several background and family characteristics focal children with interethnic parents were somewhat younger on average than those with sameethnic parents by about one year the majority of main respondents in sameethnic families were white whereas whites and hispanics made up the majority of main respondents in the interethnic group interethnic parents had lower income and were in marriages of shorter duration with regard to relationship stressors or factors that could negatively influence the parents relationship only one significant difference was apparent interethnic parents reported a greater dissimilarity in values than sameethnic parents but they did not differ much in levels of marital conflict or in receiving social support from others there is no evidence that parenting quality differed between interethnic and sameethnic families based on the five indicators examined here there is only limited evidence that child wellbeing is lower among children living with interethnic parents compared with children in sameethnic families children living with interethnic parents exhibited higher levels of negative affect there were no differences however in global wellbeing positive affect or behavior problems we turn next to further explore differences in child wellbeing in a multivariate regression framework but it is worth noting that results thus far suggest rather limited differences between children living with interethnic parents and those living with sameethnic parents particularly with regard to levels of parents relationship stressors parenting quality or child wellbeing results from the regression analysis reinforce previous findings the bivariate models replicate the findings from table 1 and the addition of controls and mediating factors had little influence on the effect of interethnic status on child wellbeing negative affect was the only child outcome significantly associated with parents interethnic status with a moderate effect size of 24 3 children living with interethnic parents exhibited higher levels of negative affect than children in sameethnic families and this association was not explained by differences in background or family characteristics relationship stressors or parenting quality given that there were few differences in relationship stressors or parenting quality by interethnic status it is not surprising that these factors did not help explain the association between interethnic status and negative affect these factors were however significantly associated with child wellbeing in particular marital conflict was associated with lower levels of child wellbeing whereas parental warmth and a positive parentchild relationship 2 in preliminary analyses we estimated four models for each of the child outcomes corresponding to our conceptual model the first model was the bivariate model and the second model added in the controls for background and family characteristics the three measures of relationships stressors were added in a third model and the five parenting quality measures were added in a fourth model in order to test whether they mediated the effect of parents interethnic status on child wellbeing results from the intermediate models however did not add any new information and were consistent with the final full model controls had little influence on the relationship between parents interethnic status and child outcomes and there was little evidence of any mediation of the effect of parents interethnic status through relationship stressors or parenting quality thus we only report results from the bivariate and final multivariate models in table 2 the intermediate models are available upon request 3 because the level of behavior problems was skewed an additional set of analyses were conducted on this dependent variable using poisson regression these results also suggested that interethnic status is not associated with child behavior problems to further check the lack of association between interethnic status and child outcomes we examined the association between interethnic status and each of the individual items that made up the three outcome scales similar to results in table 2 none of the individual items from behavior problems or positive affect were associated with interethnic status with regard to negative affect interethnic status was most strongly associated with the two items assessing how often the focal child bullies or is cruel or mean to others and how often the focal child is fearful or anxious were associated with higher levels of child wellbeing many of the background and family characteristics were also associated with child outcomes in expected ways for example child wellbeing tended to be higher for girls and younger children and in families with higher income fewer children and marriages of longer duration discussion an increasing number of us children are living with interethnic parents yet we know relatively little about how they are faring this study examined differences in child wellbeing between children living with interethnic parents and those living with sameethnic parents drawing upon nationally representative data and focusing on a broad age range of children and four indicators of child wellbeing results provide only limited evidence that child wellbeing is lower among children living with interethnic parents compared with children in sameethnic families children living with interethnic parents exhibited higher levels of negative affect at the same time however no differences were found in global wellbeing positive affect or behavior problems we conclude that children living with interethnic parents may face some greater difficulties that warrant concern but they do not appear to face pervasive disadvantages we concur with cooney and radinas assessment that prior literature has overstated the extent and range of problems faced by children living in interethnic families who as a group do not fit the typical portrayal of being fairly troubled youth our results are also consistent with more recent research that has examined multiple child outcomes and found that multiracial children fare less well than monoracial children on some outcomes but not others with a moderate effect size the finding that children with interethnic parents had higher levels of negative affect than children with sameethnic parents warrants further research into better understanding the mechanisms that lead to such a difference our finding is consistent with recent research on adolescents which reports higher levels of antisocial behavior and higher rates of depression and counseling among interracial offspring than samerace offspring as our measure of negative affect taps related domains our study also suggests that this difference may start to appear before adolescence our study was unable to account for the difference in negative affect between children living with interethnic and sameethnic parents and our initial conceptual model was not supported although we found some significant differences between the two groups on background and family characteristics that tend to be associated with child wellbeing controlling for these factors had little influence our study also suggests that the differences in negative affect are not due to differences in relationship stressors or parenting quality consistent with much prior research relationship stressors and parenting quality were themselves associated with child outcomes with the exception of nonshared values we found few differences in levels of relationship stressors or parenting quality between interethnic and sameethnic families this was somewhat surprising given some prior research suggesting that interethnic couples experience greater relationship stressors and more problematic parenting in particular many interethnic couples have historically reported at least some level of opposition from others in response to their heterogamous relationship yet the married interethnic couples in our study did not report receiving less social support than their sameethnic counterparts it should be noted however that there are also studies that report few differences between interethnic and sameethnic couples with regard to relationship stressors and parenting quality given the limited and mixed findings of prior research future research would benefit from greater attention to understanding marital relationships social support networks and parenting practices in interethnic families as with prior research on child wellbeing this may be another area where differences between interethnic and sameethnic families have been overstated alternatively these mixed findings may result at least in part from differences in the groups studied for example differences in marital conflict by interethnic status may be more apparent in samples of couples regardless of whether they have children than in samples of longterm married couples with adolescent offspring as the latter group is likely more selective of higher quality marriages our study is also selective in examining families where the parents are married and at least one child in the household is five or older thus the focal children may be relatively welladjusted and have parents with relatively good relationships social support networks and parenting skills a limitation of the current study is the modest sample size of interethnic families which can hinder the ability to detect smaller group differences that may exist in the population at the same time however more confidence can be put in the significant differences that were found the modest sample of interethnic families also precluded an examination of differences in family processes and child outcomes for specific interethnic pairings although our main aim was to compare children living with interethnic parents to children living with sameethnic parents there is diversity within these groups as well that may further influence child wellbeing for example there is some suggestion that blackwhite couples may experience more challenges and stressors than hispanicwhite couples which could lead to corresponding differences in child outcomes recent research on adolescents also suggests that certain multiracial subgroups have worse outcomes than others when compared to their monoracial counterparts future research should explore these potential subgroup differences to the extent that data allow to further clarify when children from interethnic families may be at risk for poorer outcomes future research would benefit from considering children of all ages and following them over time relatively little is known regarding how family relationships unfold over time in interethnic families or whether any risks that children in these families face appear early in childhood or manifest themselves during key developmental periods such as adolescence given that the number of children living in interethnic families is likely to continue to rise a better understanding of how these children are faring and the challenges that their families face is of utmost importance and a necessary first step on the way to helping such families confront any difficulties they may encounter our study suggests that children living with interethnic parents may face greater difficulties in some domains that warrant concern and attention although they do not appear to face pervasive disadvantages

an increasing number of us children are living with interethnic parents yet we know relatively little about how they are faring using data from the first wave 1987 1988 of the national survey of families and households nsfh this study examines differences in child wellbeing between children living with interethnic parents and those living with sameethnic parents results provide only limited evidence that child wellbeing is lower among children living with interethnic parents compared with children in sameethnic families children living with interethnic parents exhibited higher levels of negative affect and this difference could not be explained by differences in background or family characteristics levels of parents relationship stressors or parenting quality at the same time however no differences were found in global wellbeing positive affect or behavior problems children living with interethnic parents may face some greater difficulties that warrant concern but they do not appear to face pervasive disadvantages

introductioneditorial cartoons editorial cartoons are generally defined as cartoons that contain subject matter and commentary on political or social issues they are more likely to be composed as single frames than strips although some editorial cartoons such as garry trudeaus doonesbury are produced as strips increasingly editorial cartoons are created entirely digitally rather than in the traditional graphic materials of ink pencil paper and pigment while the terms editorial cartoon and political cartoon are both used to describe cartoons of a political nature the term editorial cartoon can be considered a slightly more encompassing term which allows for published cartoons about social and cultural issues to be considered together with political cartoons however in the thesaurus for graphic materials the broader term for both editorial cartoons and political cartoons is cartoons an attempt to identify genres and subgenres of editorial cartoons has been discussed by pedrazzini and scheuer across the visual art media digitization of traditional visual art forms and the increasing production of borndigital art forms suggests that there is little published research about computational topic modeling using data sourced from cartoons research objective and scope of review this review aims to address the gap identified in previous related works although the coverage is intended to be selective and indicative rather than comprehensive it attempts to present a snapshot of selected research that addresses the topic of editorial cartoon indexing within a wider context of publications including those that address image indexing subject analysis and indexing challenges more generally works that address the interpretation of cartoons by readers and how readers respond to information communicated by editorial cartoons are also considered the review focuses on four perspectives of approach toward the subject of indexing editorial cartoons with the following objectives to highlight literature relevant to the wider theoretical context of image analysis for descriptive and interpretive purposes of which cartoon indexing is a specialized field to select and present recent studies that relate to national transnational multinational and multicultural aspects of editorial cartoons including publications that discuss the dynamic and rapidly changing international environment in which editorial cartoonists have worked since the year 2000 with relevance to the topic of reader responses to editorial cartoons inclusion of these resources is intended to assist awareness of the wider social cultural and political factors which indexers of editorial cartoon collections ought to highlight and reflect in their indexing work to draw attention to resources that deal specifically with the challenges of indexing of editorial cartoons for online search and retrieval this is a narrower field of research which nevertheless has major implications for the wide range of academic disciplines which draw on data contained in editorial cartoons from time to time in selecting resources that are of special relevance to indexing editorial cartoons it has been necessary to exclude publications that deal more specifically with related genres and formats such as comics graphic novels zines photography and moving image resources that deal with the challenges of indexing such materials have only been included where the indexing principles they outline apply more or less equally to indexing editorial cartoons the search strategies utilized were relatively simple due to the comparatively limited amount of published research on editorial cartoons available across multiple academic disciplines and the very limited amount of published research specifically about indexing editorial cartoon collections it was found that in the process of searching databases of academic publications for research on editorial cartoons the most productive search strategies for material relevant to this project were very simple including the following more complex searches such as all editorial cartoons and indexing were found to produce very limited numbers of relevant results suggesting the specialized nature of the core research topic searches were conducted across a wide range of databases of academic publications including communication and mass media complete ebscohost emerald encyclopedia of library and information science jstor proquest and taylor and francis online google scholar was also used to identify relevant material materials identified in results returned by google scholar were then researched for in databases enabling more precise accessible results identified resources were assessed individually for relevance keyword searches of the term cartoon were applied to each resource to help determine inclusion or exclusion editorial cartoon collections more recent studies into indexing techniques for visual materials have focused on semantic approaches to identifying image content with the aim of aiding computerized retrieval of data relating to content as well as format this area of research has seen a convergence of approaches from the fields of library and information studies and computer science around the concept of contentbased retrieval much of the research in this area has been focused around the challenges of identifying subjects in visual images according to predefined hierarchical classification structures that attempt to identify levels of meaning in the visual arts the creation of descriptive metadata for indexing and retrieval of cartoon collections is especially challenging due to the inherent difficulties for the indexer in correctly attributing subject and identifying implied meaning in individual cartoons scholars in the field of image analysis have frequently drawn on panofskys threelevel hierarchy of iconological significance as the basis of efforts to devise controlled hierarchies of subject categories for image indexes the emergence of social tagging as a democratized natural languagebased nonhierarchical method of generating indexing terms has challenged the hierarchical methodologies devised by professional indexers the advent of tagging has stimulated debate about the relative advantages of usergenerated tags versus professional image indexing and the use of controlled authority versus natural language indexing terms editorial cartoon studies more recently chen et al state that while an extensive literature on editorial cartoons exists across a wide variety of different academic disciplines very few attempts have been made to survey this literature comprehensively to map the field of academic editorial cartoon studies editorial cartoons are frequently discussed in studies of visual literacy but opinion is divided about the extent to which their implied messages can be decoded and understood by readers due to cartoons reliance on visual metaphor to convey meaning the combinations of text and visual images that are commonly found in editorial cartoons tend to increase the range and complexity of their implied metaphorical meanings and their interpretation by readers mello notes that editorial cartoons are designed for quick consumption archived editorial cartoons become harder to interpret as time goes by landbeck several classic studies have suggested that the intended implied meaning of editorial cartoons may not be correctly decoded and understood by many readers while el refaies research has shown that editorial cartoons can be misinterpreted by both school students and universityeducated readers mcgurk strongly promotes the use of editorial cartoons in the classroom shaw draws attention to the political cartoon holdings of the british library and their usefulness to students of the development of magazines and newspapers schnakenberg provides a useful summary of the pros and cons of teaching german history through cartoons caswell looks at the topic of war in american editorial cartoons eko shows that throughout the african continent cartoons and caricatures have become the critical narrative device of choice in the media hammett and mather have shown that editorial cartoons are valuable aids for teaching political geography to students in south africa the nzcca collection at the national library of new zealand has been drawn on extensively for illustrations to published research on aspects of new zealands political and social history and more recently the countrys history of race relations library and archives canada provides online educational resources providing thematic access to editorial cartoons about canadian federation library and archives canada ajim 723 as cartoonists frequently utilize a combination of graphic image and text to convey meaning the academic discourse about them frequently draws on studies of metaphor rhetoric and iconology sourced from a variety of disciplines the works of 20th century linguistic and literary and media theorists including bakhtin saussure barthes mcluhan and burke are often cited by writers analyzing the cognitive processes involved in reading and decoding editorial cartoons bostdorff discusses a burkean approach to interpreting editorial cartoons morris examines visual rhetoric in editorial cartoons through a structuralist lens a neoclassical approach that locates the visual rhetoric of cartoons within the classical tradition of rhetorical argument can also be helpful in interpreting editorial cartoons important studies of rhetoric in editorial cartoons include medhurst and desousa and desousa and medhurst drawing on academic studies of formal rhetoric these authors propose a basic taxonomy for classifying the persuasive means by which cartoonists convey their intended messages to the reader their proposed taxonomy of rhetorical devices found in cartoons includes rhetorical invention graphic disposition rhetorical style the evocation of memory and presentation as delivery where each type of rhetorical device is illustrated by a range of cartoon exemplars medhurst and desousa many studies have been published on metaphors employed in editorial cartoons on specific news topics for example bounegru and forceville studied metaphors in cartoons about the global financial crisis in terms of the theory of metaphor as it applies to editorial cartoons a frequently cited resource is lakoff and johnsons influential book metaphors we live by which suggests that the human cognitive system is structured metaphorically this work discusses the implications of common metaphors such as time is money together with associated meanings that metaphors sometimes conveniently obscure while the time is money example is a fairly basic concrete one editorial cartoons often make use of more complex multimodal metaphors to convey the meanings intended by their authors in a study of austrian newspaper cartoons el refaie observed that while interplay between verbal and visual metaphor was often present the verbal and visual modes of metaphor did not operate analogously and that cartoons must be studied in their sociopolitical context profound differences exist between literal and metaphorical thought as expressed in a variety of verbal and visual modes moreover every individual reader or viewer is likely to bring his or her own experiences and assumptions to the interpretation process schilperoord and maes meanwhile argue that full interpretation of editorial cartoons requires the viewer to combine two distinct types of reasoning schematic and taxonomic the concepts of modality and multimodality are valuable in analyzing meaning in all types of visual images rafferty discusses multimodality and its relationship to interpretation in the context of user tagging of website images lin and chiang discuss multimodal fusion in cartoons addressing us beef imports into taiwan for instance however researchers have pointed out that the full spectrum of multimodal meanings intended by cartoonists may not necessarily be understood by viewers if they do not have all of the necessary background knowledge to inform their individual interpretation increasing political sophistication and public awareness of political strategy around election campaigns may also account for changes in depictions and humor found in editorial cartoons published in the united states since 1960 the metaphorical approach is useful for analysts of editorial cartoons in all disciplines sŏrm and steen discuss editorial cartoons among other types of visual art materials employing visual metaphor from the opposite perspective editorial cartoons can also be useful in the study of metaphorical thinking and how it develops dom ınguez discusses an evolutionary model of metaphor development using published cartoons about the charlie hebdo cartoonist murders in this study cartoons expressing the relatively simple metaphors pencil is a weapon pencil is a cartoonist and pencil is freedom are examined editorial cartoon collections a similar rhetorical analysis of two published cartoons created in response to the charlie hebdo murders is discussed by bezanzon olson and olson meanwhile use editorial cartoons as examples to illustrate ways in which readers perceive irony the concepts of aboutness and ofness have been useful to scholars researching the design of metadata schemas for visual materials these concepts are especially useful in the analysis and decoding of editorial cartoons thus a cartoon can appear for instance to be a picture of an orange lavatory but be intended by guardian cartoonist steve bell to be about us president donald trump in other studies lan and zuo explore aspects of pictorialverbal metaphor in chinese editorial cartoons on food safety sourced from the website and ulubeyli et al conduct a semiotic analysis of workplace health and safety cartoons from several countries in an examination of editorial cartoons concerning the referendum on the european constitution held in france in 2005 mar ınarrese compares and contrasts visual perceptions and representations in cartoons published in the english and spanish press in order to explore the cognitive mechanisms involved in constructing meaning cartoon controversies notwithstanding the many questions of interpretation that editorial cartoons present for their viewers many editorial cartoons have the potential to polarize viewers and opinions and at times provoke extreme or unexpected responses the former editor of the new york times and longtime editor of the nation navasky provides a brilliant summary of the history of political cartooning from its origins in the italian renaissance to the present the commentary includes sections on the cartoon as content the cartoon as image and the cartoon as stimulus as well as a useful section on caricature about 31 internationally influential cartoonists are profiled in individual chapters including the new zealandborn cartoonist david low acknowledged as the twentieth centurys greatest caricaturist a fascinating timeline at the end of the book presents a chronological selection of events from 1831 to 2012 in which cartoonists were charged with offenses or subject to violent attack for their works benson demonstrated how the unusual license accorded to low by his publisher lord beaverbrook allowed the cartoonist an extraordinary freedom of expression lows status as both artist and influential journalist remains of interest to contemporary media commentators dramatic changes in traditional news media publishing brought about by the advent of the internet have impacted on editorial cartoonists and their work with many former staff positions being disestablished by publishers around the world and many cartoonists becoming independent contractors such changes have altered the traditionally close relationship between editorial cartoonists editors and publishers in the 21st century the role of editorial cartoonists is increasingly at the center of debate about press freedom since the 911 terrorist attacks in the year 2000 the traditionally satirical role of editorial cartoonists in the international news media has come under intense pressure and scrutiny from many directions in the wake of the 911 attacks some usbased commentators suggested editorial cartooning was in decline partly because cartoonists found it challenging to express their natural inclination to negative satire in the context of increasing nationalism editorial cartoons and cartoonists have been at the center of international controversies for example the danish jyllandsposten muhammad cartoon controversy of 2005 edwards noted that although editorial cartoonists were once treated as celebrities they no longer enjoyed the same respect nevertheless the media prominence of cartoon controversies has stimulated academic studies of the mechanisms by which satire operates in the popular media some commentators have suggested that editorial cartoons can play a healing role in the recovery of communities from terrorist attacks while others have suggested that while editorial cartooning may not be in decline it must take place within a rapidly changing media environment ajim 723 against this dynamic background the editorial independence of cartoonists has increasing been questioned in the context of press freedom berkowitz and eko noted that while issues of religious freedom of expression and freedom of speech were frequently associated by the international media with the jyllandsposten muhammad cartoon controversy the controversy came to represent wider issues such as beliefs about national identity core cultural values immigration and multiculturalism in their analysis of the jyllandsposten muhammad cartoon controversy codina and rodr ıguezvirgili drew attention to the global aspects of press actions in the context of cultural coexistence as recently as 2018 a new zealand cartoonist and his publisher have been the subject of legal action regarding implied and inferred racial prejudice in their editorial cartoons around the world there are many editorial cartoonists who are imprisoned or have been threatened with imprisonment by oppressive regimes for instance zunar of malaysia this has led to the establishment of the cartoonists rights network international an organization that aims to help cartoonists safeguard their freedoms of expression it has been suggested that politicians are able to suppress negative criticism more effectively if they are able to frame editorial cartoons as attacks on a whole nation rather than on an individual whether or not editorial cartooning is in fact in decline it continues to attract attention and dialogue increasingly this attention is focused on transnational and multicultural contexts the jyllandsposten muhammad cartoon controversy of 2005 has stimulated studies of editorial cartoons in several academic fields and the publication of research investigating multicultural and transnational responses to editorial cartoons the fatal shooting of editorial cartoonists staff and police at the paris offices of the satirical charlie hebdo journal in 2015 highlighted the sometimes dangerous conditions under which editorial cartoonists may have to work visual framing by international media in response to the charlie hebdo shootings helped to communicate and construct narratives about press freedom and further stimulated research into the multinational aspects of editorial cartooning and reader responses constantinou looks at the complex crosslinguistic and translational aspects of narratives constructed in the international media concerning the charlie hebdo attacks the ability of cartoon images to bypass linguistic and national barriers may be consciously used by political regimes to try to influence and set global and transnational political agendas for sanadjian the charlie hebdo attacks emphasized a profound change in the traditional roles of author and reader with the authors role becoming increasingly restricted and the role of the diverse readership becoming correspondingly more autonomous 5 indexing editorial cartoons for online search and retrieval 51 editorial cartoon searching these days large collections of digital cartoons can also be accessed via the websites of news media publishers such as the new york times the guardian and china daily the american association of editorial cartoonists maintains a website providing access to archived digital cartoons in addition to news and educational resources increasingly editorial cartoonists also maintain their websites giving access to archived digital cartoons extensive collections of editorial cartoons in all formats have been built up for political and social research purposes by universities as well such as the university of kent and the ohio state university the british cartoon archive and the billy ireland cartoon library and museum have been energetic in publishing guides to searching their collections for instance in a variety of formats including webbased platforms such as blogs baines editorial cartoon collections provides a number of tips in blog posts on searching for archival materials and special collections at the university of kent including the british cartoon archive collections examples of tips include thinking around the research area differentiating between published and unpublished materials searching by keyword and authority terms such as artist place and date using advanced search functions and checking copyright status national libraries have also developed large research collections of editorial cartoons including the library of congress library and archives canada and the national library of new zealand the practical challenges of managing large collections of editorial cartoons include the large volume of works produced by cartoonists who are often required by their editors to produce finished works regularly in archival collections cartoons created in traditional formats require the technical support of controlled environmental conditions to maintain archival digital cartoon collecting also requires stateoftheart digital curation and preservation resources including the employment of professional digital archivists and the use of digital archive systems for longterm preservation of digital materials notwithstanding anecdotal accounts of how cartoon collections are useful for research for example shaw american cartoons offer a rich resource for the study of american culture and the development of magazines and newspapers this literature review has found little published research on the ways in which remote users consult indexed cartoon collections this may well be a fruitful area for further research the challenges of cartoon interpretation confronted by general readers impact on the practice of indexing cartoons for access in electronic catalogues of formed cartoon collections in their study of image attributes perceived to be important for identification as access points for retrieval choi and rasmussen include cartoons among types of images retrieved by user queries for images relating to american history despite the large numbers of editorial cartoons that are now searchable online wu states that many readers have seen cartoons in newspapers or on the web but few have searched them in a cartoon database landbeck compared user responses to editorial cartoons in the context of both user tagging and querying behaviors zhang et al designed a search system for a small collection of historical political cartoons based on the assumption that the search engine should serve historians on this basis they included search engine design features intended to maximize users ability to explore by supporting both serendipitous and focused searching farmer examines information architecture in relation to indexing for the comic arts including graphic novels and japanese manga and analyzing such materials at the level of component elements such as text bubbles strips panels and gutter comments the challenges of describing editorial cartoons can be thought of as a special subset of these broader sets of image description challenges for indexers little consideration has been given in the literature however to whether it might be possible to develop a storybased system for indexing images benson discusses aspects of describing relationships between entities such as people places and things as expressed in photographs and other images including cartoons for the purposes of creating machinereadable collection records many glam sector organizations maintain exportable data sets for collection records formatted in schemas such as encoded archival description available for downloading by external users the emerging techniques of computational topic modeling in the social sciences have raised the potential for exported metadata from editorial cartoon indexes to be datamined to help shed light on historical social and political trends baker discusses the results of an experimental analysis performed on an export of xml metadata from the british cartoon archive using topicmodeling techniques to interrogate the metadata for topic trends interestingly metadata created in the 1960s and ajim 723 1970s was found to be richest in this study with the most interesting data being found in the title and subject fields k€ ontges discusses how topicmodeling techniques applied first to data sets relating to editorial cartoons on earthquakes in the national library of new zealand were subsequently applied to use cases at the open philology project university of leipzig and the roshan institute for persian studies at the university of maryland these use cases adapted topic modeling for research on ancient greek latin classical arabic and persian language corpora demonstrating that the techniques were effective for multilinguistic humanities research and suggesting that topic modeling could be more widely utilized by digital humanities researchers provided the techniques are used to help answer specific research questions editorial cartoon indexing ambiguities inherent in cartoons present challenges to natural language understanding by computers hackbartdean provided a detailed case study of a project to identify preserve and provide itemlevel cataloguing of the clifford baldy baldowski collection of original editorial cartoon artworks at the richard b russell library for political research and studies the author noted that assigning subjects to historical editorial cartoons was made complicated by changing opinions the relevance of subject headings and the time required to crossreference original cartoon artworks to the specific newspaper editions they were published in to ascertain context many of the basic challenges and solutions for electronic indexing of editorial cartoons were outlined by bovey during the development of an online catalogue for the extensive cartoon archive at the university of kent landbecks summary of the state of the art of providing online access to editorial cartoons remains highly relevant over the past two decades there has been an explosive growth in the literature on search and retrieval of images indexed in electronic catalogues and databases however within this dynamic rapidly growing field of research there are relatively few published studies that focus specifically on indexing editorial cartoons the intellectual challenges of indexing editorial cartoons are complex the difficulty of attributing subject to editorial cartoons for indexing purposes exists both for traditional paperbased cartoon formats and for digitized or borndigital cartoons despite the muchacknowledged paucity of published research on editorial cartoon indexing there has been some outstanding work done on the topic nevertheless notably by chapplesokol and landbeck landbeck noted that the categorization and organization of political cartoons has historically been a nonstarter lack of resources and lack of interest have been cited as reasons for the exclusion of these works from the historical record for the purposes of the research landbeck used the term editorial cartoon as a more encompassing term than political cartoon his enquiry focused on two questions whether it is possible to define categories for classifying cartoons to enable research by users and whether there is a research demand for such classification to test these questions a threepart study was conducted using 12 voluntary participants who were asked to look at and interpret a range of editorial cartoons from different periods landbeck outlines three basic cataloguing needs for editorial cartoons indexed in electronic databases bibliographic descriptive and subject bibliographic needs for editorial cartoons have much in common with those of documents subject and context are very challenging to describe a metadata schema is useful for describing editorial cartoons to allow for wider faster and more effective indexing for retrieval dyer describes a project to catalogue a group of some 300 original cartoons and artworks by the editorial cartoonist charles sykes at the virginia commonwealth university editorial cartoon collections libraries many of these cartoons were published in the evening public ledger in the 1930s and 1940s challenges encountered by indexers in cataloguing this collection included the lack of earlier cataloguing lack of accurate date information difficulties in identifying subject matter the need for background research to determine accurate library of congress name and subject headings and uncertainty around whether characters depicted in the cartoons represented real people or fictional symbolic identities created by the artist extrapolating from the findings from the sykes cartoons indexing project dyer identifies several categories of challenges for cartoon indexers image cataloguing challenges include problems of aboutness and ofness and the accurate interpretation of intended visual metaphor challenges specific to handling cartoons include lack of available data relating to the cultural context of editorial cartoons especially from earlier time periods and this was compounded in the absence of available subject experts for the relevant periods in history the personal artistic style conventions and innovations of individual cartoonists also have an impact on the ability of later cataloguers to identify subjects in their works particularly when it comes to people who may be difficult to recognize subjects of a more ephemeral timespecific nature which have been caricatured by cartoonists in daily papers may be more difficult to identify because of the fleeting nature of their topicality at the time of publication and lack of relevant contextual documentation finally dyer notes that the intricate relationships between text and image in editorial cartoons require that accurate capture of captions and other text elements and provision of keyword access to these elements should be prioritized in cataloguing and indexing such items dyer suggested some solutions including matching original cartoon artworks with their published versions referencing front pages of relevant newspapers to determine broader contemporary news context and the provision of additional indexing fields controlled vocabulary freetext and usertagging approaches to editorial cartoon indexing a detailed study carried out by landbeck compared terms and phases used by two sample populations to describe a group of recent editorial cartoons by pulitzer prizewinning cartoonists one sample user population was drawn from academics considered likely to provide detailed descriptions of the cartoons the other population was drawn from nondegreequalified participants participants were asked to provide descriptive terms in a tagging environment and subsequently asked to provide terms for searching for cartoons in a query environment descriptive terms supplied by the two groups were sorted according to j€ orgensens 12 classes of image description it was found that while the terms could be fitted into the 12 classes users described editorial cartoons in significantly different ways to other types of images j€ orgensens abstract concepts class dominated descriptions and searches the class viewer reactions also played a large role in descriptions supplied by users in the experiment major differences in tagging behavior existed among participants with different education levels and in querying behavior among participants with different genders and political views results were discussed with professional image indexers and cartoonists and it was found that the information could potentially be helpful for indexing and retrieval of editorial cartoons as noted earlier the work of panofsky on identifying levels of meaning in the visual arts has been extremely influential on research by scholars in the field of library and information studies research aimed at devising classification and metadata schemas for the description and indexing of visual materials including editorial cartoons frequently cites panofskys threelevel system of iconological significance some scholars ajim 723 have however criticized panofskys schema as being inherently hierarchical and eurocentric having the potential to be inappropriate or disadvantaging when applied to descriptions of noneuropean cultural materials including editorial cartoons that reflect the sociocultural aspects of a noneuropean context building on panofskys basic threetier hierarchy more elaborate classification schemes for identifying levels of meaning in images have been proposed rafferty and hidderley propose several multilevel models for the classification of levels of meaning in multimedia materials j€ orgensen et al propose a tenlevel pyramid of image attributes featuring four syntactical and six semantic levels of meaning based on j€ orgensens 12level classification model for levels of meaning wu proposes an adaptation of panofskys threelevel model including sublevel data fields designed specifically for the description of borndigital editorial cartoons wu notes that there is no standard metadata scheme for describing digital political cartoons within public collecting institutions such as the british cartoon archive it has formerly been the norm for professional indexers to do the work of indexing editorial cartoons in recent years however indexing projects have been initiated utilizing crowdsourcing in which nonprofessional volunteers contribute metadata to indexing records for editorial cartoon collections many public collecting organizations around the world provide options for tagging online catalogue entries whereby users are encouraged to annotate entries for indexed items with noncontrolled natural language subject terms of their own choice over time large folksonomies of tag terms develop through the contributions of individual users folksonomies can be presented online in the form of word clouds which graphically show the relative popularity of tag terms in relation to indexed items through this process usergenerated indexing has been suggested as a democratized product rather than a hierarchical authoritative one while the extent to which social tagging can add value to image indexing has been questioned by some as wu has demonstrated there can be substantial variability of editorial cartoon indexing between professional indexers even when they are using controlled vocabularies and operating identical business rules zhang et al conducted a project to crowdsource the generation of metadata for a small group of cartoons published by a single dutch cartoonist between 1937 and 1942 digitized by the national library of the netherlands online volunteers were provided with an online survey modeled on questions that historians would typically ask about a cartoon these were presented as 31 questions in eight stages cartoons were randomly assigned to volunteers and answers were validated by the project organizers interestingly the authors do not report variations between volunteer responses to the questions in this study the relative mix of controlled vocabulary versus freetext components of records for visual and digital materials collection has received considerable attention in recent years baker found that the semantic richness of collection records compiled by professional indexers working with the cartoon collections of the university of kent was particularly useful for contemporary computerized datamining research on social science topics in collectionlevel metadata the use of freetext description fields in combination with controlled vocabulary fields can provide more accuracy and completeness in the representation of subjects and object types than specified fields alone at the alexander turnbull library national library of new zealand borndigital cartoons are received regularly from editorial cartoonists examples are the borndigital draft versions of a cartoon by mark winter in the nzcca mentioned earlier cartoons assigned to the nzcca are catalogued using encoded archival description standards a detailed inhouse cataloguing manual provides guidance for staff on mandatory fields and default field values titles are taken from the work itself wherever possible and titles supplied by artists are preferred to titles supplied inhouse freetext scope and contents editorial cartoon collections notes are usually generic due to the volume of borndigital cartoons received and the time it takes to provide scant catalogue records for them the authors practical experience in administering this collection tends to support dyers observation that having the date of publication would provide important information about the cartoons which in turn would assist in cataloguing the collection in the case of borndigital cartoons received in bulk from cartoonists for the nzcca it is not always clear which version of an image has been published if at all as cartoonists often provide editors with multiple versions of a cartoon image on a particular date covering a particular subject in such instances the librarys practice may include noting the following statements in the eadotherdescriptivedata field colour and black and white versions available versions with alternative colour grading available or multiple versions of this cartoon are available conclusion and implications for research the present study suggests that since the year 2000 there has been limited but considerable research on indexing collections of editorial cartoons the work of landbeck wu and johnson and k€ ontges has added to this specialized field of indexing studies a common theme in the literature is that of the relative values of controlled language versus freetext metadata fields for cartoon description in automated indexing a parallel debate concerns the relative values of professional indexing versus social tagging for the identification of content in editorial cartoon indexes the value of freetext natural language descriptive fields for identifying and making accessible semantic content in editorial cartoons has been highlighted in recent works including that of capturing the date of publication of the original cartoons a useful further work on this topic could be a systematic comparison of metadata schema and standards as applied to editorial cartoon collections in a range of relevant collecting institutions for example landbeck provides a discussion on the use of various metadata schema and concludes despite some reservations that cdwa is the best one to use when describing editorial cartoons a detailed analysis of metadata schema and subject authorities implemented in a range of largescale established cartoon collections around the world could provide useful insights toward best practice for editorial cartoon indexing despite recent growth in the literature on cartoon indexing identified by this literature review it would appear that there is still very little published research available on the ways in which remote users consult indexed cartoon collections indicating scope for further research into this topic the potential for large indexed cartoon collections to be datamined for topic modeling for research especially in the social sciences points to the urgent need for indexers to improve metadata standards and structures to allow improved access to editorial cartoon metadata for computational analysis in an increasingly international linkedand opendata environment the adoption of application programming interfaces such as the international image interoperability framework iiif also has the potential to enable glam sector institutions including image libraries and archives to present image metadata more effectively and to improve interoperability where desired empirical research into these areas would enhance understanding of editorial cartoons indexing and image indexing in general and their findings and evidence could usefully inform practice

purpose the difficulty of attributing subject to editorial cartoons for indexing purposes exists both for traditional paperbased cartoon formats and for digitized or borndigital cartoons this paper presents a selective review of literature on indexing editorial cartoons and the associated challenges designmethodologyapproach a gap exists in published research on indexing collections of editorial cartoons for online search and retrieval this paper presents a review of selected works that specifically address the topic of editorial cartoon indexing within a wider context of research that addresses image indexing subject analysis and indexing challenges more generally works that address the interpretation of cartoons by readers and how readers respond to information communicated by editorial cartoons are also considered findings cartoon controversies in transnational and multicultural contexts experienced through the international news media since 2000 have dramatically increased research attention and publications in this area profound changes in media publication since the advent of the internet have had an impact on editorial cartoonists and cartoon publishing subject indexing of editorial cartoons remains a challenge research limitationsimplications the potential for large indexed cartoon collections to be datamined for topic modeling for research in the social sciences points to the need for indexers of cartoon collections to improve metadata standards and structures to allow improved access to cartoon metadata for computational analysis originalityvalue this paper places discussion of the technical challenges facing indexers of editorial cartoons within a broader context of discussions about the nature and future of editorial cartooning in rapidly changing media and publishing environments

background until the 1960s ethics as an academic discipline hardly ever dealt with ethical questions of everyday life and had a strong focus on abstract debates such as the nature of morality 1 medical practice and the dramatic rise in medical technology gave rise to several pressing ethical questions that increasingly demanded ethical attention and guidance it led to the birth of bioethics a field in applied ethics to provide orientation to ethical issues in medical practice 23 these days societies and certainly also medicine become more and more permeated with technology here used to refer to methods systems artefacts and devices which are the result of scientific knowledge that can be used for practical applications 4 similarly the fields of medicine and the biomedical sciences are increasingly influenced by the development and use of new technologies gene editing organoids and artificial intelligence constitute some prominent examples such technologies have large potential to increase the possibilities for medical research better diagnostics personalised treatment more care at home smarter hospitals and may potentially cure or prevent the onset of diseases simultaneously emerging biotechnologies are paired with ethical questions that include concerns about effectiveness and safety but also with regard to the changing understanding of the human body fairness and equity identity governance and societal implications to deal with ethical questions of technological innovation a comprehensive approach to proactively or parallel guide these technologies into society in an ethically sound way is required while scholarly attention has been paid to identifying and anticipating ethical aspects of innovation in other technological fields like engineering and design 5 6 7 such an approach has not been spelled out yet for medical research and innovation this is remarkable as there are frequent calls for ethical guidance of biomedical innovation also by biomedical researchers themselves new and emerging biotechnologies require anticipation of possible effects and implications meaning that the orientation is not evaluative after a technology has already been developed or about scenarios with hypothetical technologies but realtime for a real technology here we identify six ingredients that are increasingly adopted by ethicists as tools to study and proactively coproduce emerging biotechnologies but these ingredients are only rarely brought together and have not comprehensively been described in the literature we refer to the combination of these six ingredients as ethics parallel research which allows to fulfil two aims guiding the development process of technologies in biomedicine and providing input for the normative evaluation of such technologies parallel refers in this notion to the ethical guidance realtime along the development process and interwoven in the field rather than a lack of interaction with the field or only interaction after the technology has been developed ethics parallel research can be seen as a pragmatic and constructive approach to scrutinize ethical issues of biomedical innovations parallel or proactively as the field develops in order to guide the development process of biotechnologies and to provide input for the normative evaluation of such technologies this approach draws on aspects of bioethics as developed from the 1960s onwards and is inspired by other disciplines such as science and technology studies the social sciences and philosophy of technology to suit the challenges of ethically guiding medical innovation in this paper we outline what we see as the characteristics of ethics parallel research and discuss how we should understand it in the context of medical ethics main text ethics parallel research 6 ingredients we identify six ingredients that together can be referred to as ethics parallel research it concerns disentangling wicked problems upstream or midstream ethical analysis it is ethics from within it includes empirical research draws on participatory design and it focuses on societal impacts as we will describe these aspects are related and even overlap and taken together these six ingredients help to provide meaningful guidance in the development of new technologies in health care and convene to identifying the ethical implications as the input for a normative evaluation we first describe the ingredients of ethics parallel research and we will subsequently reflect on the use of these elements in bioethics disentangling wicked problems biomedical innovations often invoke fierce public reactions and academic controversies that include a large number of stakeholders this also means that many different perspectives questions and implications are involved the societal and ethical challenges of novel biomedical technologies closely resemble what in sts and in policy studies is known as wicked problems 10 wicked problems differ from other problems in the sense that they concern several disciplines and stakeholders on various societal levels and there is no agreement on what constitutes the problem nor on the desired solution in order to understand what stakes are involved which concerns the stakeholders have and which problems are essential a first step to disentangle wicked problems in the field of medicine is to unravel the different viewpoints to identify different stakeholders and to clarify which arguments and interests are involved 11 the aim is to illuminate and unravel the messy debate to separate arguments and values to recognize whether and if so which fallacies have been made to recognize equivocations and to identify whether there are important questions or positions missing or underrepresented this can be crucial to break up deadlocked opposition in strongly polarized debates disentanglement may show that different stakeholders are concerned about different arguments interpret uncertainties differently or may not be informed by reliable information this first step of disentanglement does not presuppose the outcome of such debate yet and aims to identify different stances and arguments which contributes to making the debate more transparent 12 disentangling arguments requires theoretical knowledge to recognize different arguments for which ethicists are wellequipped one needs to be able to convene theories and knowledge to new contexts and to different types of arguments in a second step the different arguments can be weighed and evaluated based on their coherence validity and persuasiveness this second step helps in providing ethical orientation for the debate and the development process of the new technology for example germline gene editing spawned ethical and societal debate about its goals and the desirability of its development and application from the very onset the debate is rich of arguments stakeholders and positions with no consensus on how to proceed there is fundamental disagreement between those who perceive germline modification as a line in the sand 13 others who argue for regulated policy due to potential collective action problems 14 while still others view germline modification in line with other reproductive genetic technologies that can offer carriers of hereditary disease the possibility to have healthy children to those who argue that gene editing research on human embryos is a moral imperative 15 the problem is wicked as there is fundamental disagreement about whether the aim of germline genome editing is worthwhile to pursue in addition even when one would agree about the desirability of the aim one can debate whether the approach is appropriate underlying this discussion are different viewpoints and concerns that depart from completely different understandings of the moral status of the embryo parental rights and duties the value of genetic relatedness and attitudes to technology in addition in many countries the application of clinical germline editing would require a law amendment which makes it not only an academic and public debate but also a political affair there has also been a call for global governance of germline editing 8 which means that international collaboration is also required in other words apart from mere technological concerns the alignment between laboratories clinicians patients ethicists regulators the general public and international partners will be a bigger challenge for developing germline genome editing germline editing is thus an excellent example of a wicked problem as multiple disciplines and stakeholders are involved who are needed to determine how to proceed responsibly and there are diverging views on both the problem and the solution this is partly due to the fact that it is an emerging technology meaning that there is uncertainty about its effects safety and efficacy which is inherent to the early stages of development how such uncertainties are interpreted however differ which underlie the different moral stances of the stakeholders in the debate in order to assess the ethical acceptability of germline editing insights into its safety efficacy and alternatives are helpful but also the potential medical indications and moral considerations need to be disentangled the underlying debate is essentially a question about values meaning and governance for which clarification about the meanings and use of notions such as human identity naturalness and equity are a starting point for understanding disagreement and clarifying the debate ethicists can bring the debate further by disentangling such wicked challenges and by weighing and evaluating the different moral stances upstream or midstream ethical analysis not merely end of pipeline ethics parallel research focuses on ethical guidance of emerging technologies in order to provide guidance during the development process the question about the right time of assessment and intervention of a technological development has been debated since collingridge introduced his famous dilemma 16 in the early stage of development it is still possible to influence the technology itself but it is difficult to anticipate how the technology will impact society whereas once the technology has been developed and implemented it is difficult to influence and undo its impact ethical analysis can be conducted in several phases of technological development reijers and colleagues categorize three phases for such ethical analysis ex ante approaches dealing with nonexisting or emerging technologies intra approaches dealing with technology design and ex post approaches dealing with the ethical analysis of existing technologies 17 there is increasingly a need to provide real time ethical guidance to emerging technologies ethics parallel research focuses on the early phases of technological development to provide upstream or midstream ethical analysis in the early phases of technological development important morally relevant decisions are made that influence the design as well as the effects roles and accessibility of these technologies ethical analysis in these early phases aims to explicate and reflect upon these morally relevant decisions in order to identify the underlying assumptions implicit goals and possible effects of the technology ethical analysis can help in explicating hidden normativity with regard to foreseen users in explicating goals and effects and possibilities for abuse and unintended effects 18 ethical analysis of such upstream phases is helpful to formulate conditions under which technological innovations are acceptable and desirable it thereby overcomes the trap of being too little too late and enables the ethicist who is engaged in the innovation process to guide the innovation processes and governance in a morally sound way for example in the past years a new type of biobank has emerged organoid biobanks the storage of organoids in socalled living biobanks will serve the combined goals of future research and clinical purposes 1920 this mixedmodel of biobanking brings along a distinct set of ethical challenges that should be addressed proactively before it becomes impossible to reverse a socially embedded inert technology biobanks are an excellent example to illustrate the need for guidance during the development as traditional governance methods such as informed consent and ethics committee review are illsuiting to the open ended research of biobanks and illfitting to the ethical challenges that come with the particularities of organoids after all the creation longterm storage and exchange of organoids means that new value is generated out of ordinary bodily material human tissues are transformed into biotechnological artefacts that can grow expand and be stored limitlessly some organoids are even immortal and they have considerable scientific clinical and commercial value 19 20 21 consequently these organoids are of interest to various parties which may raise integrity conflicts and other ethical challenges among these parties are donors patients researchers clinicians industry and the wider public moreover organoids may acquire distinct types of moral value particularly if they resemble human tissues for which research use is ethically controversial and under different legal jurisdictions such as brain organoids gonadal organoids and selforganizing embryo models that mimic early human embryonic development 22 the governance of such organoid biobanks should be organized in a manner that suits the goals stakeholders and values at stake several projects have been set up to include stakeholders of organoid biobanks in an early phase in order to align the design and governance of these biobanks with researchers patient organizations private parties and ethicists 23 one example to achieve ongoing involvement during the biobanking activities is for example working with consent for governance that entails an initial consent procedure that provides donors with information on governance and shifts the ethical emphasis from initial consent to ongoing governance obligations which include protection of donor privacy participant engagement benefit sharing and oversight 21 the benefit of ethical reflection in upstream or midstream phases is that the governance and design can still be influenced and therefore shaped to strike a balance between the sometimes conflicting interests between various parties and to enable this kind of research in a trustworthy way the success of this step also relies heavily on the reflexivity and willingness of researchers to integrate perspectives and interests of outsiders in their technology an example is the h2020 hitcf project which amongst others aims to build a european organoid biobank for rare cf mutation in which the ethics and governance is builtin proactively ethics from within ethics parallel research is conducted from within this means that the ethicist should be embedded and work together with researchers and experts developing new technologies to identify the ethically relevant aspects and implications of new technologies parallel to the development it is crucial to understand the specific technology which mechanisms are essential to its functioning and to stay up to date with new insights and ongoing experiments ethics from within means that ethicists collaborate with benchscientists datascientists or physicians to proactively study and understand emerging technologies and to move beyond the often rather speculative discourses that surrounds new and emerging technologies in the societal and academic discourse 24 by studying biomedical innovations in the settings where they are developed discussed and experimented with reflexivity and awareness of normative implications can be built in the development process so that possible effects and implications of the technology can be better anticipated and steered 2526 by analysing and explicating such normative implications along the design process in close collaboration with the scientists clinicians and developers the ethicist becomes engaged in reshaping or redesigning the technology into more desirable products ethicists can also play a role in identifying desirable contexts and applications of the technology furthermore such collaboration can help identifying safetymechanisms that can be built into the technology and challenges that demand institutional oversight or a procedural solution such as governance to simultaneously steer the use of such technologies in desirable directions while remaining flexible to the further development of the technology along the way for example for the development of biobanks for complex tissues such as organoids the scientific and clinical applications of such tissues need to be understood in order to assess the ethical dimensions possible challenges and solutions by working from within the ethicist is able to provide realistic guidance to the researchers and simultaneously steer the societal debate away from farfetched hypothetical scenarios as indicated above the applications and manifestations of organoids are multiple and the development of new types of organoids and possible applications goes rapidly by working together with researchers and other experts the ethicist is not only uptodate about new insights and applications of these type of complex tissues but the ethicist can also help in shaping the ways organoids are stored and used 20 these aspects are important to formulate conditions and models among which the above mentioned consent for governance models that enables meaningful consent procedures a policy for recontacting donors and terms for the use and ownership of such materials empirical research technologies and innovations in biomedicine commonly focus on enabling new types of research improving care or preventing illnesses once these technologies are developed they will interact with users of such technologies such as patients healthy citizens or health care professionals technologies and innovations in biomedicine differ from other technologies in the sense that they influence our bodies health and wellbeing and also our perceptions of health and disease this specific context demands extra scrutiny and alignment with endusers perspectives given that the effects of such technologies will affect pertinent and private aspects of their lives the perspectives of patients and other societal stakeholders are helpful for understanding how such technologies may be used or which effects it may have in practice given that endusers have a particular type of knowledge 2728 ethical guidance to steer the design of new health technologies is enhanced by including users perspectives 28 29 30 empirical ethics researchsuch as interviews focus groups and surveys constitutes an appropriate way to explore users moral beliefs intuitions and reasoning ethical theory and clinical or bedside reality are complementary and are both important sources of knowledge for providing ethical orientation for such applied questions 3132 foreseen users of the technology have knowledge about their everyday life that is helpful for identifying potential effects and implications of the implementation of the new technology and how the technology can be aligned with the users needs such as the workflow of a clinician or the routine of a patient similarly during the first use of new technologies empirical research can help in analysing how the technologies change values and realities and whether the intended use matches the actual use of the technology for example interviews with organoiddonors with cystic fibrosis have provided useful insights into how donors perceive their relation to the organoid many donors express an ambiguous relation towards organoids 33 they see organoids as both closely and distantly related to them influenced by the material nature of organoids the intended type of application and the donors motives for donating 33 these insights help in formulating conditions under which patients are willing to donate their material and to articulate appropriate governance for the storage and use of organoids in biobanks these insights also inform more abstract debates about the moral status of complex tissues and ownership about bodily tissue and can be used to design consent forms for organoid biobanks participatory design technologies in biomedicine serve societal goals such as prevention or treatment of illnesses and the relief of pain and suffering because of this integration of societal goals in technologies the development of these technologies is no longer perceived to be external enterprise but intrinsically embedded in society 12 this means that societal actors have a stake at scientific developments involving members of society in participatory design can thereby contribute to the legitimization of the development of new technologies which is a different legitimization than the knowledgebased justification for empirical research as outlined under ingredient 4 participatory design has close ties with the notion of coproduction that originates from sts and refers to the simultaneous processes through which modern societies form their epistemic and normative understandings of the world 34 in ethics parallel research participatory design means that patients or publics are not only asked for their opinion or understanding but they are involved in several or all steps of the research they have influence on what the research is about how it will be developed who will be recruited and how the results can be translated into practice ethics parallel research draws on participatory research to focus on the reasons goals and motivations that drive technological innovation and to evaluate whether the driving forces align with societal needs the level of participation can vary based on the questions phase of development and feasibility and should be designed to navigate between inclusiveness and demandingness of participatory practices 35 an example for the value of participatory design can be found in the development of ai it is increasingly recognized that ai has the potential to radically change multiple aspects of our society how we do business how we teach and learn our work environment and tasks our interactions with other humans and also the healthcare we give and receive the ethical implications of the application of ai in medicine go much further than mere technical questions about safety and effectiveness medical ai may change the practice of physicians and thereby influence the patientphysician relationship it may not be understandable how the underlying algorithms come to certain recommendations and it has been widely recognized that if we are to develop ai it should be contributing to the common good 36 given the expected extent and widespread influence of ai on basically all aspects of society publics should be included in decisions about the development design and use of ai especially the participation of publics for the application of ai within medicine is precarious given the central role that health and wellbeing plays in attaining other societal goals participatory design can help to align the goals of these technologies with what constitutes the common good and helps to identify goals and motivations that should drive the further development of medical ai see for example the raidio project societal impacts hard and soft impacts the midstream of technological development is a crucial step because it moves the technology into society this means that first tests are performed in practice for example by a pilot study firstinman study or a first field trial it is also an exciting phase for the ethicist because the analysis can shift focus from intended use to actual use traditional analysis of such early phases focus strongly on safety harm and effectiveness which are in the literature sometimes referred to as hardimpacts 37 hard impacts such as costs and risks are generally relatively easily quantifiable for example an appropriate balance of benefits over risks is one of the cornerstone requirements of clinical research ethics and can be classified as a typical hard impact while hard impacts are important focusing solely on these aspects of technologies will not provide a comprehensive picture of the diverse societal implications of technologies ethics parallel research therefore also focuses on the unquantifiable effects and more complex evaluations of new technologies these effects sometimes referred to as soft impacts focus on the influence of new technologies on our values such as autonomy and human flourishing experiences identity relations and perceptions 37 38 39 the analysis of hard and soft impacts helps to provide orientation to a comprehensive understanding of the most desirable ways of dealing with and interacting with new technologies the analysis of hard and soft impacts can be informed by empirical research but can also be a mere analytical exercise that draws on examples and bioethical theories to give an example one of the pressing questions in the ethical and societal debate on the implementation of ai in medicine is how humans and ai should cooperate while ai is able to deal with an overwhelming amount production speed and multidimensionality of data that well exceeds the limits of understanding of the human brain 40 the role of ai in clinical judgement and in clinical decisionmaking is far from clear the role ai will take will however influences its societal acceptability similarly the ways in which ai can integrate diverging patient values and respect individual patients autonomy have been raised as important conditions for the implementation of medical ai 41 in order to comprehensively evaluate the desirability of implementing medical ai we should focus on both its soft and hard impacts conclusion ethics parallel research brings together elements from traditional bioethics learned from the empirical turn in bioethics 27 and from approaches of sts and philosophy of technology including responsible research and innovation 42 it is as we described characterized by six related and even overlapping ingredients that can be conducted in somewhat overlap next to each other it concerns disentangling of wicked problems it is upstream or midstream it is ethics from within it includes empirical research draws on public participation and it focuses on societal impacts including hard and soft impacts while these six ingredients are increasingly adapted by bioethicists and are not new by and in themselves similarly like in cooking the sum of these six ingredients is more than their parts it should be noted that one does not need all ingredients all the time to still have a lovely mealindeed ethical analysis of new biotechnologies can be conducted without combining all six ingredients together these six ingredients constitute ethics parallel research even if they can vary in terms of intensity depending on the particular technology the combination of these six ingredients allows to fulfil two aims guiding the development process of technologies in biomedicine and providing input for the normative evaluation of such technologies with regard to the former the ethicist aims to guide technology that is not fully developed yet this means that a typical source for ethical evaluation namely morally relevant experiences with a practice or technology is not available to guide the development including the design of technology parallel or proactively the ethicist needs to anticipate possible effects by drawing on multiple sources such as information from the developers publics and endusers simultaneously ethics parallel research interacts with societal stakeholders as the development of new technologies and should be responsive and aligned with societal values by following the ethics parallel approach the ethicist is able to identify and evaluate ethical questions already in the early phases of technological development and to constructively guide the development of new technologies by bringing reflexivity in the design process and information and structure to the societal debate this expands rather than replaces the types of evaluation and roles that bioethicists have in more traditional approaches where ethicists evaluate developed technologies evaluate whether technologies are aligned with existing guidelines or speculate and reflect on questions whether the development of a nonexisting technology would be desirable moreover a distinctive aspect of ethics parallel research is a constructive rather than a pure critical outlook it aims to develop and contribute to bestpractices rather than outlining worst practices importantly ethics parallel research does not aim to replace more traditional approaches for developing normative theories and principles but it results in both empirical and more theoretical insights that can provide the input for normative analysis and the formulation of more abstract normative recommendations the formulation of such normative recommendations remains certainly also an important task for bioethicists and would require an additional approach the insights obtained by the six ingredients can for example be used as input in the widely adopted wide reflective equilibrium 3043 ethics parallel research has like any approach also drawbacks and pitfalls first it is an approach to think with rather than think about practice this means that the ethicist is embedded in technological and scientific practice and must take care to avoid going native embedded ethicists will need to navigate between staying embedded and finding a critical constructive voice as with other potential conflicts of interest ethicists should be transparent about the nature of the collaboration and potential support in addition it may be helpful to also involve an external ethicist to the project when proposing specific guidelines 44 a related point is that for the outside world the ethics parallel researcher may be perceived as a window dresser for technological developments because in contrast to the more traditional image of an ethicist who outlines what is wrong with a certain technology ethics parallel research works closely together with developers of technology and aims to enable and improve technological development one has to stay alert to stay distant from socalled ethics washing second morality does not only influence technology but also vice versa as the technology influences societal values during the technological process the values identified more upstream in the development may differ from the values with which the technology is evaluated more downstream of the development due to socalled technomoral change the moral yardstick to assess the desirability of a certain technology may change along the development of the technological innovation the goal of ethics parallel research is not to formulate conditions for technological innovation that are carved in stone but to remain flexible and reflective throughout the development process so that ethical guidelines remain fit for purpose rather than a dogma the benefits of ethical guidance during the development process should however not be underestimated mitigating negative effects of technologies enhancing positive impact and sensitizing researchers and developers to the ethical and societal impact of their research are in themselves desirable aims within applied ethics third the development of new technologies is unpredictable some technologies develop faster than foreseen others fail unexpectedly while still others may have unforeseen and unintended impacts these issues relate to the anticipation side of the collingridge dilemma in the early stages of development meaningful guidance is very difficult the aim of ethics parallel research to provide guidance in the early phases of technological development therefore brings forward the challenge of finding the right time to jump on and off board the timing will much depend on the specific technology and the way in which it will develop ethicists will have to learn to recognize the right time and widen their skillset to make sense of the early phases of technological innovations in addition they will have to adapt ways of exploring expectations needs and anticipation of patients and other societal stakeholders with regard to new technologies rather than focusing solely on their experiences only then meaningful orientation and anticipatory governance can be formulated to meaningfully guide development of new technologies in this paper we have drawn on three examples organoids gene editing and ai to illustrate the types of issues ethics parallel research is suited for these examples vary greatly in terms of their development societal implications and wickedness we believe that ethics parallel research is a valuable approach for guiding the development of these technologies and virtually any other innovation within biomedicine to conclude ethics parallel research is an approach that is wellsuited to the ethical evaluation of biomedical innovations it means that ethicists identify and evaluate the ethical issues of a novel biomedical technology parallel or even proactively as the field develops by bringing together ingredients that orginate from traditional bioethics empirical bioethics sts and philosophy of technology this approach can ethically guide the increasing permeation of technologies and innovations in the field of biomedicine it widens the roles and judgements from the ethicist to a more anticipatory and constructively guiding role the benefits of this approach are to provide guidance along the process of biomedical innovation to sensitize medical scientists for the ethical aspects of their work and to mitigate negative effects availability of data and materials not applicable supplementary information supplementary information accompanies this paper at 1186s1291002000524z additional file 1 supplemental file 1 description of the technologies used to illustrate the approach of ethics parallel research abbreviations ai artifical intelligence crispr clustered regularly interspaced palindromic repeats authors contributions kj and ab have made substantial contributions to the conception of the work kj and ab have substantively revised earlier version of this manuscript kj and ab have have read and approved the manuscript and kj and ab have agreed both to be personally accountable for the authors own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated resolved funding not applicable ethics approval and consent to participate not applicable competing interests the authors declare that they have no competing interests

background our human societies and certainly also bio medicine are more and more permeated with technology there seems to be an increasing awareness among bioethicists that an effective and comprehensive approach to ethically guide these emerging biomedical innovations into society is needed such an approach has not been spelled out yet for bioethics while there are frequent calls for ethical guidance of biomedical innovation also by biomedical researchers themselves new and emerging biotechnologies require anticipation of possible effects and implications meaning the scope is not evaluative after a technology has been fully developed or about hypothetical technologies but realtime for a real biotechnology main text in this paper we aim to substantiate and discuss six ingredients that we increasingly see adopted by ethicists and that together constitute ethics parallel research this approach allows to fulfil two aims guiding the development process of technologies in biomedicine and providing input for the normative evaluation of such technologies the six ingredients of ethics parallel research are 1 disentangling wicked problems 2 upstream or midstream ethical analysis 3 ethics from within 4 inclusion of empirical research 5 public participation and 6 mapping societal impacts including hard and soft impacts we will draw on gene editing organoid technology and artificial intelligence as examples to illustrate these six ingredients conclusion ethics parallel research brings together these ingredients to ethically analyse and proactively or parallel guide technological development it widens the roles and judgements from the ethicist to a more anticipatory and constructively guiding role ethics parallel research is characterised by a constructive rather than a purely critical perspective it focusses on developing bestpractices rather than outlining worst practice and draws on insights from social sciences and philosophy of technology

compatible to individuals life experiences and cultural values• accepts their identities in order to provide a personal collective and ecumenical dimension • supports the usage of ecumenical and culturalfocused strategies during the therapeutical procedure• and brings to balance the importance between individuality and collectivity during the procedure of evaluation diagnosis therapy and resolution of individuals difficulties 5 social workers belong to firstline professionals who are called upon to support individuals families or groups for a smooth adaptation to a multicultural society where different cultures and ethnicities collide with each other to this matter social workers are called upon to act as intercultural mediators as intermediates between the cultural and the ideological burden of the host country and the burden of the minority groups putting into practice evaluation negotiation and routing of possible issues in multiple levels 6 issues related to insufficient knowledge of the spoken language economic problems loss of social identity difficulties in job placement are reflected on psychological instability of minor populations which is deteriorated by the fact that they are not accepted 78 as ethno cultural religious social entities from the national population it turns out that managing such data is a demanding and difficult task but also a challenging and binding one both for the individuals who seek for help and for the society itself but when the existing and available financial resources and the subordinate social and welfare structures within the framework of the applied immigration policy do not contribute to this direction the operation gets more complicated 9 on this basis the dimension of the implementation of social work can be described as bilateral on the one hand it focuses on the prevention aversion and avoidance of dysfunctional cases in the field of the everyday life of a person a family or even of the social reality of a community and on the other hand it has to deal with difficult conditions that have to be suppressed and eliminated the definition of counseling the meaning of counseling by default calls to mind a dialectical procedure with a clearly advisable and teleological character between the transmitter and the receiver and gradually manages to reach the state of self awareness on this basis the roots of the examined definition had definitely been spotted in ancient years as an indicative element of ideological and internal pursuit and as a clear evidence that internal introspection will always be a human characteristic it is pinpointed not only as a everyday practice among usual people but as a professional practice between a specialist advisor and a civilian client • noted that the counselor does not give advice to his client but acts more supportively and cooperatively in a rather implicit way that second dimension in recent decades has now been reduced to a contemporary independent scientific field certainly there has been a multitude of recorded definitions of this concept from time to time just due to the evolvement and the process of counseling over time apart from the fact that expectations according to human relations are evolving and probably differentiating since rapid changes in local national and international level have taken place there is also a mobility among the scientific field in terms of theoretical approaches and applications as counseling comes closer to a variety of theoretical directions action plans and similar practices listed below a counseling is a procedure focused on learning and takes place in a interactive relationship in order to help individuals reach the state of self awareness and use this knowledge properly in order to become effective members of the society 9 b counseling is a specialized and principle based use of a relationship to enable self awareness emotional acceptance and growth and the optimal development of personal capabilities the ultimate goal is to provide for the individual an opportunity to live adequately and productively αdvisory relationships may vary according to equivalent needs but they can also deal with development issues they can address and solve specific problems they can make decisions and confront with crisis and they can also develop personal ideas and knowledge on a basis of negotiation with emotions of internal conflict or the enhancement of relations with one another c counseling is an interactive procedure of learning between the counselor and the client whether they are individuals families groups or organizations and approaches in a rather holistic way any social cultural economic andor emotional issue according to the above preview it turns out that within the framework of counseling implementation a the counselor and the individual develop a dynamic and lively relationship b the ultimate goal in the whole process is the emotional restructure of the individual the realization of his healthy potential his deficits and misconceptions the need for motivation not passive attitude and to ensure every possible change and better adaptation to lifes data c the element of the emotional and cognitive interaction between these two parts is a determining element for the type of their communication and the heading of the whole therapeutic effort as 10 points out nowadays in the educational texts the terms counseling and psychotherapy are not often discriminated from one another since the theory based to their study is the same characteristically they both rely on audition and discussion by focusing on psychological and psychosomatic volume 3 issue 4 peer rev j foren gen sci copyrights konstantina sklavou 223 problems and changes without the use of drugs in contrast to biomedical approaches 11 differentiation is undertaken only by professionals who practice in the same field of research as well as professors based on differences between these two such as the fact that counseling is of short duration and is mainly used to manage external problems focusing on the development of every positive elements of personality while longterm psychotherapy is used for handling deeper meaning issues focusing on error correction with customers who experience revelations and changes similar to each grade etc κα 12 of course as stated by 11 the term psychotherapy in the strict sense of the term refers to the psychiatricmedical field whereas the term counseling usually has greater applicability in the educational field or even in the field of social work theoretical approaches and models theoretical approaches and models of intercultural counseling on a rather analogical basis and with the variety of problems and consequently the multiple needs of a modern society a wide range of approaches seems to arise with professionals being very interested in it as it seems like a field of education and specialization and hence of methodological practice hereto there will be a reference to the widespread and applied methods in the field of social work as an applied science as well as the prons and cons in relation to the article in question according to the humanitarian existential approach the most important point is its contribution to raising awareness in terms of internal dynamics and freedom personal choice and responsibility on the part of the individual especially when it comes from restrictive environments and there is a need of release from any relative bonds of course this is also a point of censure as this may either collide with culture and temperament or any realistic possibilities for future changes in an external level that would be considered as of nil or of great exceedance and subversion 13 the gravity attributed to the clients value system and target is both valuable and decisive but the nondirectional and clarified attitude of the therapist may work confusingly or frustratingly for someone who looks for a more structured and compact intervention it is therefore important that the existential therapist will motivate him in order be able to search for his her own freedom to make his her choices and take responsibility for them taking under consideration what kind of sacrifices have to be done even if the individual experiences an internal disagreement in the end he will find out what he really wants and finally strike his own balance 13 the point therefore is for individuals to be able to identify the cultural factors that contributed to shape their present self by separating and choosing through a critical process the elements with which they themselves agree and not with everything that simply is part of their culture 14 this of course will be possible only through the assessment of the binary relationship that is being developed on which the existentialists focus based on respect in terms of making choices and the understanding of the subjects world as it is expressed by them 15 thus there is no question of limiting the expression and dictation of the therapists personal values to the other since it is a adaptive approach centered more on universal rather than individualcentral concepts the point is to take under consideration all these elements that make up the identity of people as worthwhile speech 16 οutstanding personalities who contributed to these developments were rollo may irvin yalom and victor frankl the clientcentered or individualcentered approach sometimes referenced as a nondirectional therapy founded by carl rogers reaches the minority groups in a unique way that it has greatly contributed to convergence and mutual understanding between the different adjacent cultural 14 the emphasis given by the counselor on the expression of empathy and respect for his her clients is catalytic and important principles that are used for socialization with various ethnic groups as a demonstrated respect for their heritage facilitate better communication 16 and promotes a necessary emotional support for those who may have been accustomed to unequal treatment also the aspect of the individual being the focus of the whole process is in line with the need when it comes to intercultural cooperation in order to shape it in a context that focuses on the specific characteristics of the individual served rather than the general ones another aspect of the individualcentered approach that is in line with the concept of multicultural sufficiency is that of a nondirectional mindset that allows therapists to learn about every different culture which could be presented by another person with the awareness of the former of their own values and limits strong aid and encouragement on the part of the therapist without the countervailing value of the exhortations and the playcoordination role strengthens the risk of a cumbersome or even negligible impact on the person concerned and thus ineffective intervention of course this applies to cases of servants in need and work more efficiently in structured frameworks otherwise a less directional attitude may be more convenient and more tolerable for individuals with a particular origin and culture the emphasis on the here and now of the individual allows the adoption of short and effective methods responding to urgent situations faced by minority populations without having to deal with inner processes of psyche whose analysis is rather time consuming and often painful of course the above is also supported by the optimistic side of the approach on the basis that the solution lies in the human being itself so it is possible to be found 17 it is obvious that it has contributed in a significant way to counseling as far as its intercultural perspective is concerned the basic contribution of behavioral therapy in the context of its intercultural application is that it attaches particular importance to the cultural and environmental payments of the servant 18 it is argued volume 3 issue 4 peer rev j foren gen sci copyrights konstantina sklavou 224 faithful to modes of operation that have yielded positive results hoping to repeat a similar outcome therefore by developing a new learning framework of rewarding or punishing the expert sets the bases for reworking remodeling and ultimately correcting changing the hitherto unfavorable behavior 19 the control of the current realistic environmental element which is also the manifest form and causality of every problematic situation seems to be more feasible thus a sense of security is ensured because having a secure way and more than one method to achieve a goal they feel fathered and closer to it 20 in addition techniques are used in order to stabilize a plan according to which the whole treatment process will take place in any case positive is the fact that the constant need of its supporters to verify scientifically the results after the continuous evaluation of their work and the corresponding modification of it if necessary 21 has led to a treatment with a proven and clear mode of action which is being considered and reviewed regularly in any case we conclude that there is a need to ensure correct weighing and comprehensive assessment not only of all the dimensions of the problems including those of interindividual intercultural and interpersonal and the available resources for change but also for the consequences and knockon effects of any changes in person and its fields of action the focus of cognitive behavioral in cognitive processes and similar actions is also the nuclear positive element of this practice also for minority populations the recognition by the consultant of being at the crossroads of two cultures and of any confusion and dysfunctional reality that this entails is the basis for creating a ground of gradual awareness of what this means and how they can evolve and operate with the new data of course a targeted careful and discreet approach of the experts side is needed in an effort to assist the individual identify the structural shapes that define himself and to make any required functional changes and not to directly cancel them 2005 a key feature of the ga approach is moreover the empowerment of the individual himself through techniques that he will be able to reapply without the constant guidance of the specialist consequently we have the creation of a cooperative relationship in which particular cultural characteristics are appreciated as part of the personality of the individual without being underestimated 22 in any case however this is a demanding process as the expert calls on the individual to look at a second level the effects of proprietary values and practices 23 which brings the risk of denial even discontinuation of cooperation since while aiming at disengagement from ineffective practices it gives rise to feelings of rejection or even of interference and also that of internal conflict in any case the denial of some personal data does not mean we remove the identity of that person given the depending tendency of many individuals skills and conscientiousness are required by the specialist to ensure the active involvement of the other side avoiding an imbalance in distributed roles to direct and define in an absolute degree an important link between the multicultural treaty and this approach is the emphasis that both sides give to the notion of uniqueness although the concept of multiculturalism refers to the uniqueness and peculiarity of each culture while cognitive behavior of each individual they both do not cease to recognize the need and the right for separate and case by case treatment 24 particularly this treatment can be demonstrated as legitimate and effective when it comes to cases of individuals who come from environments where the family has a decisive role in everydays life of this member and especially when it is extensive collaboration in such a case not only with the individual but also with other family members ensures high chances for a universal utilization of all the available human resources codes norms and family experiences are emerging at both individual and collective levels which should be the key point in the assessment and regulation of the whole process by the specialist 25 the person is usually impregnated as an entity by the elements that make up the culture the social position of the family its ethnic and religious identity and therefore the importance and necessity of taking them into consideration in such cooperation is highlighted there has already been a talk about the gc focusing on cognitive processes where it also has another advantage in dealing with culturally diverse individuals just because it analyzes specific behaviors rather than something abstract or subconscious for someone who communicates in a second language not in his mother tongue or even through a third person clearly serves best an event based approach feelings and behaviors ie more clear concepts 18 the contribution of group systemic theories lies in their particular emphasis on the reduction of any psychosocial problems which are the result of interaction between the individual and the environment in the context of new developing communication systems this manifest itself as a tendency to move away from the traditional linear and rather binding interpretation and practice which is based on the cause effect model the reason for this is a holistic view of the problems with each organization being considered in terms of belonging to systems divided into subsystems and attaching to super systems 2627 thus the person is counted with his emotional burden and his biological dimension as one system a part of a wider family system which in turn is a subsystem of the wider social one 28 the goal here is to acknowledge the achievement of changes in the family system and in the individual as it is a chain process in which the individual is influenced of any change in the functioning of the whole family and vice versa 13 27 with his organizational model 29 with his structural theory and haley 30 with his strategic model are referred as representatives of key family therapies intervention in crisis situations requires beyond the necessary knowledge of the therapist to determine its origin a special approach with a similar focus on the differentiated characteristics of the cultured servant 31 this with the therapist always pursuing an axis of respect actively listening to the information and messages of the individual attaching particular importance to any meaning and making similar correlations and assumptions leads to the foundation of a legitimate and safe therapeutic relationship 3132 the expression of emotions and the way of experiencing and interpreting varying situations has a particular weight in the whole process which is very different from culture to culture in terms of both the way and the degree this is a delicate point for the therapist because through his effort to collect more information it is so easy to exert pressure on the caregiver and make him react 33 it should be remembered that individuals from different cultural backgrounds may recognize their difficult situation and the necessity for help but in fact they rely on identifying it as a concept of therapeutic practice which is developed in western standards 34 intervention in the crisis is therefore offered as a response to such cases as it operates rather independently of binding techniques and monocultural orientations thus allowing the user to identify contact points in a more cohesive framework of cooperation finally the holisticeclectic approach is characterized by diversity due to the incorporation of elements from other counseling models which is considered to be an advantage in working with migrant populations because of the link between multiculturalism and multiformity that itself presents depending on the case freelance is given to the professional in order to choose from a wide range of techniques and methods a proper one and produce the best possible results 35 as a necessary prerequisite for this it is underlined and given the specificity of the population the awareness and proper weighing of the elements which are offered for selection whereas in their individual view they may seem beneficial and productive but in their synthetic exploitation they may not prove compatible 36 the controversial internal situation of most individuals leaves no space for such mistakes in any case a legitimate and not arbitrary manipulation can ensure an equal relationship with the servant in which it is clearly recognized that the former possesses specialized knowledge but does not disregard the life experience of the individual an encouraging fact since he will feel that his own load is respected thus uniqueness is supported and discernment is rejected conclusion the influx in particular unpredicted and uncontrolled of foreign population in each host country and host society is an important condition 37 which is translated in multiple needs such as highlighting the weakness of national and welfare mechanisms polarizing inclinations and discomfort and generally a state of imbalance which requires multifocal intervention substantial involvement with various minority groups should be a realistic goal rather than a desired status cross cultural social work is a golden ticket to this as it approaches by definition minority populations and has the dynamic to schedule a multitude of tasks relevant to them 38 on this basis the framework into which the professional relationship and the relevant ambiance will be developed with the social worker and the interviewee as interactive parts and as exponents of different ethnοcultural and religious heritage comes out as a vital component for a correct and successful or nonsuccessful way of the counseling process these element has become a catalytic component for the correct and successful or not successful course of therapeutic practice each side is not only a physical presence but also a carrier of an alliance of perceptions values and attitudes that are impossible not to interfere in the whole interaction and influence it and while for the interviewee the control of effect of that mixture is not and cannot be the desideratum for the specialist… definitely is… as the status and the project he is called upon to perform do not allow him to be prejudiced on any basis of familiarized meanings certainly that doesnt mean that he must decline those meanings but on the contrary he should be aware of them just like of his temperament and identity and at a later stage being able to realize the interviewees concerns and evaluate any differences that will be found 39 for such purposes among any personal fortification there is also a need for an equivalent fortification in terms of knowledge that of fundamental elements of each culture and the characteristics of its people as some of those representatives a specialist will be asked to cooperate with this is an extremely essential element with increased chances of effectiveness not only for the correct course of the whole procedure from start to finish but also for the operational preparation installation and fulfillment of this procedure 40 already from its initial stage volume 3 issue 4 peer rev j foren gen sci copyrights konstantina sklavou

in our times the extent of the migration phenomenon and its consequences especially on host societies highlights the importance of multiculturalism a highly topical concept that indicates social change and it is translated as the differentiation of the ethnocultural composition of the population therefore new cultural social and religious trends enter into everyday life and obviously all these trends interact with established practices customs mindsets and perceptions in a rather confrontational basis due to distinctness and nonprior contact and they are called up to coexist harmoniously and functionally in an ideal state still with the possibility of imputation to be powerful or even inevitable 1 according to these circumstances multiculturalism is a fact and interculturalism is a goal in other words the equal function and development of all cultures within one society their mere coexistence under the regime of tolerance by the carriers of the dominant culture does not reflect the intercultural ideal from that point of view interculturalism requires multiculturalism but it does not automatically derive from it 2 the basis for the conformation of a society into intercultural one could be a migration for economic or political reasons b repatriation of populations c coexistence of indigenous social groups who share a common ethnic origin with distinctive cultural roots or d the existence of an intermediate civilization by definition it is a process that affects both minority and majority groups with willingness and expectation for solidarity among both sides as they certainly have a decisive role 3 αdaptation to new data on the axis of selfdetermination and awareness requires a lot of effort by both sides like what their functional coexistence requires for as they are representatives of different religious beliefs and different cultural and ethnic identities at this point two essential issues arise the maintenance of cultural elements and the procedure of contact participation and interaction 4 the desideratum or a contemporary social imperative according to the diversity of given circumstances in terms of cultural composition on the one hand is the recognition of value and the reassurance of the equal function on each cultural identity and on the other hand bridge over differences social work and multicultural reality on this basis and according to this direction the concept of intercultural social work has been emerged and updated and it also signifies not only a practice with a supporting role but also a procedure which uses techniques and defines goals

introduction depression one of the most frequent psychiatric illnesses affects around 7 of the worlds older population according to a metaanalysis the incidence of depressive symptoms among older chinese adults aged 60 or above is as high as 227 with more than 90 not receiving quick and regular treatment depressive symptoms not only reduce ones quality of life but it also has a financial impact on society and families depression is more likely to be associated with suicide in older individuals than in any other age group depression was predicted by the world health organization to become the second largest cause of mortality in older adults endangering their health and safety given the deteriorating course and consequences of depression it is critical to discover effective methods of preventing and treating depression in older adults the social participation of older adults is receiving increasing attention as one of the three pillars of active aging social participation has grown in importance as a means of gaining social resources taking on responsibilities gives older people a feeling of meaning and purpose which improves their mental health depressive symptoms are reduced by active social participation in old age in recent years a growing number of studies have discovered that social participation has piqued the interest of researchers due to its low cost and widespread availability it was noted that the influence of social participation on the health of older people varies greatly depending on the type of group involved however little is known about which type and at what frequency of social participation impact the risk of depressive symptoms among older adults these findings encouraged us to investigate the impact of various types and frequency of social participation on depression in chinese older adults previous studies have discovered that older males and females had different levels of mental health and social participation gender differences in mental health are largely constant across studies with older females suffering from greater depression than older male adults prior research revealed the disparities in depression prevalence between men and women previous research on social participation has discovered a gender difference in several forms of social participation furthermore greater levels of social participation may benefit elderly women more than older men as a result we hypothesize that older male and female individuals may have different degrees of social participation and depression as well as different effects of social participation on depression given the importance of social participation in mental health this study investigated the link between different type and frequency of social participation and depressive symptoms in people aged 60 and older as well as whether there is a gender difference in these correlations from a theoretical perspective we propose the following hypotheses hypothesis 1 social participation has a positive effect on the mental health of older adults hypothesis 2 different social participation types and frequency have different effects on the mental health of older adults hypothesis 3 there are different mental health effects on older adults per gender based on social participation the findings will aid in the development of programs to promote active and healthy aging in older adults methods study design and participants china health and retirement longitudinal study national survey of wave four was conducted from august 2018 to march 2019 the charls is a highquality nationally representative longitudinal survey of chinese people aged 45 years or older facetoface interviews were conducted to collect information the multistage probabilityproportionaltosize methodology was used to select participants in four stages randomly in the first stage of sampling 150 counties were randomly selected as representative socioeconomic and geographic areas in china then three main sampling units were selected according to their population following that all households were mapped in each selected main sampling unit and 24 households were randomly selected from all households as samples finally participants eligible for the age requirement were selected the inclusion criteria for this study were as follows being aged 45 and older with no upper age limit and having barrierfree communication skills those who had difficulty communicating were excluded the fourth national survey included 19816 participants we applied to the online charls database in december 2020 and it was approved quickly we limited our sample to participants aged 60 years or older for the handling of missing data the simple deletion method was used to delete the cases with missing variables the final sample contained 6287 individuals with 3163 older male adults and 3124 older female adults symptoms of depressive symptoms the center for epidemiological studies depression scale10 was used in the charls questionnaire to assess depressive symptoms to ensure that respondents understood the content of the scale enumerators were trained on how to correctly interpret the scale entries in the local language so that respondents could accurately understand the scale entries and enumerators correctly recorded the interviews the cesd10 consisted of 10 questions about depressive symptoms with four possible answers rarely some days occasionally and most of the time total cesd10 scores ranged from 0 to 30 with higher scores indicating higher depressive symptoms previous studies have suggested that the cutoff point for depressive symptoms among older adults is 10 for the cesd10 scale cronbachs α for the total scale was 0786 indicating good reliability and consistency the cesd10 has highly validated reliability and validity for older adults in china social participation social participation is the primary explanatory variable in this research the charls questionnaire inquired about individuals engagement in 10 social activities throughout the previous month there were 12 possible answers to this question interacted with friends played mahjong chess or cards or attended a community club assisted family friends or neighbors who did not live with them attended sports social or other kinds of clubs participated in a communityrelated organization did voluntary or charity work cared for a sick or impaired adult who did not live with them attended an educational or training course invested in stocks utilized the internet other or none of these in the last month based on the mainstream social participation classification in this study we examined four types of formal social participation social groups interacted with friends hobby groups played mahjong chess or cards or went to a community club sports groups went to sports social or other kinds of clubs and communityrelated organizations took part in a communityrelated organization the frequency of social participation was graded as never not regularly almost every week and almost daily according a prior study we categorized the answers of almost daily and almost every week into one group as once or more each week therefore the frequency measure of each social participation in this study was coded at three levels 0 none 1 occasionally and 2 one or more each week control variables based on previous research we described the possible confounders of social participation and depression gender age marital status residence educational level sleep duration chronic pain chronic diseases and physical disabilities were all possible confounders these were chosen because prior research has linked them to social participation and depression selfreported sleep duration was obtained via a structured questionnaire with the question during the past month how many hours of actual sleep did you get at night selfreported data on chronic diseases was supplemented with diagnostic evidence from medical records or physician prescriptions chronic conditions included hypertension dyslipidemia diabetes cancer chronic lung disease liver disease heart disease stroke kidney disease stomach disease psychiatric problems memory related disease arthritis and asthma due to the design of the survey chronic pain was assessed by asking participants whether they were troubled by any such body pains chronic pain was recorded as positive if participants responded yes and negative if they responded no physical disability status was assessed with the question do you have one of the following physical disabilities brain damagemental retardation vision problem hearing problem speech impediment disabilities responses were recoded as yes or no data analysis all analyses were conducted using stata 16 first all study variables were analyzed using descriptive analysis to assess the normality of continuous variables the kolmogorovsmirnov test was utilized characteristic differences were examined using the students ttest for continuous variables and the chisquared test for categorical variables the coefficients of social participation were then examined using multiple linear regression models and separate correlations between each category of social participation and depressive symptoms were estimated we introduced the multiplicative interaction term to assess the heterogeneity of gender across the four categories of social participation and depressive symptoms the models were adjusted for gender age marital status residence educational level physical activity chronic pain and chronic diseases the test level was twosided with a p 005 deemed statistically significant results the distribution of cesd10 scores by gender a total cesd10 score of ≥10 was used to identify patients with depressive symptoms the distribution of cesd10 scores in older male and female individuals was depicted in figure 1 using a score of ∼10 as a cutoff point the right side of the score for older women was higher than that of male adults implying that older female adults had poorer mental health than male ones participants characteristics table 1 presents the characteristics of older adults according to gender of the 6287 participants 4969 were women the respondents average age was 7183 years and the majority of them were married in terms of socioeconomic status male participants tended to have a greater degree of educational when compared to female participants most of the participants were from rural areas with respect to the life behaviors of participants female individuals were more likely to have physical activity than male ones furthermore female participants experienced a greater proportion of chronic pain than male participants more females in the study had divorcedunmarriedwidowed status than males with a significant pvalue regarding social participation the high level of participation of older adults in social groups was attributed to the lower physical and residential requirements for this type of social participation it also reflects the strong demand for emotional and social activities among the elderly generally most participants have never participated in sports or communityrelated organizations according to the findings older male individuals were more likely to be active in hobby groups and communityrelated organizations whereas older females were more likely to be involved in social groups and sports clubs regarding gender differences in social participation rates we can see from table 1 that the participation rates of social groups were equal for older male and female adults the participation rate of hobby groups and communityrelated organizations was higher for older males than for older female adults however female seniors had a higher participation rate in sports groups than male seniors social participation and depressive symptoms table 2 presents the multiple regression results for the cesd10 scores in model 1 we find that with the exception of social groups sport groups and communityrelated organizations with the frequency of occasionally all four categories of social participation variables are substantially adversely linked with cesd10 scores however the sign is positive for social groups sport groups and communityrelated organizations with the frequency of occasionally but this relationship was not statistically significant model 2 includes the participants demographic information when the estimates in model 2 are compared to the estimates in model 1 the coefficient of communityrelated organizations with the frequency of occasionally becomes significant and the coefficients of hobby groups and communityrelated organizations with the frequency of one or more each week fall somewhat after including socioeconomic status into model 3 the coefficients of social groups hobby groups sports groups and communityrelated organizations with the frequency of one or more each week decline but remain significant model 4 adds life behavior habit such as sleep duration and we find that all the coefficients of social participation groups are lower than those of model 3 model 5 is further adjusted for health status and the coefficients of social groups hobby groups sport groups and communityrelated organizations with the frequency of one or more each week are weaker in completely adjusted models than in model 1 and continue to be significant female older adults were more likely to suffer from depressive symptoms older adults in rural areas were more likely to suffer from depressive symptoms those older adults with primary and high school or above education level and below had lower odds of depressive symptoms compared with those who were illiterate in addition longer sleep duration was identified as a significant protective factor against depressive symptoms regarding the health status chronic pain and chronic diseases were shown to be highly associated with depressive symptoms in the full model as for physical function those who had physical disabilities had higher odds of depressive symptoms specifically older individuals who engaged social groups one or more each week had cesd10 scores that were 0875 points lower than nonparticipants participants in hobby groups one or more each week received an average of 0641 points less on the cesd10 than nonparticipants participants in sports groups one or more each week received an average of 1672 points less on the cesd10 than nonparticipants individuals who engaged in communityrelated organizations one or more each week scored 2267 points lower on the cesd10 than those who did not the interaction effect between gender and social participation on depressive symptoms to examine the heterogeneity of gender interaction variables between gender and social participation are included in table 3 this interaction is also depicted in figure 2 the interaction effect between gender and social participation on cesd10 scores among older adults significant interaction between gender and social participation was deconstructed by calculating the basic slopes of gender on occasionally and one or more each week frequencies of several categories of social participation older female individuals who participate in social groups are significant in both the occasionally and one or more each week frequency categories in model 6 the findings were positive suggesting that the link between social groups and depressive symptoms was stronger in males than in females in model 7 the effect of hobby groups is significantly stronger among older male adults the coefficient of the interaction between sports groups and gender becomes insignificant in model 8 those older female adults who engaged in communityrelated organizations were substantially more likely to be in the frequency category of one or more each week in model 9 and the sign was positive discussion this study used the charls data in 2018 to explore the effect of social participation on depressive symptoms among older adults in the current investigation we discovered that the average cesd10 score was 746 ± 603 which was slightly lower than the prior study in china furthermore we obtained evidence indicating that older females are more likely to suffer from depressive symptoms which is consistent with the findings of earlier research the findings mean that public health initiatives to enhance mental health should be gender sensitive with a special emphasis on older female individuals we explored the links between different type and frequency of social participation and depressive symptoms we found that when we just adjust for demographic factors the correlations change indicating that gender or married status may have a moderating impact chronic pain chronic diseases and physical disabilities were shown to be highly associated with depressive symptoms in the full model our results are in accordance with prior research that found that health status influenced by physical conditions can be the main and direct reason for depression our major findings demonstrate that there are substantial connections between the four categories of social participation and depressive symptoms participating in social groups hobby groups communityrelated organizations and sports groups with the frequency of one or more each week are connected with a reduced risk of depressive symptoms many prior studies have proven the relevance of social participation in older peoples health scholars have pointed out that participating in social groups hobby groups and communityrelated organizations and sport groups effectively improves mental health in older people participating in social groups can assist individuals in gaining greater social support which may protect against depression social groups are the most accessible form of socialization for older individuals particularly in chinas humane society older individuals who participate in sports and communityrelated organizations are more likely to be content with their lives and retain good attitudes resulting in better mental health high levels of participation in sports and communityrelated organizations have been linked to improved health outcomes particularly mental health among older individuals older adults who participate in sports groups have personal social networks with higher frequencies of interaction and intimacy hobby groups are involved in activities such as playing mahjong chess cards and going to community rooms which are important forms of recreation for the older adults in china a prior study found that playing mahjong or cards predicted a decline in depressive symptoms in older urban respondents participating in hobby groups regularly may reduce the risk of depression in older adults by improving social support participation in communityrelated organizations can provide older individuals with specific social roles and the more roles they have the better their psychological and physical functioning thus we speculate that high frequency of participation in social groups sports groups hobby groups and communityrelated organizations may reduce the risk of depression among older adults we have also found that social groups hobby groups and communityrelated organizations are associated with a higher rate of depressive symptoms of a significantly greater magnitude among older female adults in contrast older male adults are comparatively less likely to suffer from depressive symptoms at a high frequency of social participation one key aspect that may explain the division of gender roles is deeply rooted in ancient chinese society according to a chinese adage the man goes out to work while the woman takes care of the house traditional chinese society holds that women should handle more family intramural affairs while participating in public arena activities is the responsibility of men after retirement men are more likely to be idle while women are still taking care of household chores although china has been promoting gender equality the division of gender roles has been deeply rooted in the generation of older adults in addition most current older adults grew up in a patriarchal era combined with the scarcity of higher education resources most families generally place more emphasis on mens academic education resulting in a higher degree of education among current male older adults than women older adults with higher literacy levels have better financial ability and stronger health awareness and are also more likely to adopt new health concepts and be open to social participation as a result men have better mental health than women as a result older male individuals are more likely than older female adults to acquire a feeling of spiritual fulfillment and appropriate social support from social groups hobby groups and communityrelated organizations it is worth noting that the coefficient of interaction between sports groups and gender became insignificant as a common form of sport with chinese characteristics square dancing is a popular pastime due to its low cost and cheerful atmosphere which also has a significant impact on the mental health of retired older female adults in china the sample obtained for this study is representative of the older population in china and has almost equal male and female representation so the results of this study are generalizable however it must be acknowledged that this study does have several limitations first the depression variable in this study was assessed using the cesd10 with no objective measures second chronic diseases were ascertained by selfreport supported by diagnostic evidence from medical records or physicians prescriptions which may lead to unavoidable misclassification future studies should link participation in different waves of the charls and investigate the trends and patterns of different types of social participation on depression conclusions and implications in conclusion this study offered a foundation for developing depression prevention methods and individual preventative measures through social participation which will most likely provide evidence to enhance mental health among older adults this study suggests that increasing targeted social participation in older individuals of both genders may successfully enhance mental health in china which contributes to the hypothesis regarding the relationship between social participation and depression more research is required to examine the underlying mechanisms behind gender differences in the relationship between social participation and depression the findings of this study have several policy implications first given that the results of this study emphasized the importance of social participation the chinese government should enhance public childcare services and communitybased senior care activities to relieve older individuals of the onerous burden of family care second the government should endeavor to create an atmosphere of respect for women in society and enhance the confidence of older female adults in greater social participation with a more positive attitude data availability statement ethics statement charls was approved by the biomedical ethics review committee of peking university beijing china the patientsparticipants provided their written informed consent to participate in this study 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

objectives social participation may prevent depressive symptoms in older adults but research to date ignores gender differences in the associations between social participation and depressive symptoms the purpose of this study was to determine the effect of different type and frequency of social participation on depressive symptoms as well as if there is a gender difference in these correlations among older chinese adults methods data was obtained from adults aged 60 years or above in the 2018 china health and retirement longitudinal survey a nationally representative sample of older adults in china depressive symptoms were measured using cesd10 social participation included participation in social groups hobby groups sports groups and communityrelated organizations the independent relationships between each type of social participation and depressive symptoms were assessed using multiple linear regression models results a total of 6287 older adults were included in this analysis of whom 4969 were women participating in social groups sports groups and communityrelated organizations with a frequency of one or more per week was all linked to better mental health furthermore our findings suggest that the positive relationship between participation in social groups hobby groups and communityrelated organizations and depressive symptoms is more flexible for older men than for women conclusions older individuals who participate in social participation at a high frequency may have better mental health the findings provide novel insights into mental health from the standpoint of social participation in older adults gender differences in the associations between social participation and depressive symptoms need to be considered when formulating interventions to prevent depression

h azardous drinking and alcoholrelated prob lems such as drinking and driving remain prevalent among adolescents in the united states the 2012 monitoring the future survey indicated that 11 of 8th graders 276 of 10th graders and 415 of 12th graders had consumed at least one alcoholic drink in the past 30 days whereas prevalence rates for heavy episodic drinking in the past 2 weeks were 51 156 and 237 among youth in these three grades respectively the 2012 monitoring the future survey also indicated that 575 of 8th graders 782 of 10th graders and 906 of 12th graders thought that alcoholic beverages would be fairly easy or very easy to get the majority of adolescents obtain alcohol from social sources notably from friends older than 21 and at parties a growing number of states and communities are enacting social host laws to prevent or reduce underage drinking in private settings there are two types of sh laws laws prohibiting hosting of underage parties involve statutory prohibitions enforced by state or local governments generally through criminal proceedings that can lead to sanctions such as fi nes or imprisonment host party laws often are closely linked to laws prohibiting the furnishing of alcohol to minors although laws that prohibit the hosting of underage drinking parties may apply without regard to who furnishes the alcohol second sh civil liability laws which are at the state level only involve actions by a private party seeking monetary damages for injuries that result from permitting underage drinking on the hosts premises sh laws of both types may be effective strategies for reducing underage drinking and related problems such as drinking and driving however research on the effectiveness of either type of sh laws is very limited one study examined effects of state sh civil liability laws on alcoholrelated motor vehicle fatalities among 18to 20yearolds from 1975 to 2005 results indicated a 9 reduction in alcoholrelated traffi c fatalities that was attributable to the presence of sh laws this study also examined effects of state sh laws on selfreported alcohol use heavy episodic drinking and drinking and driving among 18to 20yearolds who participated in the behavioral risk factor surveillance survey from 1984 to 2004 results indicated modest nonsignifi cant reductions in alcohol use and heavy episodic drinking however a signifi cant reduction in the frequency of selfreported drinking and driving was observed in states with sh laws compared to those without such laws when overall trends were controlled for less evidence for the effectiveness of sh policies was found in a recent crosssectional study the presence of local or state sh policies was unrelated to drinking at home or in someone elses home on the last drinking occasion heavy drinking or drinking consequences among adolescents however youth living in communities where sh ordinances had been in effect longer were less likely to report drinking with large groups of peers limited evidence for effects of either type of sh laws on alcohol use and heavy episodic drinking may be attributable to the lack of specifi city regarding drinking settings as both types of sh laws pertain to private settings where underage youth may obtain and consume alcohol in addition the available studies have examined only effects of the presence of sh laws regardless of the content of the law which varies considerably across states and communities in states such as california where no comprehensive statewide hostingprohibition law exists some counties and cities have enacted such laws often in response to a tragic event related to underage drinking in a private setting as part of a study on local alcohol policies related to underage drinking thomas et al obtained information on the presence or absence and the content of hostingprohibition laws in 50 california cities of the 50 cities 24 had an sh law in 2009 sh laws in the 24 cities were rated for comprehensiveness and stringency based on recommended best practices for local alcoholcontrol policies and a model sh ordinance the fi ndings indicate that the most effective sh laws apply specifi cally to underage drinkers require civil adjudication with a swift administrative penalty and do not require prior knowledge variation in sh laws across the 50 cities and interview data collected from adolescents as part of the 50city study allow for an assessment of associations between the strength of sh laws and underage drinking in general and in private settings we hypothesized that adolescents living in cities with stronger sh laws would report less frequent drinking at parties than youth living in cities where sh laws were absent or relatively weak we also hypothesized that sh law ratings would not be as strongly associated with drinking in general as with drinking at parties based on fi ndings of two recent studies with data from the 50 cities we also took into account other city and individual characteristics that may act as confounders including adult drinking bar density enforcement of underage drinking laws and demographic characteristics method study sample and survey methods sample of cities beginning with a list of all 138 california cities with populations between 50000 and 500000 a purposive geographic sample of 50 noncontiguous cities was drawn to maximize representativeness with regard to the geography and ecology of the state the sampled cities tended on average to have slightly smaller populations somewhat less ethnic diversity smaller household sizes and lower median household incomes than unsampled cities on the list of importance however none of these differences was statistically signifi cant and the coverage of these measures across cities was good resampling using different starting seeds provided much the same results offering further evidence regarding the robustness and representativeness of these sampled places youth sample and survey methods this study includes adolescents who participated in at least one of three waves of an annual survey conducted in the 50 cities between 2009 and 2012 the survey targeted adolescents who were 1316 years old in 2009 households within each city were randomly sampled from a purchased list of telephone numbers and addresses an invitation letter describing the study was mailed to sampled households and followed by telephone contact interviewers obtained parental consent for the interviews followed by assent from the youth respondents respondents received 25 at waves 1 and 2 and 35 at wave 3 for their participation in the study institutional review board approval was obtained before study implementation computerassisted telephone interviews were given in either english or spanish at the respondents request and lasted 3040 minutes interviewers assured youth that their responses to survey questions would be kept confi dential and checked to ensure that their responses could not be overheard by someone else in the household of 3062 sampled households with eligible respondents 1543 participated in the fi rst interview of these youth 1312 participated 1 year later in wave 2 and 1121 participated 2 years later in wave 3 the current study is based on data from 1483 youths who participated in at least one wave of data collection lived in the same city across study years and provided complete data for all demographic measures an average of 30 adolescents per city provided data for this study youth survey measures alcohol use respondents were asked have you ever had a whole drink of an alcoholic beverage a whole drink is a bottle or can of beer malt liquor or fl avored malt beverage a glass of wine a shot of liquor or a whole mixed drink respondents who answered yes were then asked in the past 12 months on how many days did you have a whole drink of an alcoholic beverage and in the past 12 months on the days when you drank alcohol how many drinks did you typically have response values for these two variables were multiplied to create a pastyear alcohol quantity × frequency measure alcohol qf consumption measures have been shown to have testretest reliability and validity in clinical and nonclinical studies with adolescents respondents who indicated any pastyear drinking were also asked in the past 12 months on the x days when you drank on how many of these days would you say you had fi ve or more drinks they were also asked thinking about the past 12 months how many times did you drink alcoholic beverages at parties all pastyear drinking variables were log transformed to reduce skewness demographics youth reported their gender age and race ethnicity raceethnicity was treated as a dichotomous variable citylevel measures social host policy hostingprohibition policies in the 50 cities in 2009 were identifi ed through a review of local alcohol policy data using city ordinances available online and interviews with city clerks we rated each citys sh policy based on a coding system developed in previous studies of state underage drinking laws and recommended best practices each city received a 1 if it had an sh ordinance or a 0 otherwise each element of law was assigned points for comprehensivenessstringency or the reverse where individual provisions weakened the law for example 2 points were assigned if the law applied to underage persons or parties 2 if it was a civil law only 1 if it was a criminal law only and 3 if it was both a civil and a criminal law 1 if the law applied to the full range of property types and 1 if there was a knowledge requirement in the law this gave each city the possibility of 7 total points the same approach was used to rate sh policies in 2010 and 2011 strong correlations among the ratings for sh policy in the three study years and comparisons of city sh policies from year to year indicated that there were very few changes during that time we therefore used 2009 sh policy ratings in the current analyses this variable was log transformed to reduce skewness local enforcement activities the level of enforcement of underage drinking laws by police departments in california cities is determined to some extent by funding from the california alcohol beverage control agency therefore we used total funds received from the ca abc from 20082009 to 20102011 as a surrogate measure of enhanced enforcement activities fifteen of the 50 cities had received ca abc funds in at least one of those years ranging from 11500 to 200000 total compliance checks to reduce alcohol sales to underage youth are the most common type of enforcement activity using these funds but they may also be used for other activities such as enforcement of minorinpossession laws because city population size could infl uence level of funding the per capita funding rate was computed this variable was log transformed to reduce skewness bar density in a previous study with two waves of youth survey data from the 50 cities we found that bar density was positively related to youth drinking whereas offpremise outlet density was not bar density may therefore represent both the physical availability of alcohol and community norms regarding alcohol use based on records of licensed establishments obtained from the ca abc we computed bar densities based on the number of bars per roadway mile this measure is thought to be a better indicator of access to alcohol outlets than outlets per square mile adult alcohol use a randomdigitdial household telephone survey of 8553 adults in the 50 cities was conducted in 2009 to assess levels of alcohol consumption and related problems the number of adult respondents per city ranged from 109 to 204 respondents ages ranged from 18 to 98 57 were female and 59 were white the survey included a graduated frequency measure that was used to calculate the total volume and frequency of alcohol use in the past 28 days the mean level of past28day alcohol use was then obtained for each city this variable was log transformed to reduce skewness city demographics measures of city demographics were obtained from 2010 census data city demographics included population density percentage of the population younger than 18 years old and percentage of white and hispanic residents a socioeconomic status factor score was derived from median family income percentage of the population with a college education and percentage of the population that was unemployed these measures were signifi cantly correlated principal components analysis yielded a single factor solution accounting for 751 of the variance data analysis attrition analyses were conducted to determine whether adolescents who participated only in the fi rst survey differed from those who also participated in the second and third surveys with respect to demographic characteristics and alcohol use behaviors at wave 1 multilevel linear regression analyses were conducted with hlm version 70 software to examine associations between citylevel sh policy ratings and drinking behaviors sh policy rating and other alcohol environment indicators and city demographics were included as citylevel variables in all models youth gender age and raceethnicity were included as individuallevel variables in all models drinking behaviors and a time variable were included at the observation level the crosslevel interaction between sh policy rating and time was examined to determine whether it was predictive of outcome slopes the interaction term was dropped from models if it was not statistically signifi cant parallel analyses were conducted for 667 youths who reported any pastyear alcohol use for at least one wave of data collection to determine whether effects of sh policies and other community characteristics would differ when the sample was limited to drinkers results sample attrition attrition analyses indicated that the percentage of female youth did not differ signifi cantly across the three waves nor did the percentage of whites t test results indicated that wave 1 mean levels of pastyear drinking at parties pastyear alcohol use and heavy drinking were similar among youth who did and did not participate in wave 2 mean levels of pastyear drinking at parties and pastyear alcohol use were signifi cantly higher among youth who did not participate in wave 3drinking at parties t 274 p 006 pastyear alcohol use t 261 p 009 mean levels of pastyear heavy drinking were similar among youth who did and did not participate in wave 3 descriptive statistics descriptive statistics for study variables are provided in table 1 the mean sh policy rating was 284 as noted previously this variable and others were log transformed for analyses to reduce skewness prevalence rates for pastyear youth alcohol use were 202 at wave 1 320 at wave 2 and 445 at wave 3 prevalence rates for heavy drinking were 82 at wave 1 146 at wave 2 and 227 at wave 3 prevalence rates for drinking at parties were 15 at wave 1 25 at wave 2 and 37 at wave 3 social host policy and pastyear drinking results of multilevel analyses examining associations between sh policy ratings and alcohol use behaviors are notes qf alcohol quantity × frequency measure a m of log transformed variable b measured as a factor score derived from median household income percentage of population with a college education and percentage of population unemployed reported in table 2 no associations were found between sh policy rating and any of the three pastyear drinking outcomes in addition no crosslevel interactions were found between time and sh policy rating on any of the alcohol use behaviors of the other alcohol environmental indicators bar density was positively related to drinking at parties whereas adult drinking was positively related to pastyear heavy drinking being older and being male were consistently associated with greater heavy drinking greater alcohol use in general and drinking at parties whereas ethnicity was not related to any of the pastyear drinking outcomes we further examined these associations among the 667 youth who reported pastyear alcohol use for at least one wave of data collection a statistically signifi cant inverse association was found between sh policy rating and youth pastyear alcohol use at parties indicating that a stronger sh policy was associated with less frequent alcohol use at parties among drinkers to help with interpretability we also ran the model using poisson regression with the original variables results indicated a modest although signifi cant 3 lower incidence of drinking at parties with each unit increase in the sh policy rating this represents a 20 lower incidence of drinking at parties among adolescents in cities with the highest sh policy rating compared to those in cities with no sh law no association was observed between sh policy rating and overall pastyear alcohol use or heavy drinking no crosslevel interactions were found between time and sh policy rating on any of the alcohol use behaviors of the other alcohol environment indicators adult alcohol use was positively related to overall pastyear alcohol use associations between youth demographic characteristics and pastyear drinking variables were similar to those observed for the total sample to investigate the possibility that sh policies had a greater effect for older than for younger adolescents we conducted additional analyses that included the interactions between age and the sh policy rating for both the total sample and drinkers only these analyses indicated that age did not signifi cantly moderate the relationships between sh policy and any of the outcomes discussion many states and local communities have enacted hostingprohibition laws to reduce hazardous drinking by underage youth in private settings this study is one of the fi rst to examine whether local hostingprohibition policies are associated with adolescent alcohol use and heavy drinking in general and at parties that are typically in private settings results suggest that stronger sh policies are associated with less frequent drinking at parties among adolescents who have already initiated alcohol use sh policies however were unrelated to drinking at parties among all adolescents including those who have not already initiated alcohol use the general measures of pastyear alcohol use and heavy drinking were unrelated to sh policy ratings for both the total sample of adolescents and the subsample of drinkers thus sh policies may be most relevant and effective for deterring alcohol use in private settings for adolescents who have already begun to drink our fi ndings also provide some support for the validity of our sh policy ratings the fact that we found a significant association between sh policy ratings and drinking at parties among alcoholinitiated adolescents suggests that sh policies are effective in a meaningful subset of those situations for which they were designed to address more broadly the harms that result from underage drinking at parties to the drinkers themselves as well as others a larger range of underage drinking policies is needed for example policymakers and researchers may want to consider the two major types of sh laws that can be implemented the fi rst is the type of sh policy investigated here which establishes governmentimposed liability against individuals responsible for underage drinking events on property they own lease or otherwise control these laws can be implemented at both the state and local levels the second type involves an action by a private party seeking monetary damages for injuries that result from permitting underage drinking on the hosts premises only state legislatures or state courts have the authority to impose this form of civil liability these different approaches to sh liability may have different implications for preventing underage drinking and drinking problems the effectiveness of sh laws in preventing or reducing underage drinking will depend not only on the content of the laws but also on public awareness and enforcement of sh laws neither of which was examined in this study public awareness of sh laws may be enhanced through a variety of media channels including written or electronic messages from schools public service announcements and news coverage of related enforcement activities enforcement of sh laws will most likely occur when there is strong support from the city government and appropriate training of law enforcement offi cers who may be accustomed to using partydispersal operations that do not focus on the party hosts when underage drinking is involved in addition resources to support sh law enforcement operations may be limited thus some communities have adopted response costrecovery ordinances where fi nes are imposed on party hosts to cover the costs of enforcement operations and emergency medical services findings of this study should be considered in light of several limitations we cannot make causal inferences because this study examined only the association between sh laws and youth drinking adolescents in our sample may not be representative of all adolescents in the 50 california cities and sample attrition may have affected our results in unknown ways in addition california cities in our sample may not be typical of other cities in the united states in terms of demographic makeup as many california cities have ethnically diverse populations with a relatively high percentage of nonwhite or hispanic residents therefore fi ndings of this study may not generalize beyond the study sample responses to survey questions were subject to recall and social desirability biases which may have led to underreporting of alcohol use although measures were taken to ensure privacy of telephone interviews and truthful responses to survey questions we also recognize the diffi culty of interpreting analysis results given that many of the variables were log transformed before analyses in addition we did not directly measure the level of enforcement of sh policies by local law enforcement agencies a high level of enforcement may enhance their effectiveness additional research is needed to determine whether fi ndings of this study can be replicated in other settings ideally studies with controlled or natural experimental designs are needed to determine whether sh laws are effective future research should also examine the level of enforcement of sh laws which may vary considerably across communities without adequate enforcement support from the public and city offi cials and parental awareness sh laws may be less effective research is also needed to better understand the mechanisms through which sh policies may affect youth drinking such as alcohol availability from social sources perceived acceptability of alcohol use and perceived enforcement of underage drinking laws in addition future research should examine effects of sh policies on adverse consequences of adolescent alcohol use in private settings such as drinking and driving

many states and local communities have enacted social host sh laws to reduce underage drinking in private settings however little is known about whether such laws are effective this study examined relationships between city sh laws and underage drinking in general and at parties in private settings method sh policy data were collected for 50 california cities in 2009 and sh policies were rated for comprehensiveness and stringency annual telephone interviews were conducted with a cohort of 1483 adolescents ages 1316 at wave 1 from 2009 to 2011 to assess pastyear alcohol use heavy drinking and drinking at parties multilevel analyses were fi rst conducted for the total sample to examine relationships between sh laws and adolescents pastyear drinking with other city and individual characteristics controlled for parallel analyses were then conducted for a subsample of 667 youth who had reported any pastyear drinking results sh policy ratings were unrelated to any of the pastyear drinking outcomes for the total sample of adolescents however among pastyear drinkers a stronger sh policy was inversely related to drinking at parties β 06 p 05 but was unrelated to pastyear alcohol use and heavy drinking in general there were no moderating effects of sh policy on change in adolescents pastyear drinking over the 3year period conclusions local sh policies that include strict liability and civil penalties that are imposed administratively may be associated with less frequent underage drinking in private settings particularly among adolescents who have already initiated alcohol use j stud alcohol drugs 75 901907 2014

introduction rural areas in the united states are ravaged by the opioid epidemic 12 residents of rural appalachia are 43 more likely than the rest of the us to die from a drug overdose 3 the rural opioid overdose epidemic has not spared oconee county which is located in the northwestern corner of south carolina and is designated as an entirely rural appalachian county by the us census bureau 4 the overdose death rate in oconee county in 2020 was 189 deaths per 100000 5 and the south carolina state overdose death rate was 349 per 100000 which was ranked as the 17th highest among 50 us states and washington dc 6 while the underlying reasons for the high risk of opioid overdose mortality in oconee county are unknown excess availability of substances a risk factor for misuse 7 was noted by a us drug enforcement administration report which indicated that a pharmacy in oconee county receives the 4th highest number of prescription opioids in the state 8 additionally stigma towards persons with opioid use disorder manifests in low rates of willingness to help someone experiencing addiction or overdose 9 and fits the pattern of low social capital seen in rural communities 10 11 12 a single definition of social capital is not well established 13 14 15 16 it has been defined as the ability of people to work together for common purposes in groups and organizations 17 18 19 and as a capability that arises from the prevalence of trust in a society or community with trust being the expectation of regular honest and cooperative behavior from other members of a community 2021 recent literature has continued to emphasize the trust and collaboration that are inherent to a solid definition of social capital 22 in addition to these less tangible aspects of social capital a tangible definition of social capital has been undertaken and includes such metrics as the number of establishments in religious organizations civic and social associations business associations political organizations nonprofit organizations with a localregional mission athletic clubs and the like 1223 so while social capital has been rightly described as a collective manifestation of the behaviors attitudes and values of individual members of a community 12 it is also more than these attributes these attributes should ultimately manifest themselves in support for and participation in communitylevel institutions when these different perspectives on social capital are combined a holistic definition emerges social capital is a capability arising from both the intangible attributes within a group or community including trust and a willingness to collaborate to achieve a common goal and the presence of tangible social assets institutions capable of improving the life of the community large swaths of the country are negatively affected by low social capital including many rural areas the south and appalachia 12 exploring the reasons for this phenomenon falls outside the scope of this study but several references are included for interested readers 24 25 26 a community with low social capital will find itself at crosspurposes as it attempts to solve problems like the opioid overdose epidemic 27 while the perception that addiction is a failure of morals or of willpower has long plagued americas approach to the opioid epidemic 28 increased social capital in communities has been linked to improved protection from drug overdose 29 still ideologies and attitudes that penalize cooperation and solidarity result in a lack of community resources that might help neighbors experiencing poverty addiction mental health conditions homelessness and other societal ills low social capital creates a vicious cycle or fukuyamas distrust tax 20 as those most in need of the communitys help end up stigmatized marginalized and ignored the problem becomes larger and the community feels even less safe studies have shown that inadequate social capital at a societal level is associated with increased prevalence of oud 112930 since low social capital fuels the oud epidemic and its worst outcomes improving both the intangible and tangible aspects of social capital that directly address the opioid overdose epidemic will attack it at one of its roots and break the vicious cycle keeping oud so prevalent in rural communities harm reduction and recovery support services fall into the category of tangible social capital as nonprofit organizations with the mission of improving the wellbeing and health of the community to combat the local effects of the opioid epidemic oconee county opioid response taskforce was formed in 2019 by multiple community stakeholders including the prisma health addiction medicine center ocort members include representatives from local law enforcement emergency medical services primary care practices county administration the school district and the departments of health and social services treatment and recovery organizations and concerned members of the community to assess community needs and make a strategic plan to address the most pressing opioid unemployed populations could be a step toward improving community uptake of the harm reduction and recovery service resources critical to individual recovery efforts keywords social capital rural overdose opioid use disorder recovery harm reduction epidemic issues ocort conducted a comprehensive community needs assessment in 2019 by disseminating a 24item survey to county residents to measure stigma knowledge and opportunities for interventions and educational initiatives pertinent to oud 9 this survey was updated revised and expanded in 2022 with newly added demographic items and additional recovery and harm reduction services items to assess support levels for organizations capable of mitigating the opioid overdose epidemic in this study using the ocort 2022 survey responses we aimed to identify demographic factors and knowledge beliefs and attitudes toward harm reduction and recovery support that if improved might increase support for community resources to mitigate the opioid overdose epidemic methods setting and design oconee county has a population of 78314 with whites composing 823 of the population according to the 2020 census with respect to tangible social capital the county has one hospital prisma health oconee memorial hospital two community improvement organizations three family support and assistance organizations organizations for poverty and hunger and 34 churches 31 although some of these organizations provide support for individuals with oud the county is currently lacking in resources intended to reduce substance use disorders and mitigate the opioid overdose epidemic the 2022 ocort community attitudes survey had a total of 46 items inclusive of demographic factors and elicited beliefs and attitudes toward individuals with oud and medications for oud in addition to sud knowledge and support for harmreduction services the survey was disseminated via online methods using the redcap platform and solicitation of paper surveys which were then entered into the redcap portal by research assistants the survey was disseminated between may and june 2022 to the general population of oconee county to this end it was distributed through social media marketing on facebook pages run by ocort members via prisma health emailing lists targeted to oconee county zip codes and through direct solicitation of participants by research assistants in 4 primary care offices throughout the county on a set schedule throughout the month the survey received a prisma health institutional review board exemption demographic factors the survey items included the following demographic factors and we dichotomized multiple responses of each item in the following manner for betweengroup comparisons age sex race ethnicity marital status employment household income item responses with prefer not to answer were treated as missing harm reduction and recovery support score outcome we developed an outcome to measure a level of support for oud recovery and for building harm reduction service resources this composite score included 2 items addressing recovery and 7 items addressing harm reduction services the score was calculated as the number of agree responses to these 9 items this composite score is herein referred to as harm reduction and recovery support score the score ranged from 0 to 9 with the internal consistency estimated by a cronbach alpha as 072 the hrrss items included 1 emergency naloxone boxes should be placed in public places for emergency response to overdose 2 i would support provision of moud in the incarcerated population 3 i would support hiv and hepatitis c screening in the county 4 i would support condom distribution in the county 5 i would support having a syringe service program in my neighborhood 6 i would provide financial support for a syringe service program 7 i would support the syringe service program by utilizing the services they provide 8 i would support the concept of syringe services in the community 9 i would support safe consumption sites defined as health services where individuals can inject or consume substances in a hygienic environment under the supervision of trained staff and have opportunities to engage in other health and social services we note that there were additional three items on support for moud methadone buprenorphine and naltrexone however these items were not included in the above hrrss since a factor analysis revealed that these items belonged to a factor different from that of the above harm reduction and recovery support items possibly representing a different underlying construct survey item predictors we considered 22 items related to oud knowledge attitudes and beliefs related to oud individuals with oud and harm reduction as potential factors associated with the hrsss outcomes two groups of each item were classified based on the response to each survey questionnaire item the first and second groups consisted of respondents who agreedtrue and those who disagreedfalse respectively however positive responses between agree and disagree depend on items and are not consistent across all items and some item responses are neutral between them statistical analysis descriptive statistics included mean standard deviation frequency and percentages of survey responses significance of difference in mean hrrss between groups was tested by twosample ttests to identify factors associated with hrrss after adjusting for demographic factors we tested significance of adjusted mean difference in hrrss between groups of each candidate factor using a general linear regression model that included all demographic factors as adjusting covariates we anticipated that at least n 300 residents would respond to the survey to detect with 80 statistical power a relatively small effect size of cohens d unit scale 03 between groups categorized by survey responses all statistical analysis was conducted using r software v405 32 with rstudio 33 and test results with a twosided pvalue 005 were declared statistically significant results participant demographic compositions a distribution of predictor item responses a vast majority of participants agreed that anyone can become addicted to pain medications that it is possible to sustain recovery from oud that it is important for individuals with an opioid use disorder to be part of supportive community and that pregnant women with substance use disorders should have access to comprehensive prenatal care including appropriate counseling andor moud in contrast a distinct minority of participants agreed that oud only affects lowincome individuals and that individuals who receive rehabilitation or treatment will just overdose again approximately three quarters of the participants agreed that an opioid use disorder is a real illness like diabetes and heart disease approximately one quarter of the respondents agreed that they can easily spot an individual in their community with an opioid use disorder the rates of agreetrue responses of all the other items ranged between 25 and 75 distribution of positive responses of hrrss items the agree response rates for individual hrrss recovery support items were 583 for placement of emergency naloxone and 262 for hrrss support for moud among the incarcerated the agree response rates for harm reduction services support items were 907 for support for hiv and hcv screening 829 for support for condom distribution 210 for support for ssp in neighborhood 115 for financial support for ssp 101 for support for utilization of ssp 423 for support 3 factors associated with hrrss the strongest factor associated with the hrrss was the understanding of oud as disease oud as disease which has the greatest adjusted mean difference of hrrss p 0001 after adjusting for demographic factors the effectiveness of moud factor had the second greatest adjusted mean hrrss difference of 111 p 0001 other factors significantly associated with greater adjusted hrrss scores are displayed in table 4 as follows agree on willingness to live in neighborhood of oud same right to a job oud part of supportive community and naloxone administration to a stranger and disagree on can stop drug use abstinence therapy only and oud dangerous discussion this study found a relatively low overall harm reduction and recovery support score in oconee county south carolina at a mean of 41 below half of the maximum hrrss this is consistent with the known low countylevel scores on metrics of social capital and suggests that hrrss could be indirectly measuring levels of social capital as it relates to oud recovery potential particularly as harm reduction and recovery support service organizations fall into the category of tangible social capital furthermore the rates of positive response were smaller than 50 for 6 of the 9 hrrss items nonetheless hrrss of younger and employed respondents are significantly greater than their older and unemployed or retired counterparts although a further analysis revealed that the effect of the employment status was no longer significant after adjusting for age respondents who agree that oud is a disease and who agree with the effectiveness of moud also had greater hrrss in addition respondents with less stigmatizing attitudes in general had significantly greater hrrss a majority of survey respondents support placement of naloxone boxes in public places condom distribution and hiv and hcv screening for recovery support or harm reduction services although respondents are neutral for supporting the concept of ssp and scss they appear to disagree somewhat strongly on locations and utilizations of ssp financial support for ssp and moud treatment for incarcerated population the factors associated with support for ssp found in a subanalysis of the 2019 ocort data 34 were mostly replicated in the present analysis while respondents perhaps understand the need for harm reduction resources such as ssps or scss they might also be somewhat resistant to building or placing physical resources to that end such resistance quantified as lower hrrss is greater for those who disagree that oud is a disease and that moud is effective and is also greater for those who hold stigmatizing attitudes towards individuals with oud thus there is a clear and significant positive correlation among higher hrrss knowledge regarding oudsud and less stigmatizing attitudes toward individuals with oud these results reported in table 4 were not significantly different when the employment status was adjusted for in the model even after further broken down into three categories of employed seeking and retired in rural communities the beneficial effects of ssps and scss have not been well studied although a qualitative analysis and systematic review 35 supported expansion of ssps and scss into nonurban setting as evidencebased interventions to reduce overdose and transmission for infectious diseases in other settings however the effectiveness of ssps and scss has been welldocumented with consistent evidence showing that availability of a ssp or scs does not increase drug use or improper disposal of syringes but reduces overdose mortality and crime for instance ssps reduced drug use and increased drug treatment enrollments in seattle 36 and reduced infectious disease without increasing improper syringe disposal in high population areas such as california 37 a study of ssps in baltimore indicated that after just 2 years of the program improper syringe disposal had been significantly reduced by 46 38 unsanctioned scss have succeeded in overdose prevention infectious disease transmission reduction and have even reduced crime in the united states 3940 similar findings have been reported in urban cities in canada australia switzerland and spain where studies focusing on supervised injection services reduced public drug injections and improper disposal of syringes without any increase in drug injecting drug trafficking crime or overdose mortality 41 42 43 naloxone programs have also substantially contributed to drug overdose reversals from 2010 to 2014 local naloxone program sites increased from 188 to 644 distributions of naloxone from 53032 to 152283 overdose reversals from 10171 to 26453 and the participating states including washington dc from 14 to 30 4445 community harm reduction resources such as ssps scss and naloxone distribution programs are tangible local social capital as it relates to mitigating the opioid overdose epidemic while the attitudes toward these resources are intangible aspects of social capital in a community a lack of support for these harm reduction resources in this studys results and the accompanying correlation between lack of support and stigmatizing attitudes suggests that the hrrss is likely indirectly measuring social capital as it relates to attitudes and institutions that would improve oud outcomes accordingly increasing levels of oudrelated knowledge and decreasing stigmatizing attitudes in the community could be expected to increase support for harm reduction and recovery support resources thus tangibly and intangibly increasing social capital levels these findings highlight the importance of emphasizing education of the general population regarding the neurobiological model of oud and other substance use disorders in general along with communitywide educational efforts to reduce stigma towards individuals with oud if interventions can successfully target older and retiredunemployed persons the improvement may be more marked at the same time to leverage an increase in social capital for mitigating the oud epidemic future research should strive to develop and evaluate comprehensive communitylevel multidimensional interventions targeting populations with high levels of stigma or with inadequate knowledge of oud and its treatments to build resources for recovery services and harm reduction in our rural community a few limitations should be taken into consideration when the study findings are interpreted first the measure developed and reported in this study has not been tested in any other population to date second oconee county may not be representative of us rural counties in terms of rurality population composition or extent of oud burden this limits the generalizability of the findings to a broader rural or urban population third our survey sampling strategy might have not resulted in a representative random sample of the oconee county population as they might have been more motivated to respond by interest in the oud epidemic collecting survey results in medical office waiting rooms may have contributed to the number of responses from women as women are more likely to visit a doctors office people with sud or historically excluded groups are less likely to engage with formal institutions including healthcare and so also may have been underrepresented in this sample therefore the implicated potential influence of response bias further limits generalizability of the findings furthermore the dichotomized associations chosen for the analysis may have combined disparate groups within the community and affected results all but two of the survey items read at an 8th grade level but the other two read at a 9th grade level so it is possible that readability of the survey affected results lastly the prefer not to answer response was treated as missing and its rate was approximately 11 for the potentially sensitive income item although the mechanism underlying any missing item is unknown it was assumed to be missing completely at random conclusions building tangible or physical resources to improve recovery and harm reduction services and improving the intangible attitudes and knowledge that surround and affect the opioid overdose epidemic may mitigate the community destruction caused were the epidemic to spread unchecked in communities with low social capital although the need for these services appeared to be well recognized community willingness to develop the social capital is inadequate as reflected in the low hrrss reported in this study nonetheless respondents with adequate knowledge of the disease model of oud and the effectiveness of moud treatment and those with lower levels of stigmatizing attitudes have greater support for recovery and harm reduction services development and evaluation of comprehensive interventions to improve knowledge and reduce stigma and focusing more on older and unemployed or retired individuals could hold promise as a strategy to mitigate the opioid overdose epidemic in rural communities data availability the datasets used and analyzed during the current study are available from the corresponding author on reasonable request abbreviations competing interests the authors declare that they have no competing interests

background rural areas in the united states us are ravaged by the opioid overdose epidemic oconee county an entirely rural county in northwest south carolina is likewise severely affected lack of harm reduction and recovery resources eg social capital that could mitigate the worst outcomes may be exacerbating the problem we aimed to identify demographic and other factors associated with support for harm reduction and recovery services in the communitythe oconee county opioid response taskforce conducted a 46item survey targeting a general population between may and june in 2022 which was mainly distributed through social media networks the survey included demographic factors and assessed attitudes and beliefs toward individuals with opioid use disorder oud and medications for oud and support for harm reduction and recovery services such as syringe services programs and safe consumption sites we developed a harm reduction and recovery support score hrrss a composite score of nine items ranging from 0 to 9 to measure level of support for placement of naloxone in public places and harm reduction and recovery service sites primary statistical analysis using general linear regression models tested significance of differences in hrrss between groups defined by item responses adjusting for demographic factors results there were 338 survey responses 675 were females 521 were 55 years old or older 873 were whites 831 were nonhispanic 530 were employed and 538 had household income greater than us 50000 the overall hrrss was relatively low at a mean of 41 sd 23 younger and employed respondents had significantly greater hrrss among nine significant factors associated with hrrss after adjusting for demographic factors agreement that oud is a disease had the greatest adjusted mean difference in hrsss adjusted diff 122 95 ci 064 180 p 0001 followed by effectiveness of medications for oud adjusted diff 111 95 ci 050 171 p 0001 conclusions low hrrss indicates low levels of acceptance of harm reduction potentially impacting both intangible and tangible social capital as it relates to mitigation of the opioid overdose epidemic increasing community awareness of the disease model of oud and the effectiveness of medications for oud especially among older and

introduction an earthquake of magnitude 8 struck sichuan province in china on may 12 2008 the catastrophic event caused 69142 deaths with 17551 people missing 1 the disaster was most severe in areas where majority of people of qiang ethnicity resided wenchuan beichuan mao county li county and pingwu the disaster caused a range of negative psychological consequences among survivors such as anxiety depression and posttraumatic stress disorder 2 3 4 numerous studies have concluded that resilience protects against certain negative psychological consequences such as ptsd 5 and depression 6 resilience has been shown to contribute to disaster survivors recovery 7 and is usually positively related to individuals mental health and quality of life 8 there are fiftyfive ethnicities in china from they have different cultural backgrounds which had come to live together in this diverse society gradually forming a plural multicultural society 910 in these culturecontact settings acculturation plays an important role in determining how well people adapt both psychologically and socioculturally 11 acculturation refers to the ways in which members of ethnocultural groups undergo a change following intercultural contact and become involved in the larger society in which they reside 12 some acculturation scholars have asserted that the principles of acculturation theory are grounded in the broader psychological theory of stress and coping 1314 a resiliencebased model of acculturation found that acculturation hassles have both direct and indirect effects on negative affect and have an indirect effect on positive affect specifically threat appraisal and sensemaking coping have a partial mediation effect on acculturation hassles and negative effect while the effect of acculturation hassles on positive affect is mediated by threat appraisal sensemaking coping and meaninginlife 15 the protective factor model of resilience also suggested that in relation to low levels of protective factor higher levels of protective factor buffer the relation between the risk factor and adjustment 1617 over the past several years positive psychology research has focused on relationships between individual positive psychology variables and outcomes however only a few studies have examined the relationships between multiple positive psychology variables such as resilience social support and spiritualityreligion and their differential influence on mental health outcomes therefore the aim of the current study was to examine the relationships between acculturation strategies and resilience taking into account the mediating role of other protective factors of resilience such as spiritual belief personality and social support on people of qiang ethnicity following the 2008 chinese earthquake acculturation acculturation is broadly defined as a process of cultural and psychological change that occurs when two cultural groups interact 11 cultural changes include alterations in a groups customs and in their economic and political life psychological changes include alterations in individuals attitudes toward the acculturation process and their cultural identities acculturation has a strong conceptual and empirical appeal in psychological research because of its hypothesized as well as demonstrated relationships to a wide array of psychosocial factors among ethnic groups that are in culture contact settings these include mental health 18 sociocultural adaptation 14 acculturative stress 1920 selfidentity and personality 21 to name a few berry 1222 proposed a bidimensional acculturation model based on two issues important to those who are in intercultural contact these issues refer to the extent to which individuals and groups seek to maintain their heritage culture and identity and seek to have interactions with people of other cultures in the larger plural society when these two dimensions are crossed four acculturation strategies are defined assimilation separation integration and marginalization assimilation exists when individuals do not wish to maintain their heritage culture and seek to become fully involved with the larger society separation exists when ethnic people place a value on holding on to their original culture and at the same time wish to avoid interaction with the dominant culture integration exists when individuals wish to maintain their heritage culture and also aspire to be fully engaged in the life of the larger society marginalization an exact opposite of integration reflects minimal interest in either heritage cultural maintenance or connection with dominant culture a number of studies have assessed the association between acculturation strategies and psychological outcomes following a traumatic event 2324 some suggest that low assimilation is associated with poorer health outcomes 2526 while others show no differences in health due to low assimilation or that low assimilation is associated with better outcomes 2728 in the current study we examined the effects of these four acculturation strategies on resilience these four strategies are based on two qiang cultural identities their identity with their heritage culture and their identity with the larger national chinese society resilience particularly during the last two decades numerous researchers clinicians psychologists and sociologists have shifted their focus from risk to resilience 29 30 31 32 although no universal definition of resilience has yet been established it is frequently described by two theoretical perspectives a personality trait and a process as a trait resilience is defined as a personal characteristic that allows for success in the face of adversity 3334 as a process resilience involves contextual environmental societal and cultural aspects as well as relationships and opportunities that are available to individuals 3536 generally resilience can be defined as reduced vulnerability to environmental risk experiences the overcoming of a stress or adversity or a relatively good outcome despite risk experiences 37 for the current study we defined resilience as a cluster of personality traits which undergo a change along with personal growth 33 these characteristics of resilience enable individuals to deal effectively with adversity there is much evidence supporting that resilience might help to improve ones wellbeing and promote recovery from stressful situations 3839 moreover characteristics of resilience can alleviateindividual depressive symptoms following trauma events 1640 despite many studies on resilience over the past decade much of the available research has focused on risk for poor outcome rather than resilience per se 4142 in the current study we focus on predictors of resilience and on mediating and moderating effect paths acculturation personality spiritual belief and social support effect on resilience a growing number of studies have assessed the association between acculturation and psychological outcomes following a traumatic event 4344 many empirical studies have emphasized the positive contributions of cultural identity and acculturation in promoting resilience among the youth from diverse cultural and ethnic backgrounds 4546 it is widely assumed that resilience is determined to a large extent by personality 47 some studies have also demonstrated associations between personality variables and explicitly defined resilient outcome trajectories 4849 with reference to protective factors at the individual level other factors that promote resilience include a persons spirituality beliefs religious assets and social support valentine and feinauer 50 noted several resiliency themes one of which was spirituality spirituality has been shown to be a key in promoting resilience 51 and enhancing coping mechanisms in negative life events 52 higher levels of religious involvement are modestly associated with better health after taking account of other influences such as age sex and social support 53 the social support systems are important protective factors for children and adolescents experiencing environmental hazards 54 the buffering model of social support hypothesizes that social support protects individuals from the potentially harmful effects of stressful events 55 hence in the current study in addition to acculturation strategies we considered personality and spiritual beliefs as mediators in the mixed model that attempts to predict resilience under the moderating effect by social support the present study the aim of the current study was to examine a structural model of resiliency in relation to four acculturation strategies personality spiritual beliefs and social support among people of qiang ethnicity in china first we examined the intercorrelation among all variables second we attempted to construct a structural equation model for testing mediation and moderation effects between acculturation strategies and resilience third a oneway analysis of variance was conducted to observe the influence of acculturation strategies on resilience method measures qiang acculturation questionnaire to assess the acculturation of qiang people in chinese society we developed the qaq 56 there were 47 items with participants responding on a five point scale higher scores indicated more acculturation on two dimensions of acculturation framework qiang cultural identity and national cultural identity factor analysis of 30 items in the qci revealed three dimensions qiang knowledge and behavior qiang religious identity and qiang pride the cronbachs alpha coefficient of qci was 092 nci was assessed with 17 items factor analysis showed that this identity also had three components national cultural knowledge national symbolic beliefs and national customs cronbachs alpha coefficient of nci was 088 the neo personality inventory 57 is a widely used instrument to assess personality variables the revised chinese version of the neopir consists of 60 items which assess the personality dimensions through 12 traits with a list of descriptive attributes 58 these 12 traits are supposed to cluster into the 5 factors each trait consists of several items asking participants to indicate to what extent each item fits their condition higher scores on each construct indicate higher levels of that trait the internal consistency reliability coefficients of the scale is 088 connordavidson resilience scale 33 is a 25item measure influenced by kobasas 59 work with hardiness the chinese version cdrisc was revised by yu and zhang 60 respondents rated items on a scale from 0 to 4 higher scores indicated higher resilience this study produced a threefactor structuretenacity strength and optimismwhich corresponded to certain features of chinese culture more notably the chinese version of cdrisc was demonstrated to be a reliable measurement in assessing resilience among chinese sample after the 2008 earthquake 61 in this study the cronbachs alpha coefficient was 086 spiritual belief questionnaire compiled by song and yue 62 was used it had 39 items including 3 branch scales supernatural belief social belief and pragmatic belief respondents rated items on a scale of one to five the cronbachalpha of the whole scale was 068 and those of the three branch scales ranged from 066 to 084 perceived social support scale is a 12item measure compiled by blumenthal et al 63 and it was used for assessing social support psss were assessed on 5liket score ranging from 1 totally disagree to 5 totally agree and higher scores indicated more perceived social support cronbachalpha of the whole scale was 089 and those of the three subscales ranged from 081 to 083 demographic characteristics we measured two demographic characteristics of qiang people age and education statistical analyses the data analysis was carried out using spss 180 the measured model analyses were conducted using amos 200 applying maximum likelihood estimation methods the structural model was conducted to test the significance of the mediated and moderated effects of cultural identities on resilience fit statistics assessed included the root mean square error of approximation as the primary fit criterion with an rmsea of 005008 64 or less an indication of excellent fit and other model fit indices would be reported such as gfi agfi nfi cfi and ifi results and analysis the statistical analysis of common method biases since data from selfreports may produce method biases we adopted an anonymous survey and reversed some items in data processing 65 after data collection we examined the common method biases by the harman 66 single factor test the results indicated fivefactor eigenvalues greater than one and the first factor could explain the variance of 1435 thus the threat of common method biases is not present in this study intercorrelations between all variables table 1 presents zeroorder correlations and descriptive statistics among the primary variables all variables presented significant positive correlations a structural equation model of resilience among qiang sample we proposed a conceptual model based on a previous research on resilience personality and spiritual beliefs were used as mediating variables and perceived social support as the moderating variable the three qiang cultural identity factors formed one variable and three national cultural identity factors formed another since this model on resilience involved a combination of two cultural identities and personality trait and spiritual beliefs overall this measurement model provided a good fit to the data table 2 reports the standardized estimates for the structural models that were conducted to evaluate the mediation hypotheses the standardized path estimates in table 2 for the a 1 a 2 b 1 b 2 and d 1 d 2 paths corresponded to those illustrated in fig 2 for each mediator and resilience analyzed separately the c1c2 paths represented the direct effects of cultural identities on resilience separately and f path indicated the direct effect of spiritual belief on personality in the modified model in addition there was a covariant relation between the two cultural identities the mediation effect analysis found that ethnic cultural identity prediction effect on resilience decreased from 015 to 001 and ethnic cultural identity prediction effect on personality was 014 after adding the mediator variables thus personality and spiritual belief played a complete mediation effect on ethnic cultural identity and resilience and the effect size of 0057 in the same way the national cultural identity prediction effect on resilience also decreased from 040 to 020 after adding the mediation variables and the mediator had a partial mediation effect on national cultural identity and resilience the mediation effect size was 0099 which accounted for an overall of 3311 furthermore the f path indicated that spiritual belief significantly affected personality and the prediction effect size was 0355 in addition we compared modified model and validation model of resilience and the results showed that most of the fit indices were very close it was suggested that the modified model was supported by the other half of the total samples table 3 shows the results of moderating effect between cultural identities and resilience through perceived social support we examined two models using two levels of social support one was default model the other was constraint model grouping regression analysis showed that chisquare value changed significantly therefore social support remarkably moderated the latent variables in this model how does social support exert the moderating effect we explored the interaction of different social support levels and cultural identities on resilience the result showed that there was significant interaction effect f 2857 that is the four cultural identities had an effect on resilience with changes in high or low level of social support oneway analysis on cultural identities and resilience for different acculturation strategies in qiang sample according to the acculturation strategies framework there are four expected acculturation strategies in this study two cultural identities were used to create four acculturation strategies by dividing them at the mean of each scale we found that there were 341 persons in the integration group 270 in the marginalization group 188 in the assimilation group and 99 in the separation group the resilience levels across the four acculturation strategies were significantly different and the effect size was at about medium level qiang people who used the integration strategy had the highest level of resilience in contrast those who adopted the marginalization strategy had the lowest level of resilience those using the assimilation strategy were in the second place with the separation strategy in the third place 67 discussion with 3000 years of history behind them chinas qiang ethnic group has attracted much attention in recent times because of the earthquake in sichuan which occurred on may 12 2008 the earthquake caused an enormous disaster which was not only a natural calamity but also a cultural catastrophe many precious qiang cultural relics were destroyed and some of the qiang intangible cultural heritage inheritance of the people was lost in the earthquake thus it is important to understand how to preserve the qiang ethnic heritage culture and their ways of acculturating after this disaster and also to understand the challenges faced by them in recovering their mental health the current research sought to describe and explain the relationship between acculturation and resilience of the qiang people resilience from a crosscultural perspective involves the examination of multiple phenomena including individual development community impact and cultural systems of thought the variablefocused approaches to resilience research focus on the relationships among stress adversity the influencing factors of resilience and psychosocial functions in this study the structural equation model of resilience showed that personality and spiritual belief had a mediating effect on resilience and perceived social support play a moderation effect after the 2008 chinese earthquake it was found that 898 qiang peoples integration acculturation strategy could positively predict resilience these results are consistent with the previous research 68 69 70 the mediating effect of personality and spiritual belief intercultural psychology has shown that cultural groups and their individual members usually undergo cultural and psychological changes following intercultural contact 1011 retaining norms and values of their original culture is associated with their lower ptsdsymptomatology in the current study qiang cultural identity and national cultural identity were two main cultural identities in qiang ethnicity the correlational analysis indicated that qiangs two cultural identities were positively related this indicates that the qiang people were able to identify with both cultures and both the identities were positively related to personality spiritual beliefs social support and resilience particularly important were the positive correlations between resilience and qiang identity and national identity showing that both identities had a positive impact on resilience other correlations ranged from 49 for resilience and personality to 13 for resilience and social support these findings correspond to recent research by ikizer 71 who found that religion health and positive personality characteristics were the most pronounced factors that were perceived by survivors as being associated with resilience the conceptual model was based on previous research on resilience that showed that personality and spiritual belief could mediate the effect on cultural identities and resilience in order to verify this conceptual model we introduced all variables into the modified model fig 2 clearly shows the paths of the effect of personality on cultural identities and resilience and the effect of spiritual belief on resilience moreover the role of the two cultural identities on resilience displayed significant changes after combining with personality or spiritual belief that is personality and spiritual beliefs had mediating effects on cultural identities and resilience in essence the model pertains to protective factor model the stressors impacted qiang peoples cultural identities and disrupted their state of resilience the personality traits and spiritual beliefs buffered the exposure to extreme stress and promoted resilience recovery acculturation is not a unidimensional process 22 people may acculturate towards the new culture while retaining their heritage culture 11 though qiang people lived in mountains and valleys they successfully integrated into the culture of the larger society with the development of economic and social ties with china qiang society has been gradually influenced by the dominant culture in daily life social customs and religion this is evidenced by their mean score on nci being higher than qci while qiang people strived to hold on to and cherish their ethnic culture they also attempted to adapt to the chinese society koenig and colleagues 72 have provided hypothetical causal models of the religionhealth connection religion and spirituality lead to some psychological traits such as forgiveness selfdiscipline and patience moreover spirituality beliefs served as an intrapersonal factor associated with social adaptation and were a coping resource 73 this was manifested through trust and faith and by promoting individual strength to sustain the hope for a future 74 moreover qiang peoples personality traits such as extraversion and openness could promote their integration into the dominant chinese culture and society in a metaanalysis of the role of integration in adaptation during acculturation this double identity and the acculturation strategy of integration have been shown to help individuals adapt while living interculturally 75 recent research has indicated that immigrants personality traits were closely related to their resilience 76 resilience was associated with a personality trait pattern that is cooperative responsible optimistic and mature 77 interactions among different combinations of personality traits have strong effects on the perception of mental health 78 in our study qiang peoples two cultural identities jointly contributed to 3311 of the variance being accounted for resilience through personality and spiritual beliefs in addition fig 2 also presented the direct effects of two cultural identities on resilience and spiritual belief s effect on personality all the path coefficients of validation model were good fit for the data these results supported the view that personality traits and spiritual beliefs can be subject to cultural influence 79 and predict on resilience 4780 the moderating effect of social support social support refers to the resources provided by others that assist individual in daily activities 81 higher levels of perceived social support are known to decrease negative psychological outcomes by providing a buffer from stressful events 82 after the wenchuan earthquake the chinese government provided a large number of resources for positive coping such as rebuilding houses public facilities and roads to recover from adversity as soon as possible many nongovernmental organizations also played a large role in the reconstruction of their community and society there were many temporary tent schools set up by volunteers in the earthquake zone some important donations from all over the world through nongovernmental organizations were transported to the disaster area meanwhile the qiang people took some positive selfhelp measures in daily life to cope with the adversity caused by the disaster adversity in this process qiangs heritage cultures and customs attracted unprecedented attention of the public and qiang people got additional social support s including sufficient relief materials rebuilding of many of the postdisaster rebuilding projects by the state and local government and a lot of spiritual encouragement and emotional supports from family and friends moreover optimism selfconfidence and persistence as the invisible power existed in qiang ethnic culture and this helped people cope with the distress and adversity however an important question here is whether these sources of social support influenced the relationship of cultural identities with resilience we supposed that there was a moderating effect on cultural identities and resilience through perceived social support table 3 verified this assumption the result showed that there was a significant difference in prediction effect on cultural identity and resilience under the high or low level of social support or low furthermore the interaction analysis verified that the effect of cultural identities was effect on resilience was affected by high or low levels of social support that is social support moderated the path of cultural identity to resilience research has shown that social support can be a robust protective factor when people experience stressful events often people can rely on friends and family for support they can rely on their own strengths or seek meaning in religious and spiritual beliefs 84 in the present study perceived social support from family friends and important others became the main source of support among qiang people to sum up it was inferred that resilience was promoted via a number of protective factors linked to lower stress including a strong sense of spirituality belief and perceived social support 8586 moreover perceived social support moderated the path of cultural identity to resilience of qiang people after the earthquake integration is the optimum acculturation strategy for qiang peoples resilience berry 12 proposed that there were four acculturation strategies based on peoples orientation to two underlying dimensions in this study these two dimensions were conceptualized and operationalized as qiang cultural identity and national cultural identity when crossed they produced four acculturation strategies of integration assimilation separation and marginalization a oneway analysis on cultural identities and resilience indicated that there were significant differences in resilience across all four acculturation strategies and the acculturation strategies could significantly affect qiangs resilience the integration strategy was the most optimal style to promote the development of resilience followed by assimilation separation and finally marginalization as expected the integration strategy was the most the preferred style by qiang sample indicating that multicultural values were accepted by them which is consistent with the chinese policy of national unity furthermore qiang people may not have suffered intense psychological conflict when they attempted to integrate into dominant cultural society this result is consistent with many other findings eg 1268697587 a recent study has found that low assimilation individuals were more likely to experience negative life events and also more likely to experience postdisaster panic attacks and have higher anxiety and have poorer mental health status 23 conclusion resilience is the ability to spring back from adversity and to successfully adapt after traumatic events the present study verified that two cultural identities and four acculturation strategies could significantly predict on resilience in people of qiang ethnicity the structural equation model analysis also showed that personality and spiritual beliefs had a mediating effect on resilience and social support moderated the path of cultural identities to resilience perhaps the most significant contribution of this study is that the qiang peoples cultural identities and their acculturation strategies were able to predict their resilience after the devastation of the 2008 sichuan earthquake there are some limitations to the present study first the research is largely based on quantitative methods in future studies it would be illuminating to combine quantitative and qualitative methods in order to explore the meaning of the relationship between acculturation and resilience second the four acculturation strategies can be measured in various ways including using scales to directly measure the four strategies in the present study we used an indirect measure and inferred the four strategies from the two cultural identities in future studies crossvalidation could be achieved by using both kinds of measurement all relevant data are within the paper and its supporting information files

international research has mostly confirmed the positive association between acculturation strategies and resilience in ethnic groups but the mediating and moderating mechanisms underlying the relationships are still underinvestigated the present study aimed to investigate the associations between acculturation strategies based on two cultural identities and resilience of 898 qiang ethnicity volunteers mean age 295 especially exploring the mediating and moderating effects of personality spiritual belief and social support on the relationship between acculturation strategy using two cultural identities as latent variables in model analysis and resilience following the occurrence of 2008 wenchuan earthquake in sichuan taking such mechanisms into account results were as follows 1 all variable presented significant positive correlations 2 consistent with the mediating hypotheses personality and spiritual beliefs played a partial mediating role in the relationship between two cultural identities and resilience 3 high or low level of perceived social support had a moderating effect on cultural identities and resilience 4 the integration strategy was the most optimal style to promote the development of resilience but marginalization was the least effective style

our current consumptogenic food system has exceeded planetary boundaries and is a primary driver of deteriorating human and planetary health held in march 2022 the public health association of australias food futures conference was an opportunity for those working across the food system to connect share their work and advocate for a sustainable equitable and healthy food system the conference theme transforming food systems for the planetary and public good consisted of five subthemes food systems for local and global good ecological nutrition social mobilisation for planetary and public good food sovereignty and food equity students and young professionals as future leaders are integral in transforming food systems however given the scarcity of funding available for research academics early in their careers have reduced opportunities to contribute to research and thus are underrepresented in grants publishing scientific societies and conference plenaries thus we developed the satellite event the future of food research an early career showcase to platform initiatives from early career researchers in areas integral for improving planetary and public good the showcase presented valuable opportunities for capacity development networking and reflections from ecr about how to navigate the challenges of building an engaged academic career this commentary synthesises the valuable internationally applicable work and perspectives of ten emerging food systems leaders to highlight their voice and opinions and to demonstrate the value of including ecr in all aspects of conducting and disseminating research this includes fostering leadership developing intersectoral partnerships and building workforce capacity this work describes key food systems considerations and highlights implications for future research policy and practice in this space food systems governance and regulation healthy and equitable food systems transformationwherein the systems of food production through to food consumption contribute to a safe sustainable affordable accessible and nutritious food supplyrequires widespread transformation in the policies and processes governing food systems ecr have been pioneering research into the impacts of international trade and investment agreements on national food environmentsmaking a significant contribution to our understanding of the impact of public policy on nutrition and health this work demonstrates that the current trade and investment system has produced a global food system that preferences heavily processed products and increasing corporate concentration intersections with contemporary issues such as calls for reduced animal products in the global food supply have also been highlighted for example trade and investment rules regarding nondiscrimination may inhibit national policies which attempt to obstruct the marketing of alternative plantbased proteins at the request of domestic meat industries greater engagement from public health nutritionists in this space is required to ensure that trade and investment agreements can be leveraged to deliver healthy and equitable food systems breastfeeding is the optimal or first food system for infants when a mother cannot provide her own milk the who recommends donor human milk obtained from a milk bank or through safe informal arrangements in the community various milksharing practices and policies address concerns about risk and ethics but face commercial pressures from novel technologies and international trade potentially distorting infant feeding systems by drawing theories of multicentric governance empirical studies of legal structures and interviews of key actors research demonstrates that in australia the regulation of milk sharing is fragmented with conflicts between policy and social objectives and sources of authority policy focused on milk as a product and milk banking lacked integration with breastfeeding while informal systems of milk sharing captured local social processes important to resilient infant feeding systems globally local food policy in research and public fora on food system governance much attention is given to the role of state and federal governments and the food industry however relatively little is known about how local governments and civil society organisations contribute to creating a healthy sustainable and equitable food system the strengthening local food systems governance project included a policy mapping study that audited food systemrelated policies developed by all local governments in the australian states of new south wales and victoria to expand on these findings focus groups with six local governments identified common enablers of and barriers to development and implementation of these policies additionally a survey of civil society organisations revealed a wide variety of organisations activities and policy priorities which were further explored through focus groups with nine organisations to strengthen the role of local governments and civil society organisations in food systems they require dedicated funding to undertake food systems work and better coordination across all levels of government between government departments and across all sectors of society this research provides evidence to support advocacy for food and nutritionrelated legislation that protects and promotes health complementary research has explored the policy response of local government authorities globally to contribute to the populationwide shift towards healthy and sustainable diets called for by the eatlancet commission based on a review of relevant united nations publications a set of thirteen desirable dietrelated practices were identified and presented to demonstrate how they can trigger a wholeofsystem transformation including where food is sourced what is eaten and how food is consumed to explore and map policy options available to local government authorities to facilitate the populationwide uptake of these practices a scoping review of milan urban food policy pact signatory cities was published demonstrating bold leadership and innovation occurring by these urban cities this review highlighted that while a holistic approach considering health equity and the wide scope of the food supply chain is being taken opportunities exist to leverage the dual benefits to human and planetary health of policy actions such as those which discourage the overconsumption of food including animalderived foods and the regulation of ultraprocessed foods commercial determinants of health national dietary guidelines are one important lever to promote healthy and sustainable food systems and diets yet research suggests that few dietary guidelines present straightforward advice regarding ultraprocessed foods instead reverting to euphemisms that can be exploited by food companies for marketing understanding the gap between evidence and policy is a political question research has been undertaken to explore the intersection between corporations politics and healtha field referred to as the commercial determinants of healthand questions who has power where power comes from how power is exercised and how to challenge power applying a commercial determinants of health lens to food system governance questions the logic of publicprivate partnerships and the risks of conflicts of interest when powerful food companies have a seat at the table with nation states ultimately efforts to promote more sustainable healthy and equitable food systems must contend with the vested interests that pull the financial strings and drive evergrowing corporate consolidation the food and beverage industry frequently acts to influence food and nutrition policies preventing the introduction of barriers to the sale of their unhealthy products research is underway to describe the commercial determinants of health in the philippines and how this disrupts policy development the food and beverage industry in the philippines builds its power and influence by occupying key positions forming coalitions operationalising its extensive resources and swaying constituents to support industry objectives industry engages in a range of tactics aimed at influencing policy development and implementation including contacting policy makers directly promoting substitute policies presenting evidence and data that they have generated themselves and offering gifts and financial incentives to government agencies and individuals industry messaging commonly frames globally recommended policies as having unintended negative impacts and being ineffective at improving health as a result food and nutrition policies in the philippines have been delayed watereddown or abandoned as such ecrled research is important for advocating for legislation to protect and promote health through food and nutrition policies sustainable healthy diets measuring and monitoring characteristics of diets at global and national levels are needed to inform and assess the effectiveness of policy actions that promote sustainable healthy diets in 2019 the fao of the united nations and the who reported sixteen guiding principles for sustainable healthy diets but these principles have not yet been operationalised into a diet quality metric novel research aimed to develop a multidimensional diet quality index based on recommendations for sustainable healthy diets through a scoping review of the literature on how principles of such diets are considered in metrics used to assess diet quality globally no existing dietary metric captures all principles of sustainable healthy diets notably the significance of ultraprocessing environmental and cultural aspects of diets is generally understated this highlights the importance of revising current dietary recommendations especially to include emerging topics food systems monitoring has identified consumer behaviours as key drivers of the food system which can be addressed to encourage more healthful sustainable diets by individuals communities or nations however to date there have been no reported measures for assessing food acquisition preparation meal practices and storage all key components of food literacy the development of a measure to assess this component of the food system has been hindered by low agreement on a definition and conceptualisation of food literacy however a recent publication reported agreement on the vidgen gallegos model as the core conceptualisation of food literacy this allowed for the development of the international food literacy questionnaire a questionnaire which adheres to the four domains and eleven components of food literacy by vidgen gallegos using comprehensive validation techniques the iflq19 fills a substantial gap by allowing for consumer behaviour monitoring and surveillance within the food system food equity and sovereignty there is little literature in australia that acknowledges the ingenuity and adaptability of indigenous people to western agriculture with the conversation instead contending whether agriculture systems were evident before colonisation there are only a few instances which discuss the coexistence of indigenous and nonindigenous people and even less acknowledgement that considers the cross learning of cultures on stations the australian perspective is approximately 40 years behind the discussion when acknowledging international perspectives creating further tension and unease between nonindigenous and indigenous people emerging research aims to reform the current position in australia by enabling indigenous culture to be seen as a fluid concept rather than having a static demeanour ultimately this work contends that an aboriginal person farming today is as authentically aboriginal as what this person would have been throughout timewe are the same people but just a people in change with global food systems currently dominated by powerful actors fair opportunities to participate in food and health decisionmaking have been compromised indeed the voices and values of those experiencing social andor economic disadvantage and the poorest dietrelated health remain underrepresented in food system decisionmaking policies research and advocacy efforts to challenge similar exclusion practices international movements by disability and first nations advocates have long championed the phrase nothing about us without us if we are to ensure that everyone has access to a healthy diet especially in the wake of the global covid19 pandemic we must start listening to and acting on the voices of communities who are facing the harshest impacts of our unhealthy unfair and unsustainable food systems irrespective of location this is likely to necessitate the creation of safe spaces for people to share their stories shared ownership over public food system initiatives and ongoing investment in diversifying and empowering community leaders in our food systems conclusion ecr are integral in food systems transformation and advocacy improved representation and diversification of ecrs across food systems research is important both because diversity in voice and opinion are essential for equitable practice but also to foster leadership skills and innovation into the future indeed recent reforms from the national health and medical research council have sought to lower the barriers for ecr to access competitive funding overall this commentary highlights the diverse yet interconnected work guiding future research and practice related to food policies and systems governance at local national and international levels the influence of commercial factors and the need to maintain food sovereignty and equity as central foci this work highlights how ecr are integral in upholding the legacy of leaders in this field through publication contributions and by building workforce capacity these themes and the inclusion of researchers across all career stages in publishing scientific societies and conference plenaries must be prioritised and acted upon if we are to ensure continuity in progression of food systems transformation for healthy and sustainable food systems for all global

our dominant food system is a primary driver of worsening human and planetary health held in march 2022 the public health association of australias food futures conference was an opportunity for people working across the food system to connect and advocate for a comprehensive intersectoral wholeofsociety food and nutrition policy in australia to attenuate these issues conference themes included food systems for local and global good ecological nutrition social mobilisation for planetary and public good food sovereignty and food equity students and young professionals are integral in transforming food systems yet they are underrepresented in the academic workforce across publishing scientific societies and conference plenaries a satellite event was held to platform initiatives from early career researchers ecr in areas integral for improving planetary and public good the research topics discussed in this commentary reflect subthemes of the conference under investigation by ecr food systems governance and regulation local food policies commercial determinants of health sustainable healthy diets and food equity and sovereignty

introduction communitybased research in higher education offers valuable benefits to the community the university and students included in the practice yet for various reasons it remains less common than other related forms of community engagement expanding the cbr practice to reap more benefits requires cultivating greater familiarity about cbr among those potentially interested diffusing expertise about how to initiate and implement cbr projects and promoting greater institutional recognition and support for those engaged in other words it must be institutionalized at the campus level here we describe our efforts in recent years to institutionalize cbr at our small regional public university through a series of related initiatives before describing those initiatives and our plan to assess their effectiveness we will describe how cbr relates to other community engagement practices as well as how cbr is commonly implemented on our campus with attendant examples contextualizing cbr cbr is a form of community engagement in which research is conducted in partnership with and on behalf of the community typically a nonprofit organization serving the community we use the term cbr following early seminal research by strand et al but those general practices are also commonly referred to as community engaged research cbr and cenr are distinguished from traditional academic research by the communitys engagement involvement and partnership in all parts of the research process cbr also provides opportunities for community engaged learning for students as a pedagogical practice cbr goes beyond service learning which attempts to link academic study with service by creating a partnership of students faculty and community members who collaboratively engage in research with the purpose of solving a pressing community problem or effecting social change thus change within communities is forefront and student learning occurs through participation in the research process although cbr and service learning may develop independently cbr on our campus has emerged out of servicelearning initiatives in our campus framework we conceptualize cbr as a combination of two high impact practices service learning and undergraduate research in which the service conducted for the community is research facilitated by undergraduate students although cbr does not require student participation as a teaching university committed to service learning we have sought to promote student engagement in cbr while community partnership defines cbr it exists along a spectrum of community research practices communitybased participatory research defines the highest level of engagement characterized by its deep and ongoing relationship with community while cbpr represents a valuable model it is not always possible to meet that ideal nor is it always necessary community partners often need research to address specifically defined needs for which they lack resources or expertise a heavy time commitment in the process represents a cost to be minimized or balanced out such research service is particularly valuable for resourcelimited organizations that are often so busy juggling their organizations and clients various immediate needs that they do not have time for such work such projects also tend to be very applied as partners have less interest in broader theoretical issues and disciplinary debates on our campus while we recognize the value of the cbpr model most research with the community is of more targeted and limited duration to a large extent that targeted engagement model is a corollary of the characteristic noted previously studentengaged projects are conducted in the context of classes which means that most projects tend to be one semester in duration we will provide some examples to provide a more concrete sense of the general type of cbr projects that fit the description above and are engaged through our institution program assessments are a common need for partners and our students and faculty have engaged in assessments of farmtoschool programs and a local homelesstohousing program projects have also focused on clientneeds assessments to help partners better serve the community such as for a local food pantry or a free medical clinic another recent example is a survey of clients at a local center for the performing arts to find ways to serve the public better and underscore their value to the community a related type of research focused on volunteers assessing their satisfaction motivations needs etc for instance survey and interviewbased projects have focused on volunteers for a community hospice service provider a local foster youth facility and a program to provide medical services to our local homeless population another area of research partnerships focuses on providing secondary data analyses for example a demographer and his students provided detailed community information to a statewide human relations organization to better help them serve and partner with local communities another project partnered with our local commission on the status of women to provide detailed information about issues of inequality in our county such limited scope and duration cbr projects have proven successful in serving partners while providing valuable experiences to students the projects described above represent a critical mass of cbr projects to date but they do not exhaust the full range of projects as we institutionalize cbr and expand its practice the types of projects engaged will inevitably expand benefits of cbr advocates of cbr have identified various pedagogical benefits for students and how these benefits may be distinct from those of traditional servicelearning experiences perhaps most importantly it allows students to grapple with abstract and technical methodological concepts in an applied realworld situation working with community partners also increases buyin and motivation for students since they see how knowledge and information can be used as a tool for social change not just a grade cbr projects also provide valuable professional development for students as they develop their communication and research skills the benefits of cbr also extend to the community faculty and the institution communitybased organizations and by proxy the community they serve benefit by gaining access to new information or more developed analyses that may be inaccessible given their limited resources andor expertise faculty can apply their skills to realworld situations and often feel immense satisfaction and pride when students enthusiastically use their emerging disciplinary skills and knowledge through cbr institutions can also become an integrated community aspect rather than maintaining their presence as a separate ivory tower this integration facilitates the community getting to know more about the institution and those within it while encouraging the institution to think critically about its role and responsibility to the community despite its immense benefits for students and the community the unique challenges and obstacles of cbr result in its underimplementation in higher education specifically since cbr combines service learning and undergraduate research the associated teaching load and expectations are higher for cbr than either of the other two hips individually in servicelearning courses learning and even civic engagement is not a guaranteed outcome of service participation and community partners may receive relatively little in return for the resources invested in training and monitoring students service experiences in cbr when research is conceptualized as service students and faculty face greater consequences for failed service projects may have greater difficulty bridging the expectations of community partners and the goals of academia and must work within various institutional constraints those challenges represent cumulative obstacles that must be addressed at an institutional level if cbr is to be widely practiced reaping the benefits to students communities and institutions here we present our efforts to do so by raising the visibility of cbr on our campus diffusing cbr expertise and supporting those who are interested in as well as those already engaged in cbr collectively those efforts have sought to institutionalize cbr the importance of institutionalization our conception of institutionalization draws from sociological research focusing on processes by which a practice is supported and sustained through routine reproductive procedures to the extent that we have effectively institutionalized cbr on our campus we expect the practice to be sustained via initiatives we have already implemented on a more concrete level we mean that cbr becomes an accepted expected and commonly available option for faculty to choose from when they design their courses similar to how other hip teachinglearning options have become commonly recognized practices it is important to note that institutionalization is not the result of a single initiative but a number of articulated initiatives designed to work together to achieve the necessary collective foundational requirements of institutionalization the following represents the collective requisites that we recognized at our university increasing the visibility of cbr on campus and in the community so that it is recognized as a common and beneficial pedagogical practice cultivating and diffusing expertise in the implementation of cbr projects to serve as a reservoir to draw from when faculty decide that they may want to undertake a project and supporting cbr in ways that make it more feasible for the people who have to make the greatest investment in bringing it about in the following sections we describe the initiatives we designed and implemented to address each of those requisites collectively they represent our attempts to overcome key challenges of institutionalization such as gaining a critical mass of faculty involvement diffusing core competencies for practice and elevating the work of cbr so that it can be more officially recognized the three initiatives described below focus on creating and expanding awards and recognitions developing a repository of model cbr reports and building a faculty fellows program we describe each component and the role it is designed to play in the institutionalization process cbr on our campus is still in a state of incipient institutionalization in part because pandemic procedures made it significantly more difficult to initiate and engage in community partnerships thus while each of the initiatives below was implemented prior to the pandemic the expansion and institutionalization of cbr largely stalled throughout the pandemic however over the past year we have seen expansion take root and we have begun formally assessing the effects of our initiatives in the spring and summer of 2023 university context and components of institutionalization foundation for institutionalization csuci was established in 2002 as the youngest university in the california state university system over the past two decades our campus has built a foundation of initiatives to institutionalize communityengaged learning more generally which has made it an appealing beachhead for our efforts to institutionalize cbr consequently it is important to briefly describe these more general initiatives before moving to those addressing cbr specifically our campus is the youngest in the csu system and the cornerstone of our foundation in communityengaged learning began with a commitment at the system level to support and promote servicelearning experiences for our students that commitment created a critical funding source and a broader support network for communityengaged initiatives on campus moreover community engagement was integrated into our founding mission statement at the campus level as one of four mission pillars and is thus a central component of campus identity those systemlevel and campuslevel commitments led to the creation of the center for community engagement which leads these initiatives on campus the cce is centrally located and supported by permanent staff positions including a fulltime director of community engagement approximately a decade ago the campus also committed to a fulltime community partner coordinator who serves as the primary point of contact between the university and community partners the university also supports a cce faculty director who serves as the principal liaison between faculty and the cce beyond these staffing and personnel commitments the cce also benefits from a system allocation of 45000 annually and a campus allocation of 10000 annually csucis cce is one of a network of community engagement centers across the csu system with one on each campus the systemwide network and cce personnel described above have been critical in developing an interactive campuswide database of community partners this userfriendly database is designed to connect students to community partners and track their servicelearning activities faculty use it as well to explore and consider appropriate community partnerships the cce has worked to institutionalize community engagement through a range of initiatives all guided by the seminal work of furco in institutionalizing service learning recent fiveyear strategic plans for the cce have intentionally designed developmental programs to move our campus to higher stages in furcos model of institutionalization from critical mass building to quality building to sustained institutionalization some of the programs implemented to realize that transformation include annual awards and recognition programs a range of faculty development programs initiatives to build capacity for servicelearning among community partners and events to facilitate connections between faculty members and community partners these initiatives have fostered a culture of community engagement on campus and commitment to highquality communitybased experiential education for our students beyond its institutionalization of community engagement our campus has also moved toward greater support and institutionalization of undergraduate research in recent years specifically undergraduate research has become partially institutionalized through faculty positions space on campus and oncampus student conferences to this point undergraduate research has been primarily supported by grant funding although the campus is initiating a shift to internal funding sources since we conceptualize cbr when implemented with students as a form of service learning wherein the research is the service provided we see cbr as a strategy to strengthen service learning and undergraduate research given the greater institutional commitment to student research at the current juncture the increased association will likely benefit cbr although we have not yet built those bridges the following sections describe the three initiatives that have been the focus of our work toward institutionalization raising visibility awards and recognitions program one of the fundamental tasks of institutionalizing cbr is raising the practices visibility before any initiative can gain traction potential practitioners need to know what it is and why it is valuable one of the areas where the cce has had the most success in raising the visibility of service learning and community engagement generally has been the gradual expansion of its awards and recognition programs over the past decade while those programs have roots before that there was a concerted effort to expand them beginning around 2013 when two authors had the opportunity to work together in cce leadership roles the expansion started with the annual yearend celebration of service designed to highlight and bring greater visibility to all aspects of service on campus at the time the celebration was a modest affair attended by several dozen faculty staff and students with annual awards for a faculty member a student and a community partner over the next halfdecade the celebration of service expanded to become an annual signature event on campus with an attendance of approximately 200 although attendance declined significantly during the pandemic while the event was discontinued or held online it has rebounded to about 140 in the spring of 2023 as we return to inperson events awards and recognitions were also expanded and an annual activities awards and recognition booklet was created presenting notable community engagement projects all of those helped bring much greater visibility to service learning and community engagement generally and to the cbr projects initiated in that space in 2018 the celebration of service became a great showcase for all aspects of community engagement and we inaugurated the communitybased research award for a faculty member who implemented a notable project or otherwise promoted cbr in addition a concerted effort was made to highlight cbr projects through the poster session and in the annual awards and recognition booklet distributed across campus and externally those efforts have significantly raised the profile of cbr on our campus among multiple constituencies the celebration of service includes students faculty and community partners which not only disseminates notable models of cbr but also fosters networking opportunities that can lead to new partnerships another strategic audience has been higher administration and in recent years the event has typically been attended by deans provosts and university presidents in 2022 our new university president attended and commented that he had been unaware of the extent of the work being done in community engagement and that he was impressed with what was on display administrators frequently request awards and recognition booklets when they lobby with legislators in sacramento if cbr is to become institutionalized it is vital for administrative leaders to support such efforts and spotlighting cbr and its benefits both at the celebration event and in the booklet are critical ways of garnering that support raising models and marketing credit creating a cbr repository one of the ongoing challenges in promoting cbr is that the balance of benefits and challenges does not accrue to the same parties moreover the party most critical for initiating cbr projects with students the faculty member carries the largest share of the burden and arguably has the smallest direct benefit there are clear rewards for faculty in terms of satisfaction but the professional benefits are minimal despite growing pressure for communityengaged work to be formally recognized in retention tenure and promotion policies faculty conducting cbr with students are often either credited for teaching or service rather than serious research that lack of credit for faculty represents a serious limiting factor for the expansion of cbr while cbr projects can represent solid research contributions they are rarely amenable to peerreviewed publications since they are not designed to be generalizable disciplinary contributions and therefore do not satisfy current requirements for tenure and promotion consequently significant investments in cbr projects that benefit community partners students and the institutiongenerally go unrecognized in faculty advancement applications and portfolios and their professional records students are likewise often unable to properly document what likely represents their most important research experience and contribution in any formal or permanent way to provide formal recognition for significant cbr projects we worked over many years to develop an online repository of cbr reports conducted by faculty and students at our campus branded all reports included are reviewed for the quality and contribution of research and clarity appropriate to general audiences this repository serves multiple purposes most directly it creates an online home for projects that can serve as models for those interested in engaging in cbr for community partners it also creates a permanent record of their research to be accessed and used years later in addition it generates a sense of excitement and connection to the university to have the reports officially archived for students it is a potential resource for graduate school or job applications since they can provide a permanent link to reports presented in a digital home that properly highlights them perhaps most importantly it allows faculty to document significant contributions in a way that can be professionally recognized while we initially considered creating a peerreviewed repository that might represent core publications in the retention tenure and promotion process we decided that it would blur the lines too greatly between disciplinary research and the kind of community and informal research that is more common for cbr so while publishing in the repository does not contribute to the core metric for tenure it contributes in a visible way to round out a tenure file and provides credit to faculty for their work regardless of whether they want to claim that credit as part of their research service or teaching responsibilities overall the repository increases the visibility of cbr and pulling them together creates a multiplier effect that further raises the status of cbr on campus moreover we are working with library facultystaff to migrate these reports into scholarworks a csu systemwide repository of faculty work to be visible beyond our campus unfortunately we could only establish one annual volume before we entered the covid19 pandemic and have not yet completed new rounds of submissions reviews and publications so it remains somewhat sparse and skeletal however we are again receiving new submissions and the third component of our institutionalization efforts promises to cultivate new submissions to the repository cultivating and diffusing expertise cbr faculty fellows program the final strategic leg of our institutionalization efforts is our cbr faculty fellows program the cce has been expanding faculty development programs for some years building on workshops and consultations addressing various aspects of service learning for example as we deepened our focus on social justice projects we initiated our first faculty fellows program in 201920 the community engagement and social justice faculty fellows program that program was designed to include up to six faculty members in a series of workshops where we brought in nationally recognized figures in the field to discuss various aspects of service learning to deepen social justice engagement over the course of the year the cohort met for six workshops the cbr faculty fellows program was initiated in 202021 designed with the ce sj program as a model cbr faculty fellows participate in six workshops over the course of the year workshops in the first semester explore foundational issues such as definitions and the benefits of cbr to students and the community we routinely invite former faculty fellows students and community partners to discuss their experiences with cbr and its subsequent impacts the second semesters workshops are organized around the series of tasks to be completed to effectively design a cbrbased course those topics are presented in a discussionoriented context where participants help others troubleshoot challenges and identify solutions previous fellows come to each workshop to discuss their inprogress or completed projects including the obstacles they have confronted and the solutions they have developed all participants receive a 1000 stipend and are required to attend workshops arrange to teach a cbrbased course in the following year attend and present in the annual celebration of service submit a report to serve as a reviewer for the repository and to generally serve as a cbr mentor for others on campus cbr institutionalization assessment plan as noted above each of these efforts was designed to create synergies with the others and make specific contributions to the institutionalization of cbr on our campus collectively they are designed to provide more support and recognition of cbr diffuse expertise for cbr and expand the implementation of cbr unfortunately our initiatives culminated right at the onset of the pandemic which stalled progress and prevented the anticipated expansion of cbr the pandemic also forced us to postpone a formal assessment of these initiatives now that we are moving past the pandemic hiatus the initial formal evaluation will occur in 202324 we present our assessment plan here in condensed form to give readers a sense of what we will seek and what we hope to find our assessment focuses on gauging the extent to which cbr has been institutionalized on our campus that is the extent to which it has become recognized as an effective and feasible pedagogical option for appropriate courses we hope to find evidence that our initiatives have contributed to the interest and practice of cbr and that these efforts have cultivated opinion leaders who can advocate for its persistence and expansion additionally we plan to assess what other initiatives might help our campus take the next steps in deepening institutionalization assessment design our assessment design focuses on the two primary constituencies integral to institutionalization faculty and community partners as these two groups are the ones who take the lead in planning and implementing projects they are the participants who have the greatest impact on the initiation and practice of cbr students represent a third critical constituency but they are generally uninvolved in making decisions concerning the initiation of projects and therefore less directly essential to institutionalization we will utilize a mixedmethods assessment strategy which includes indepth interviews with cbr practitioners and a survey to assess interest among those currently engaged in service learning but not yet engaged in cbr additional information on the thematic focus of research components is discussed below while table 1 lays out the basic assessment logic our faculty assessment will focus on our past and current cbr faculty fellows to learn about whether cbr has established itself as part of their regular teaching practices and to find out how we can better encourage and support their efforts that research will be completed through a series of indepth interviews the secondary component of our faculty assessment focuses on the broader population of faculty involved in service learning but not yet participated in cbr these data will be collected via an online survey our goal here is to learn whether these faculty are aware of cbr and whether they may be open to practicing it in their classes in tandem these data will provide an assessment of the cbr fellows program as well as the potential for expanding cbr in the coming years undoubtedly we will also learn more about facultys specific institutional challenges as they consider adopting cbr our assessment of community partners follows a similar data collection plan the first component of our community partner assessment will be indepth interviews with partners who have collaborated with students and faculty on cbr projects in the past we plan to learn about their experiences and how they got engaged in cbr we will also ask whether they plan to engage in those processes in the future and how we can better support them like our data collection plans for faculty the second component of our partner assessment will focus on a broader set of partners specifically all partners in our community partner database maintained by the cce this component conducted as an online survey will seek information on partners interested in cbr and learn what we might do to encourage and support that interest challenges to institutionalization we look forward to exploring our formal assessment data especially since in the spring of 2022 we saw colleagues return to cbr projects that they designed as fellows we again recognized significant cbr projects at the first inperson celebration of service in three years and we have seen a renewed flow of submissions to our repository furthermore informal networks of support and assistance have emerged among those interested in cbr while the impact of our efforts is only suggestive at this point we are hopeful about the future of cbr on our campus and yet we remain aware of the challenges ahead to further institutionalization first there is still progress to be made in elevating cbr to the visibility and support of comparable programs such as undergraduate research which has received high visibility in recent years as well as extensive economic support in the form of faculty release time summer stipends and funding for both conference attendance and conference production while such support is feasible for cbr projects and can even result in longterm federal funding and research agendas those supports are not currently available for cbr on our campus it is important to recognize that the support for cbr as a type of service learning and undergraduate research is not a zerosum competition but rather a mutually beneficial practice second we need to do more to hardwire cbr into the retention tenure and promotion processes as noted above cbr bridges traditional rtp categories but there is a lack of clarity about how to count it especially as research activity each of the three components of our work above helps to clarify that but we still need to help faculty by clarifying how to present cbr in their files moreover research is arguably the most high value of the three categories but also the one where our initiatives have established the least foothold consequently we are initiating conversations with strategic academic programs about the possibility of introducing contributions to our cbr repository into the core publications metrics beginning with programs that use a point system that would allow such contributions to count toward research but not be commensurate with a peerreviewed publication additionally the structural constraints of the academic year pose several challenges similar to servicelearning courses courses engaged in cbr are often constrained by the academic semester as well as the heavier workload and expectations of cbr projects engaging in highquality cbr projects on such a timeline is extremely difficult and most faculty opt for students to work in groups to complete the research twosemester timelines are better for such work however not many twosemester sequences are available instead suppose cbr projects are planned to be more than one semester in that case the faculty member typically continues the project with a new set of students each semester which can undermine commitment and motivation for the project this also has serious complications for sustainable partnerships since communitybased organizations operate on a yearround schedule moreover faculty may have little say in their teaching assignments and may not be able to continue an unfinished cbr project into the next semester while these challenges may seem daunting there are ways to mitigate them especially with institutional support next steps and conclusion the timing of our initiatives was unfortunate in that we had just begun to make significant headway toward institutionalization when we were hit with the onset of the pandemic we are now working to regain that momentum as noted our celebration of service has nearly returned to its prepandemic vibrancy and for 2023 the cce sponsored a cbrfocused forum prior to the main event titled realizing the promise of cbr approximately fifty individuals attended a presentation from a widely recognized scholar and practitioner of cbpr followed by a facultypartnerstudent panel presenting their cbr partnershipproject followed by an opportunity to network all of which increased excitement around cbr despite this excitement and the positive outcomes cbr projects offer for students communities and institutions institutionalizing such a challenging and rewarding experience is its unique hurdle our initiatives to institutionalize cbr described here have focused on strategically building on institutional precedent and support for community engagement we plan to continue these efforts while expanding our focus to other opportunities for example the cces engaged departments initiative has focused on encouraging and supporting departments in developing strategies to more deeply integrate service learning into teaching and curricula as well as in scholarship and faculty evaluation we plan to integrate cbr into the framework for engaged departments as we expand the initiative beyond individual disciplines lies another opportunity to integrate cbr with interdisciplinary efforts interdisciplinary cbr partnerships would strengthen students learning opportunities potentially reduce faculty workload and have a larger impact on community partners another opportunity we are currently exploring is how to highlight and bring together all types of communityengaged research disciplines approach communityengaged research differently and that variety should be spotlighted and celebrated an umbrella website would be ideal for this effort preexisting archives or repositories like would not be subsumed in this effort but be incorporated as an example and maintain themselves as a standalone repository we recognize that not all universities have the same foundational principlespillars of community engagement embedded in their mission and history and may be considering how to engage in cbr in less supportive environments while other institutions are further ahead however we hope these initiatives will spawn ideas for administrators and faculty interested in making cbr a cornerstone of undergraduate education

communitybased research cbr presents a wide range of benefits in higher education to students community partners and universities yet on our campus and many others cbr remains less common than other related highimpact practices hips such as service learning and undergraduate research due to a lack of effective institutionalization here we detail our efforts to institutionalize cbr on our campus to expand the practice and its resulting benefits appropriately these efforts focus on three initiatives raising the visibility of cbr diffusing expertise to implement cbr and providing critical support for designing and implementing cbr after our narrative case study we also include our assessment plan which utilizes a mixedmethods approach to explore how our initiatives have made an impact on faculty and community partners involved with cbr as well as to assess interest and knowledge about cbr among faculty and community partners who are currently involved in service learning but not yet involved in cbr we present our efforts as a model with ideas to offer other universities seeking to increase the implementation of cbr

introduction unaids has identified ambitious treatment targets of having 90 of people living with hiv know their hiv status 90 of those diagnosed with hiv receiving antiretroviral therapy and 90 of those on art virally suppressed by 2020 despite these goals gaps across the hiv testing and treatment cascade persist according to 2016 estimates from unaids 70 of plwh worldwide knew their status 53 were on art and 44 were virally suppressed delayed art initiation and disengagement from hiv care are common particularly in lowresource settings dropoff between hiv diagnosis and art initiation has been consistently documented particularly in lowresource settings the world health organization recommendation to treat all plwh regardless of clinical or immunological status may facilitate more timely art initiation largescale success of universal treatment strategies requires a more comprehensive understanding of known barriers to early art initiation art adherence and retention in care this work aims to advance a more comprehensive understanding of the interrelationships among three known barriers to art initiation or adherence psychological distress hivrelated stigma and low social support among individuals initiating art mental disorders are among the most common comorbidities among plwh across the world and are more prevalent among plwh than in the general population it has been estimated that 50 of plwh meet criteria for one or more mental or substance use disorders psychological distress and mental disorders have been consistently associated with suboptimal hiv treatment outcomes including late art initiation and lack of timely viral suppression hivrelated stigma is also highly prevalent among plwh and consistently associated with suboptimal hiv treatment outcomes and barriers to treatment including nondisclosure of hiv status and poor art adherence hivrelated stigma has been associated with poor mental health among plwh including symptoms of depression and posttraumatic stress disorder low levels of social support have similarly been identified as a risk factor for poor engagement in hiv treatment and poor mental health among plwh ethiopia has a generalized hiv epidemic with 590000 plwh aged 15 or older for an estimated hiv prevalence among adults of 11 although estimates vary substantially across the country the government of ethiopia has adopted the unaids 909090 targets and is making progress towards attaining these goals among ethiopian plwh 67 know their hiv status 59 have initiated art and 51 are virally suppressed in recent years ethiopia has enacted laws and regulations to prevent hivrelated stigma in various spheres including employment education healthcare and housing for example ethiopian law and policy prohibit mandatory employmentrelated hiv testing and hivrelated employment discrimination in addition human rights protections for plwh have been incorporated into ethiopian hivaids policy despite such regulations and similar to research from other countries both plwh and healthcare providers in ethiopia report that hivrelated stigma persists as has been found elsewhere high hivrelated stigma and low social support have been significantly associated with depressive symptoms among plwh in ethiopia while psychological distress hivrelated stigma and low levels of social support are each independent barriers to art initiation and adherence the interrelationships between these three risk factors remain poorly understood particularly among individuals enrolling in hiv care or initiating art in lowresource settings a population key to the successful implementation of universal test and treat strategies the objective of this research was to investigate 1 if hivrelated stigma or social support was associated with psychological distress 2 if social support modified the relationship between hivrelated stigma and psychological distress and 3 if relationships among psychological distress hivrelated stigma and social support varied by type of stigma among individuals initiating art in oromia ethiopia methods the analysis is based on the multilevel determinants of starting art late study a prospective cohort of patients initiating art at hiv clinics in the oromia region of ethiopia participants were recruited from six publicsector hiv clinics that received support from blinded at blinded through funding from blinded individuals were eligible for enrolment into the parent study if they were at least 18 years of age initiated art between june 2012 and april 2013 and spoke amharic or oromiffa all clinics are secondary health facilities in urban areas inperson interviews were conducted with 1180 plwh aged 18 or older newly initiating art the structured questionnaire was administered within two weeks of art initiation and included questions on sociodemographics psychological distress hivrelated stigma and social support the study was approved by the blinded written informed consent for the interview was obtained from participants prior to study enrolment measures psychological distress psychological distress was assessed with the kessler psychological distress scale which has been previously validated in ethiopia the k10 is a 10item questionnaire designed to assess psychological distress by asking about anxiety and depressive symptoms in the past four weeks scores range from 10 to 50 scores between 10 and 16 were coded as no or low psychological distress scores between 17 and 29 were categorized as mild or moderate psychological distress and scores between 30 and 50 were categorized as severe psychological distress hivrelated stigma anticipatory stigmastudy investigators knew of no scales validated in subsaharan africa to measure anticipatory hivrelated stigma at the time of data collection thus anticipatory stigma was assessed with 12 yesno items created in accordance with the concept described by earnshaw and chaudoir a total anticipatory stigma score was constructed as the proportion of endorsed items from among all questions the participant was eligible to answer anticipatory stigma scores were categorized into tertiles based on distribution in the sample population formal validation of this scale is warranted and forthcoming recent internalized stigmainternalized stigma in the past three months was measured with the 5item negative selfperception subscale of the hivaids stigma instrument plwha developed in subsaharan africa an additional item not from this scale also was included response options ranged from never to most of the time and were recoded so that higher scores represented higher internalized stigma because responses on this scale were skewed responses were categorized into tertiles recent enacted stigmaenacted stigma in the past three months was measured with nine items selected from hasip subscales items inquired about how often the participant had experienced rejection due to their hiv status with response options ranging from never to most of the time because the reported frequency of occurrence of all items was low the summary measure was recoded as a dichotomous variable with response categories of any recent enacted stigma and no recent enacted stigma social supportsocial support was assessed using a scale developed by wortman et al for the coping and change study a psychosocial supplement to the chicago site of the multicenter aids cohort study social support was assessed with nine questions concerning whether the participant has someone to 1 talk to if upset or depressed 2 talk about an important problem 3 take care of her if she had to stay in bed for several weeks 4 borrow money get help getting to the doctor or other small immediate help 5 borrow money for a medical emergency 6 give information or guidance 7 ask for advice 8 take care of her children if she got sick and 9 accompany her to the clinic if needed response options for each item ranged from 1 to 5 scores were summed and categorized into tertiles sociodemographic characteristicssociodemographic variables included age sex education religion relationship status number of children type of living environment employment status and household food insecurity in past year the urban rural variable was derived by dichotomizing a selfreported threelevel variable that asked participants if they lived in a rural area the town where study site was located or another town individuals who reported that they lived in a rural area were categorized as rural individuals who reported that they lived in the town where the study site was located or in another town were categorized as urban household food insecurity in the past year was assessed by asking participants how often their households had trouble satisfying food needs in the past year response options included never seldom sometimes often or always time since diagnosisindividuals were asked when they first received their hiv diagnosis first diagnosis within the past 90 days was categorized as recently diagnosed analysis univariate analyses were conducted to assess the prevalence of psychological distress hivrelated stigma and social support analyses of the associations between social support stigma and psychological distress were conducted using pearson chisquared tests logistic regression was used to model the association of hivrelated stigma and social support with psychological distress all analyses accounted for clustering by health facility using surveylogistic options of sas version 93 based on previous literature adjusted analyses controlled a priori for age sex relationship status and time since hiv diagnosis because internalized stigma was highly correlated with anticipated and enacted stigma multivariable regression models were run separately to examine the relationship between each type of hivrelated stigma and psychological distress to test whether the association between hivrelated stigma and psychological distress was modified by social support the magnitude and statistical significance of product terms between each type of hivrelated stigma and social support were examined because the interaction term between enacted stigma and low social support reached statistical significance multivariable analyses of the association between enacted stigma and psychological distress were stratified by level of social support effect modification was also assessed graphically by plotting mean psychological distress scores at each tertile of hivrelated stigma stratified by tertiles of social support results of the 1180 participants assessed five were missing psychological distress data and excluded from further analysis the sociodemographic characteristics of this sample have been previously reported briefly the majority of the sample was female and had attended school approximately half reported being in a relationship and threequarters lived in an urban setting psychological distress over onethird of study participants were classified as having mild or moderate psychological distress at art initiation and 295 were classified as having severe psychological distress at this time hivrelated stigma considering anticipatory stigma almost twothirds of respondents indicated concern that people might gossip about them if they knew or suspected that they were hivpositive half of respondents with children worried that their children might become upset or fearful if they knew or suspected that the respondent was hivpositive and 428 of respondents with children reported that they were concerned that their children would be abused or discriminated against if people knew or suspected that they were hivpositive internalized hivrelated stigma was also common approximately onehalf of participants reported having felt ashamed of being hivpositive completely worthless and as though they brought a lot of trouble to their family sixteen percent of respondents reported having experienced enacted hivrelated stigma in the preceding three months the most common type of enacted stigma was having been told that god is punishing you with 92 of respondents reporting this type of enacted stigma social support social support varied by scenario most participants indicated that they probably or definitely had someone who could accompany them to the clinic if necessary similarly 800 of participants indicated that they probably or definitely had someone who could take care of their children if they got sick social support was lowest in relation to financial assistance just over half of participants reported that they probably or definitely had someone they could turn to for small immediate help like getting to the doctor or borrowing money or to borrow money specifically for a medical emergency psychological distress stigma and social support psychological distress was significantly associated with all forms of hivrelated stigma assessed there was a positive doseresponse relationship between anticipatory stigma and psychological distress approximately 185 of those with low anticipatory stigma screened positive for severe psychological distress compared to 274 of those with medium and 426 of those with high levels of anticipatory stigma a similar positive relationship was observed between internalized stigma and psychological distress more than half of respondents with high levels of internalized stigma reported severe psychological distress compared to 214 and 105 of those with medium and low internalized stigma respectively those who reported having experienced enacted hivrelated stigma had significantly higher prevalence of severe psychological distress compared to those who did not report enacted stigma social support was also significantly associated with psychological distress those who reported low social support were more likely to have severe psychological distress compared to those who reported medium or high social support multivariable analyses in adjusted analyses relative to those with low anticipatory stigma odds of elevated psychological distress were highest among those with high anticipatory stigma followed by those with medium anticipatory stigma similarly in adjusted analyses relative to those with low internalized stigma odds of psychological distress were highest among those with high internalized stigma followed by those with medium internalized stigma low social support was associated with significantly increased odds of psychological distress after controlling for anticipatory or internalized stigma effect measure modification among hivrelated stigma social support and psychological distress there were no statistically significant interactions between anticipatory or internalized hivrelated stigma and social support on psychological distress at the p 010 level of significance similarly when examined graphically social support did not appear to modify the relationship between anticipatory stigma and psychological distress or the relationship between internalized stigma and psychological distress however effect modification by social support was present when examining the relationship between enacted stigma and psychological distress among individuals with low social support there was no significant difference in the mean psychological distress score between those who reported enacted stigma and those who did not however at medium and high levels of social support the mean psychological distress score of those who reported enacted hivrelated stigma was significantly greater compared to those who did not report enacted stigma similarly among those who did not report enacted stigma greater social support was associated with lower psychological distress scores however among those who reported enacted stigma no such relationship was observed in subsequent stratified multivariable analyses enacted stigma was associated with increased odds of psychological distress among those with medium or high social support there was no significant association between enacted stigma and psychological distress among those with low social support similarly in multivariable analyses a product interaction term of low social support and enacted stigma was statistically significant in subsequent multivariable analyses stratified by enacted stigma low social support was associated with greater odds of psychological distress among those who did not report enacted stigma however there was no significant association between social support and psychological distress among those who reported enacted stigma discussion all forms of hivrelated stigma as well as low levels of social support were associated with increased odds of psychological distress although high levels of internalized stigma were relatively rare in this sample population high levels of internalized stigma appeared to have a substantial psychological impact on those who reported experiencing it effect modification between enacted stigma and social support was present such that among those who did not experience enacted stigma greater social support was associated with lower psychological distress scores however among those who experienced enacted stigma greater social support was not associated with lower psychological distress scores in this way among those who experienced enacted hivrelated stigma greater social support did not serve as a protective mechanism from the psychological impact of having experienced enacted hivrelated stigma previous evidence of interrelationships between social support hivrelated stigma and mental health among plwh remains equivocal research with plwh in south africa found that social support did not modify the relationship between hivrelated stigma and depression or ptsd however research with hivinfected pregnant women in south africa found that hivrelated stigma did modify the relationship between social support and depression the current study is among the first to examine effect modification disaggregated by type of hivrelated stigma this is significant as modification was present only in relation to enacted hivrelated stigma additional research is needed to better understand to what extent the relationship between hivrelated stigma social support and psychological distress varies by type of hivrelated stigma assessed more nuanced understanding of the interrelationships between psychological distress hivrelated stigma and social support among individuals initiating art in subsaharan africa can inform the adaptation and implementation of interventions to improve mental health and hiv treatment outcomes for this population and may contribute to more successful implementation and scaleup of universal treatment strategies throughout lowresource settings understanding whether social support modifies the relationship between stigma and psychological distress can also help identify populations that may be particularly vulnerable to poor mental health outcomes and may illuminate promising intervention strategies for further study integrating evidencebased mental health interventions into hiv care in subsaharan africa has been identified as a key strategy to improve mental health and it may also improve outcomes of universal treatment policies in lowresource settings where the burden of hiv and untreated mental disorders is greatest interventions to improve mental health among plwh should consider incorporating components to assess address and reduce stigma as all forms of hivrelated stigma were associated with greater psychological distress such interventions should particularly focus on strategies to prevent or reduce the internalization of hivrelated stigma given the magnitude of the relationship between high internalized stigma and psychological distress promising strategies to reduce internalized stigma have incorporated educational components to counter misinformation about hiv and plwh and training to enhance coping strategies providing tools to manage stigmatizing attitudes or behaviors that plwh may encounter such informationbased and counseling approaches should be incorporated into interventions to reduce internalized hivrelated stigma and improve the mental health of plwh while internalized stigma likely affects plwh throughout the hiv care cascade interventions to reduce internalized hivrelated stigma may be particularly well suited to those newly diagnosed who are still adjusting to accepting their hiv status or to those newly initiating art who are adapting to treatment and longterm engagement with the health care system strategies to manage anticipatory and enacted hivrelated stigma may be particularly relevant around disclosure of ones hiv status to family and friends or at art initiation such interventions should include coping skills training as this strategy has demonstrated promise in managing and mitigating the consequences of enacted hivrelated stigma additional strategies to accomplish this for example by fostering resilience among plwh should be investigated future research should examine the trajectories of various types of hivrelated stigma throughout the hiv care cascade in order to more appropriately target stigma reduction interventions to periods when plwh may be most vulnerable to internalized anticipatory or enacted hivrelated stigma interventions to increase social support are also important as low levels of social support were associated with greater odds of elevated psychological distress however interventions to enhance social support may be insufficient to counteract the harmful psychological effects of enacted hivrelated stigma as social support was not significantly associated with psychological distress among those who experienced enacted hivrelated stigma it is possible that social support is not protective in the presence of enacted stigma when stigmatizing actions are perpetrated by individuals within ones social support network it is possible that even when stigmatizing actions are perpetrated by those outside ones support network social support may be insufficient to protect individuals from the harmful psychological effects of such stigma structural interventions to reduce hivrelated stigma at a community level are critically needed while stigma towards plwh has been widely documented evidencebased communitylevel interventions to reduce hivrelated stigma are lacking such interventions should be developed and tested and public health practitioners should consider incorporating components that have been consistently associated with lower levels of stigmatizing beliefs towards other stigmatized groups such as individuals with serious mental illness such components include positive personal contact with stigmatized individuals targeting key groups in positions of power and focusing on the deleterious ways in which stigma affects ones capacity to achieve their goals these strategies should be adapted and incorporated into interventions to prevent and reduce stigma towards plwh research should investigate whether these strategies are similarly effective at reducing stigmatizing beliefs towards plwh potential mediators of the relationship between hivrelated stigma and psychological distress should be examined such research could help elucidate promising interventions strategies or targets address pathological mechanisms from hivrelated stigma to psychological distress reduce the negative effects of hivrelated stigma and improve the mental health of plwh this study has limitations worth noting all data were crosssectional and thus temporality cannot be established it is possible that psychological distress increases hivrelated stigma particularly internalized hivrelated stigma or reduces ones perception of social support in addition all data were collected at art initiation it is possible that the relationship between hivrelated stigma social support and psychological distress may be different at different points throughout the care cascade in addition the relationship between psychological distress social support and hivrelated stigma may be substantially different among those who refuse art are not yet eligible for it or those who initiated art some time ago it is also possible that psychological distress and hivrelated stigma share a common cause longitudinal research is needed to better understand the causal relationships between hivrelated stigma social support and psychological distress participants were recruited from six urban clinics in oromia ethiopia at the time of art initiation and may not be generalizable to populations in other parts of ethiopia or subsaharan africa or to patients not yet on art or already established on art conclusion psychological distress was common among individuals initiating art in ethiopia additional research to further understand the interconnections between hivrelated stigma social support and psychological distress is needed evidencebased interventions to reduce the occurrence and impact of hivrelated stigma are needed at individual and community levels evidencebased interventions that address hivrelated stigma and psychological distress should be integrated into hiv care

recent world health organization who hiv treatment guideline expansion may facilitate timely antiretroviral therapy art initiation however largescale success of universal treatment strategies requires a more comprehensive understanding of known barriers to early art initiation this work aims to advance a more comprehensive understanding of interrelationships among three known barriers to art initiation psychological distress hivrelated stigma and low social support we analyzed crosssectional interview data on 1175 adults initiating art at six hiv treatment clinics in ethiopia experience of each form of hivrelated stigma assessed eg anticipatory internalized and enacted was associated with increased odds of psychological distress however among those who reported enacted hivrelated stigma there was no significant association between social support and psychological distress interventions to improve mental health among people living with hiv should consider incorporating components to address stigma focusing on strategies to prevent or reduce the internalization of stigma given the magnitude of the relationship between high internalized stigma and psychological distress interventions to increase social support may be insufficient to improve the mental health of people living with hiv who experienced enacted hivrelated stigma future research should examine alternative strategies to manage the mental health consequences of enacted hivrelated stigma including coping skills training

introduction cigarette smoking prevalence remains high among persons living with hiv and in particular among gay bisexual and other men who have sex with men smoking among plwh has been linked to increased rates of cardiovascular disease pulmonary diseases and infections lung cancer and other nonaidsrelated malignancies in fact a recent study concluded that plwh lost more years due to smoking than to hiv infection itself most studies among plwh focus solely on current smoking status without regard for the frequency of use to our knowledge studies with plwh do not discriminate between daily smokers and nondaily or intermittent smokers yet approximately one quarter to one third of smokers in the united states do not smoke daily 2008 furthermore intermittent smoking in the us increased by 40 between 1996 and 2001 2008 shiffman et al 2012 and this percentage appears to be increasing notably among racial and ethnic minorities compared with nonsmokers its in the general population have increased health risks including increased rates of cardiovascular disease pulmonary infections and allcause mortality the odds ratio for allcause mortality risk in its compared with ns was 16 and the relative risk of ischemic heart disease was 274 and 2 94 in men and women respectively additionally its have the same risk for cardiovascular disease as ds shiffman and colleagues found that its in the general population tend to be better educated have higher incomes initiate smoking later in life and drink alcohol more often when compared with ds its are also significantly more likely to smoke on fridays and saturdays than the rest of the week while all smokers are at higher risk for heavy alcohol use respectively msm who smoke are particularly at risk for moderate to heavy drinking high rates of heavy drinking is a concern given that heavy drinking interferes with quitting smoking its may have different views on quitting smoking than ds among the general population its are less likely to consider themselves smokers compared with ds but they report more frequent quit attempts on the fagerstrom test for nicotine dependence its score significantly lower than ds with nearly half having an ftnd score of 0 indicating no dependence at all perhaps as a result of low levels dependence on smoking its report low use of behavioral and pharmacological aids for quitting and only onequarter of its report receiving advice to quit from a physician compared with half of all ds collectively these data suggest that its may require a unique approach to smoking cessation considering the high prevalence of smoking and significant barriers to cessation in plwh the characteristics and quit intentions of its among plwh deserve exploration quit intentions are particularly important to examine since the theory of planned behavior postulates that behavioral intentions are one of the main determinants of behavior and significantly influence the adoption of behavior change the tpb proposes that behavior change follows from changes in the beliefs that influence behavior namely behavioral intentions and perceived control a metaanalysis of 185 studies including studies predicting addictive behaviors such as smoking found that 27 of the variance in behavior was explained by intentions and perceived control furthermore previous smoking cessation studies have found that quit intentions predicted future quit attempts to our knowledge no studies to date have examined the prevalence and characteristics of intermittent smoking among plwh accordingly the aims of this study were to describe the prevalence of its in a sample of heavydrinking hivinfected msm identify sociodemographic and clinical differences between its and ds and describe the quit intentions of its methods data source the data in this manuscript were baseline measures from a prospective study of msm who reported heavy drinking and enrolled in a randomized clinical trial that tested a brief motivational intervention to reduce alcohol use among msm receiving hiv treatment the sample for this manuscript included the 185 participants who were recruited and enrolled between 2011 and 2015 from an urban community health center participantsto be eligible participants had to be at least 18 years of age drink heavily at least once per month or drink more than 14 drinks per week have a confirmed hiv diagnosis be born as and currently selfidentify as male report having sex with a male partner in the past 12 months and be a currently enrolled patient receiving hiv primary care from the health center participants prescribed antiretroviral therapy at the time of study enrollment had to be stable on their current regimen defined as no change in art regimen over the three months prior to study enrollment potential participants were excluded if they reported current injection drug use in order to limit secondary hiv transmission risk outcomes to sexual behavior or if they were currently psychotic suicidal or manic based on clinical interviews they were also excluded if they were currently being treated or had been treated in the past three months for an hivrelated opportunistic infection or if they were currently receiving treatment for an alcohol or drug problem the relevant institutional review boards approved the study proceduresparticipants were recruited through flyers posted at the clinic or through active recruitment via study staff during scheduled visits with their hiv primary care providers potential participants completed a brief eligibility screener with a study staff member either inperson or by phone those who appeared eligible and interested were invited to schedule an inperson baseline visit at this visit participants completed the informed consent process confirmation eligibility screening and the remainder of the baseline interview consisting of a series of computerassisted and intervieweradministered questionnaires measures sociodemographic variablesparticipants selfreported their age raceethnicity income education sexual identity relationship status and time living with hiv clinical variablesblood specimens were obtained at baseline to assess hiv viral load and cd4 tcell count a threshold of undetectable viral load was set at 75 copiesml and cd4 was categorized into a 3level variable less than 200 200 to 500 and 501 or higher art adherencea timeline followback interview assessed art adherence over the past 30 days the tlfb has previously demonstrated good testretest reliability convergent validity and agreement with collateral reports for drug abuse and has been widely utilized with substanceusing gay bisexual and other msm in addition the tlfb has been previously used to measure hiv medication adherence in substanceusing populations and adherence data collected with tlfb interviews correlates well with hiv biological markers the 30day art adherence variable was dichotomized at greater than or less than 95 adherence smoking variablesparticipants were asked to indicate the number of days they smoked cigarettes in the past 30 days using the following categories 12 days 35 days 69 days 1019 days 2029 days all 30 days consistent with prior research a threecategory variable was created daily smokers intermittent smokers and nonsmokers participants were also asked the average number of cigarettes smoked per day on smoking days their age of first cigarette and whether they ever smoked daily for at least 2 months participants were asked whether or not they planned to quit smoking and when in the general population quit intentions have been shown to be predictive of quit attempts and smoking cessation and has been used successfully in samples of hivinfected adults for quit intentions a threecategory variable was created immediate future and no plans to quit alcohol and illicit drug use variablesthe tlfb was used to assess alcohol and illicit drug use in the past 30 days using a calendar interviewers asked participants to report any alcohol or illicit drug use on each day of the preceding 30 days a series of aggregate variables for alcohol use was created average number of drinking days per week average number of drinks per drinking day and average number of drinks per week and illicit drug use was dichotomized as having used in the past 30 days statistical analyses sociodemographic clinical and behavioral factors were compared by smoking status using chisquare tests and analyses of variance results were considered significant if the p value was 005 when a significant difference emerged between smoking groups in anova multiple comparisons were made using tukeys multiple comparison posttests differences in sociodemographic alcohol use and clinical variables were examined by quit intentions using chisquare tests and ttests finally a multinomial logistic regression model was fit to better understand the differences in smoking status on quit intentions the outcome was operationalized to have three unordered categories immediate intentions future intentions and no intentions results participant and smoking characteristics the demographic and clinical characteristics of the sample are shown in table 1 of the 185 enrolled participants 91 reported having smoked cigarettes in the past 30 days 46 were categorized as ds and 45 as its of the its 9 smoked 12 days in the past 30 days 7 smoked 35 days 5 smoked 69 days 10 smoked 1019 days and 14 smoked 2029 days in the past 30 days regarding cigarettes smoked per day among its 10 reported smoking 1 cigarette per day on smoking days 20 reported 25 cpd on smoking days 10 reported 615 cpd on smoking days and 4 reported 16 or more cpd on smoking days of the ds 8 reported smoking 25 cpd 22 reported 615 cpd and 17 reported 16 or more cpd approximately onethird of the nonsmokers and over two thirds of its reported that they had been ds for at least two months in their lifetime participants ranged in age from 20 to 66 years in the overall sample 171 of participants identified as gayhomosexual 11 identified as bisexual and 3 responded other onequarter of the sample selfidentified as a person of color 173 latino 184 black and 05 asian the sample was relatively diverse in terms of socioeconomic status with 326 earning less than 20000 annually and 541 having earned less than a bachelors degree over half of the sample reported illicit drug use in the past 30 days and the average number of drinks per week ranged from 150 to 16375 approximately onethird of the sample reported less than 95 art adherence more than 10 of the sample had a detectable viral load and 22 had a cd4 tcell count of less than 200 in analyses comparing its and ds ds were significantly more likely to identity as a person of color and have achieved a lower educational level whereas its were significantly more likely to be white and have earned a college degree or higher there were no differences between its and ds in income relationship status or art adherence however compared with ns both its and ds were more likely to report less than 95 antiretroviral adherence alcohol and illicit drug use regarding alcohol intake its reported significantly lower average number of drinks per week compared with ds however there were no significant differences between its and ns overall its and ds were significantly more likely to report any drug use in the past 30 days compared to nonsmokers when examined by specific drug its and nonsmokers smoked significantly less marijuana in the past 30 days compared with ds in posthoc analyses comparing its and ds there were no significant differences in marijuana use in the past 30 days correlates of quit intentions of the current smokers 275 reported that they had no quit intentions 209 reported immediate intentions and 549 reported future quit intentions significant differences were observed between its and ds in terms of smoking intentions compared with ds its were significantly more likely to report immediate quit intentions or no intentions at all whereas ds were more likely to report future quit intentions finally a multinomial logistic regression was fit to better understand the nature of the differences in quit intentions adjusting for raceethnicity and alcohol use as shown in table 2 compared to ds its had increased odds of reporting future quit intentions versus no intentions in contrast compared to ds its had a reduced odds of reporting immediate quit intentions versus future intentions additionally men of color had increased odds of reporting future and immediate quit intentions compared to no intentions there were no other significant differences observed between the groups in terms of quit intentions discussion in this study of heavydrinking hivinfected msm approximately 49 of the sample had smoked cigarettes in the past 30 days which is similar to the smoking prevalence that has been reported in other samples of plwh most studies of plwh examine and report smoking behaviors broadly characterizing the sample as smokers or nonsmokers however when examined by specific smoking patterns the current study found that nearly half of the smokers in the sample were intermittent smokers given that the prevalence of its has been reported to be on the rise in the us 2008 a better understanding of its their smoking patterns and their intentions to quit within the larger group of smokers living with hiv may be important as this particular subset of smokers among plwh may require a unique approach to smoking cessation some interesting sociodemographic differences emerged between hivinfected ds its and ns compared to ds its were more likely to be white and have a college degree or higher when compared with ds conversely ds tended to have significantly lower income and less education compared with its and ns regarding alcohol use ds drank more heavily and more often than both its or ds as evidenced by their number of drinking days per week and average number of drinks per week shiffman and colleagues reported that its were more likely to smoke when socializing drinking alcohol and on weekends demonstrating that social context is importantly associated with this groups smoking behaviors within this cohort of heavydrinking smokers living with hiv being black single and lower income were more strongly associated with ds these findings are consistent with prior research suggesting that daily cigarette smoking may be part of a syndemic experienced by msm such that cooccurring physical and mental health burdens are mutually reinforced and exacerbated by discrimination and victimization thus future research is warranted to examine differences in social oppression by smoking status and cooccurring health conditions compared with ds its were significantly more likely to report future quit intentions compared to no intentions at all whereas ds were more likely to report immediate quit intentions compared to future quit intentions while the results of the regression models showed significant associations some odds ratios in the regression model were large had very wide confidence intervals most likely a result of the small sample size therefore the magnitude of the effects should be interpreted with caution of interest it has been reported that its make more frequent quit attempts compared with ds but are more likely to fail in their quit attempts its generally have lower nicotine dependence scores and do not report craving and withdrawal symptoms the pervasiveness of external cues and highrisk social settings may play a significant role in maintaining intermittent smokers smoking behaviors and impair their ability to quit smoking successfully its tend to not selfidentify as smokers and native its report they infrequently receive professional advice to quit taken together these findings highlight the need for targeted smoking cessation counseling and public health campaigns to target this group of heavydrinking smokers living with hiv this study did not examine whether ds and its differed in their risk perception or worry about smoking behaviors however it is possible to infer from their frequent quit attempts that many are indeed aware of the potential negative health effects of smoking twothirds of its in this sample had at some time been a daily smoker therefore it is plausible that concerns about negative health effects precipitated the conversion from ds to its as a potential harm reduction strategy luoto and colleagues reported that its had lower levels of unhealthy diet and physical inactivity compared with ds suggesting that other healthy lifestyle behaviors may be an important and potential motivational force during smoking cessation counseling with its this study has several potential limitations the sample by virtue of their heavy drinking status may not generalize to all smoking plwh furthermore this study examined a convenience sample of msm who reported heavy alcohol use and were engaged in hiv care it is unknown how well the sample would compare to the national population of hivinfected msm the definition of its has been inconsistent and varies by study however many define its as those who smoke 4 to 27 days per month we collected data on smoking categorically and thus recognize that smokers who smoke 2829 days per month may have smoking patterns and quit intentions that may more likely resemble ds rather than its finally data on past quit attempts were not collected therefore potential relationships between number of quit attempts and quit intentions by smoking group could not be examined a significant strength of this study is that it is the first study to our knowledge that examines the frequency characteristics and quit intentions of its among plwh despite these limitations some important distinctions between intermittent and daily smokers were found in this sample of heavy drinking msm living hiv including sociodemographic characteristics and quit intentions current smoking cessation treatment guidelines focus on providing pharmacotherapy for nicotine dependence and counseling to promote abstinence considering that smoking may be less driven by nicotine dependence in its than in ds tailored approaches to smoking cessation may be needed with this population specifically it may be especially important for smoking cessation interventions for intermittent smokers living with hiv to address social and situational cues to smoke including the influence of heavy alcohol use and related cues on smoking behaviors and to provide information regarding the adverse health effects of even lowlevel smoking grant number t32mh 078788 from the national institute of mental health at the national institutes of health 397 ns cd4 tcell count χ 2 442 ns

intermittent smokers its have increased health risks compared with nonsmokers cigarette smoking remains prevalent among men who have sex with men msm and persons living with hiv plwh yet most studies in plwh do not discriminate between daily smokers ds and its in this study the characteristics and quit intentions of its and ds are compared in a sample of heavydrinking hivinfected msm of the 185 participants enrolled 492 reported having smoked cigarettes in the past month among those 505 were ds and 495 were its compared with ds its were significantly more likely to be white and to have a college degree or higher ds reported significantly higher average number of drinks per week compared with both its and ns compared with ds its were significantly more likely to report future quit intentions ie within 6 months or more compared to no intentions at all ds were more likely to report immediate quit intentions ie within 30 days compared to future quit intentions among heavydrinking msm living with hiv intermittent smoking was associated with being white college educated and having future quit intentions considering that smoking in its may be less driven by nicotine dependence tailored approaches to smoking cessation may be needed specifically it may be important for interventions for its to address social and situational cues to smoke including the influence of heavy alcohol use on smoking behaviors and to provide information regarding the adverse health effects of even low level smoking

introduction violence against children is a global public health concern whose consequences can harm children families communities and nations 1 physical violence in school settings is one of the most visible forms of violence against children and can be perpetrated by teachers and other school staff in the playground classroom or any place within school premises 1 physical violence from teachers can include corporal punishment aimed at imparting discipline and sanctioning misbehaviours 2 3 in tanzania the use of corporal punishment is rooted in the belief that it plays a key role in shaping students to conform to societys rules and norms and steer them towards achieving good academic outcomes 4 yet severe physical punishment can result in physical harm and affect childrens mental health 5 consequently the elimination of all forms of violence against children including corporal punishment is included in sustainable development goals 5 and 16 6 several interventions have been conducted in nonhumanitarian settings aiming to prevent violence from teachers to students a cluster randomised controlled trial evaluated the irie classroom toolbox in jamaica and showed that teacher training on classroom behaviour management using a combination of workshop and inclass support sessions helped to reduce teachers perpetration of strengths and limitations of this study ⇒ the qualitative methods used to evaluate the intervention helped to get detailed information which could have been difficult to capture quantitatively ⇒ using of data collectors conversant with burundian and congolese language facilitated gathering rich data because of smooth communication ⇒ the study recruited few participants hence it was difficult to generalise findings to the whole population ⇒ adding andor replacing some of the participants may have limited our ability to compare perspectives and insights over time open access physical violence against children 7 the good school toolkit in uganda also found to be effective at reducing teacher violence 8 intervened at the wholeschool level and focused on changing schools operational culture 9 the intervention employed behaviour change strategies for schoolteachers administration and students aiming to encourage empathy by reflecting on experiences of violence imparting new knowledge on alternative nonviolent discipline and creating opportunities for practising new skills in addition to reducing physical violence from school staff qualitative research suggested that the intervention strengthened studentteacher relationships improved students voices and reduced fear of teachers 10 there is suggestive evidence that the interaction competencies with children for teachers was also effective at reducing teacher violence through strategies to improve teacherstudent interaction including reflections on maltreatment alternative discipline strategies and support for students 11 while these trial findings are encouraging and show that it is possible to reduce teacher violence no study to date has focused on teacher violence in humanitarian settings the risk of violence in humanitarian settings is exacerbated by a variety of factors at each stage of the socialecological model 12 13 specifically students in refugee camps are likely to suffer from the double burden of corporal punishment in school and the trauma of having been uprooted from home to address this evidence gap the preventing violence against children in schools study was designed to evaluate the empateach intervention to reduce teacher violence in nyarugusu refugee camp in tanzania empateach is a behavioural intervention for teachers aimed at reducing their use of corporal punishment in the classroom designed and implemented by the international rescue committee in collaboration with the behavioral insights team the study consisted of a cluster randomised controlled trial to assess the effectiveness of the intervention and embedded qualitative and quantitative process evaluations focused on assessing intervention implementation and mechanisms of action 14 15 the trial found no evidence that the intervention reduced student selfreported experiences of physical violence from teachers in schools and similarly found no effect on any of the secondary outcomes such as students experiences of emotional violence from teachers student depression symptoms and school attendance however additional analyses of the trial data showed that the intervention improved some intermediate outcomes for teachers such as using alternative discipline strategies and lowered their acceptability of violence teachers in intervention schools also reported improved selfregulation compared with those in control schools 15 in this paper we aim to explain these trial findings and provide further evidence on the experiences and perceptions of the empateach intervention among school staff and students and its perceived effects in line with the programme theory methods study setting the study was conducted in nyarugusu refugee camp in kigoma region tanzania the camp was established in 1996 to host 80 000 refugees from the democratic republic of the congo between april and october 2015 the camp expanded to host an additional 70 000 burundian refugees the latest united nations human rights council figures estimate the total population of the camp to be 150 000 16 tanzanias refugees act no 9 of 1998 stipulates that refugees are not allowed to engage in formal employment and restricts the movement of refugees after being settled in a designated area 17 consequently the camps population largely relies on relief food supplies and commodities from nongovernmental organisations and united nations agencies active in the camp the united nations high commission for refugees and the tanzania ministry of home affairs run and administer the camp meanwhile the irc is responsible for all educational activities in the camp in addition to providing genderbased violence support services the camp population is generally divided by country of origin there are 27 schools in the camp which use either a congolese or burundian curriculum these schools face numerous challenges such as poor teacher attendance shortages of qualified teachers and inadequate infrastructures leading to difficulties in implementing quality education empateach intervention empateach is a behavioural intervention that aimed to reduce and prevent teachers use of corporal punishment in schools through a series of 12 peerguided group sessions the intervention sought to shift teachers attitudes and behaviours leveraging approaches from cognitive behavioural therapy the weekly group sessions focused on teaching participants positive classroom management and alternative discipline practices by engaging teachers in reflection and planning exercises and role plays that allowed them to practice these newly acquired methods group activities were designed to develop teachers selfregulation selfefficacy openness to change and empathy towards others to facilitate teachers adoption of the new strategies and ultimately improve teacher wellbeing and ability to effectively manage students the group setting and social support offered by peers were supposed to sustain teachers throughout the process of change and promote the adoption of new norms less accepting of violence the content of the empateach intervention differs from other trialled school violence prevention interventions for its specific focus on selfcontrol and impulsive use of violence in addition to promoting teachers use of alternative discipline strategies without explicitly discouraging the application of corporal punishment the intervention implementation and content are described in further detail elsewhere 15 box 1 describes the empateach strategies for teachers open access study design qualitative data were collected at three timepoints baseline before the intervention in january to february 2019 midline soon after the 10 week of intervention from june to december 2019 and endline conducted 6 months after the end of the intervention from september 2020 patients and public involvement in research patients and the public were not involved in study design teachers coordinators and students from the schools that received empateach intervention were involved in the interviews as study participants sampling and recruitment of study participants participants were purposively selected based on the level of violence experienced in congolese and burundian primary and secondary schools in the intervention arm and were interviewed at baseline midline and endline they include teachers students and empateach intervention coordinators notably some stakeholders such as education coordinators discipline teachers and headteachers were interviewed once at midline the camp education coordinator facilitated the recruitment in this paper we draw data mainly from the midline and endline due to the focus on changes deriving from the intervention a total of 58 and 39 participants were interviewed at the midline and endline phases respectively these participants comprised three education coordinators for primary and secondary schools 29 empateach coordinators 14 stakeholders including headteachers and discipline teachers 25 classroom teachers and 26 students some participants who were unavailable at followup rounds of data collection were replaced by participants with similar characteristics while some of the participants were interviewed twice including five coordinators three teachers and three students there was no refusal data collection procedures data were collected via facetoface indepth interviews interviewers included males and females with bachelor degrees in social sciences who were familiar with kirundi and congolese swahili having experience in conducting qualitative work they received training on research methods techniques for working with children and on child protection referral procedures they piloted the tools before the actual fieldwork interview guides focused on topics such as experience of teaching emotional selfawareness and growth mindset discipline and violence in school experiences reflections on perceived changes in schools following the empateach intervention and any challenges during empateach implementation these interviews were conducted in congolese swahili or kirundi audio recorded and transcribed verbatim field notes were also taken during the interviews a private place for interviews was sought within the schools to ensure freedom of expression participants consent to participate was given with knowledge that disclosures of abuse may be passed on to child protection officers saturation was observed and so interviews stopped when no new information was coming from the interviewees for example when asking about alternative disciplinary methods or rewarding mechanisms similar information was reported repetitively indicating that the saturation point was achieved each interview lasted between 30 and 45 min data management and analysis senior researchers reread the transcripts and compared them with audio recordings to familiarise themselves with the data data analysis was thematic in identifying themes and patterns by examining the underlying ideas assumptions and conceptualisations on the use or nonuse of alternative disciplinary methods 18 analysis involved developing codes through examining the content of each sentence or sequence of texts by two coders to capture the predefined key themes in each section of the interview box 1 empateach recommended strategies alternative discipline methods ⇒ disciplinary and praise practices classroom management strategies ⇒ general classroom management and teaching practices enhancing teachers wellbeing ⇒ stress and emotional management techniques ethical considerations permission to conduct the study was obtained from the tanzania ministry of home affairs the irc and the camp authorities participants offered informed consent and the voluntary nature of their participation was emphasised so that they could withdraw from the study at any time if they wished for students under 18 years headteachers who stood on behalf of parentsguardians in their respective schools provided initial written consent for their participation and students offered their written assent study participants over 18 years provided written informed consent privacy anonymity and confidentiality were maintained throughout the study except in cases when the study team came across disclosures of child abuse raising immediate protection concerns participants were informed during the consent process about conditions under which confidentiality would be breached so that they could retain control over what they disclosed we confirm that all the methods used in this study were in accordance with relevant ethical guidelines and regulations results we examine participants perspectives of change in their schools and their experiences with the intervention in relation to the three components of the empateach intervention programme theory teachers practice empateach strategies teachers use emotional regulation and wellbeing techniques and teachers feel supported in their process of behavioural change intervention implementation study participants reported the intervention to be successfully implemented however teachers and coordinators reported contextual challenges that affected their attendance these included difficulties in balancing coordination work alongside teaching responsibilities as one of the coordinators reported to be a coordinator and a teacher at the same time was not easy because of our the rainy season also interfered with the timely and effective delivery of intervention activities there were disruptions to intervention implementation caused by a temporary firing and rehiring of new teachers which contributed to the lowering morale among teachers and may have affected both attendance and internalising some of the techniques taught teachers practice alternative disciplinary and classroom management strategies study participants who were class teachers and empateach coordinators mentioned strategies covered during the intervention sessions as part of empateach that they found useful these strategies included providing advice and counselling students using nonabusive language participatory development of class rules and regulations use of praise and reward and classroom management strategies we learned some techniques that are positive including noncorporal punishment methods rewarding students who perform well in the class and knowing how to control students in a classroom teachers described applying alternative discipline strategies that they had learnt during the intervention sessions one of the teachers explained how in the past he used to stop teaching and start caning students if they misbehaved in class but after empateach such behaviour changed this was substantiated by the following quote in the past when were some misunderstandings between a teacher and a student the latter used to be threatened and beaten but soon after attending the training teachers increased awareness on the use of alternative disciplines and realised that beating students is not a solution but they can advise students and understand subjects well advising and counselling students counselling or providing advice to misbehaving students was reported to be an integral part of changing teaching practice this strategy was used primarily with students who missed class or refused to follow teachers instructions teachers reported that they used these methods instead of whipping or caning students one of the headteachers confirmed providing advice when a student has refused to follow what i have ordered to do during the lesson i just sit down with that student and give himher advice instead of beating when seems impossible for himher to change i report to the school disciplinary committee for more advice a discipline teacher also testified i have to advise students for example let us say a student is out of class or out of school with a boy when the subjects are going on i have to give advice on the now the only discipline that i give them is through counselling and advising them to change their behaviours for example when they have dirty clothes i tell them to go and change or wash them instead of beating them these positive perceptions of a change in the use of corporal punishment occurred across both congolese and burundian schools some students also felt that beating was not common although it was less clear whether this was related to the intervention itself or not students in this school are not beaten i think it is not good to beat someone when one can only advise him or her via a wordofmouth without beating him or her beating students destroys our relationship with teachers praise and rewards both school staff and students discussed the technique of using praise and rewards extensively schools developed a system of recognising outstanding students and teachers included praise practices such as singing positive songs clapping and announcing outstanding and exemplary teachers before others as an expression of goodwill there are changes since praising students is not just necessarily giving them a gift but can also be about something saying well done and others clapping hands are enough and he or she appreciates such recognition many teachers from burundian and congolese schools mentioned clapping to applaud and encourage goodperforming students in class as one of the strategies they employed singing a good song to students who did well in class in front of their fellow students brought about a feelgood factor making it an important motivational approach this was also reported by the empateach coordinators the system of rewarding students for their academic performance also featured at endline as the participants mentioned clapping congratulating appreciating and recognising outstanding students in front of their peers as reflected in the quote when the teacher asks questions in class the one who raises hisher hand and answers the question correctly is praised by hisher fellow students by clapping of hands classroom management practices some school staff described finding the classroom management aspects of empateach useful and listed a range of techniques learnt during the intervention that they subsequently used in their teaching practice these included participatory ways of developing rules and regulations which were mentioned by teachers at midline and endline as a positive technique for managing students inside and outside the classroom who complied with what they proposed to be included in the rules and guidelines we were taught some techniques that are positive including the use of noncorporal punishment and learnt how to prepare collaborative rules and regulations in the class and know how to control the classroom so those are the various benefits that we have gained teachers also saw revising different topics as a positive strategy to keep students engaged in class teachers perceived this approach to have led to improvements in understanding among students of the lesson content hence reducing chances of attracting undue punishment yes there are changes… before we got training when you teach a lesson the students were likely to forget since their brains are not mature enough for the whole lesson to stick in however this training has made us learn that if a student fails to respond to the question asked in class as a teacher you cannot just beat him or her instead you make a simple revision to remind the lesson just learned however these practices were not as widespread as others such as the use of praise and not all teachers described using them teachers skills development learning selfregulation and wellbeing techniques to control emotions and manage stress emotional regulation and wellbeing techniques generally teachers hailed the empateach programme for imparting them crucial skills and knowledge on methods and mechanisms for improving their mental health by controlling and managing stress and emotions during the training sessions teachers reflected on their own values experiences with using corporal punishment and their ability to change phrases such as empateach intervention helps to change or correct teachers bad behaviour intends to alter types of punishments given to schoolchildren and a good programme that provides skills to enable teachers to controlmanage their classes emerged during interviews with empateach coordinators teachers and empateach coordinators described having learnt skills and techniques during the intervention which helped them to control their emotions and manage stress they reported praying to be one of the useful strategies before acting when students annoyed them when i feel stressed out i try as much as possible to avoid it through praying however teachers went further in explaining their ways of controlling emotions including playing with students open access reading books and walking around outside the class others ways that were not directly linked with the intervention included singing songs and listening to music nowadays we have been given techniques and guidelines to follow to control our emotions for example when a student annoys you you can go outside the class and walk around by the time you return to class your mood will have changed and you feel good and your emotions disappeared some teachers also reported finding these strategies helpful even when outside school such as at home despite the learnt techniques and own ways to control emotions and manage stress some study participants also described that life hardships were such that it was hard to avoid stress human beings cannot live without money and we work to earn at least a little money to get rid of lifes hardships now the stress comes when you do not have money or low salaries and this is a big problem for me…this training has helped us to change because first when i leave home i move with only one goal to go and teach students our training has focused us not on having other things occupying our minds when teaching improving empathy and relationships to support behaviour change after participating in empateach some teachers reported reaching an agreement that in cases of students misbehaviour a discussion should be held between teachers students and where necessary with parents as well who would be invited to the school for discussions both at midline and endline study participants perceived the approach to have reduced fear and brought students closer to their teachers we do sit with the students and ask them about their problems because sometimes they might be having family problems we do invite respective parents to come to school to discuss the development of the students i learn this strategy from the trainings students also reported that teachers were closer to them and listened to their concerns in addition to allocating time to discuss different issues pertaining to school performance and their health status yes we do discuss academic issues for example when a teacher is teaching and in case there is a part i do not understand i can raise my hand and say i do not understand and the teacher will repeat and elaborate more so that i can understand well staff reported that such positive communication allowed teachers to support students with challenges they faced in their lives a few students also acknowledged benefiting from such changes as one of them pointed out i have started seeing them changing previously they were treating us badly but nowadays they sit with us and talk to us in a good way peer and social support in the process of behavioural and attitude change participants reported that empateach sessions allowed teachers to reflect on their strengths and ability to change which facilitated changes in attitudes and encouraged good practices teachers confirmed the sessions to have stimulated changes of norms from their usual practice to oneness or togetherness as they started treating themselves equally and increased cooperation in problemsolving which finally enhanced and sustained good relationships among teachers and students school staff utilised the skills gained from the empateach programme to orient peers from the intervention who has missed some of the sessions in the past teachers had no habit of building each others capacity after the training programme they started some group discussions to build each others capacity for example the capacity to teach some of the subjects this support was deemed a positive move in bringing about the desired changes with implications on students behaviour and performances school staff declared to have received support from their leaders through recognition of their outstanding performance and acknowledgment which boosted their working morale during implementation of empateach activities overall support from leaders contributed to a positive experience with the empateach intervention and suggested activities were well received when you pass anywhere people may mention your name for example those people whom i have taught may say someone taught us good programme and taught us to behave well and we realised that in daily life these are useful and wherever you pass people say the programme went well persisting norms around corporal punishment despite these positive experiences with the intervention and useful strategies learnt teachers continued to support the use of corporal punishment for example some teachers insisted on using such corporal punishment based on their past experiences if a child is punished without using a stick or beaten heshe tends not to listen as i said when i was studying we were punished with sticks but i never heard of anyone who died because of being beaten using sticks i am convinced to continue the behaviour open access because children of nowadays do not listen to advice… teachers also feared that some students had lost respect for their fellows and claimed their behaviour had become less manageable without corporal punishment some students were reported to be lazy or aggressive and rude to the teachers because they knew that even if they misbehaved they would not be whipped or caned school children now do not fear anymore after learning that it is their right to stay free from whips some even say if you beat me i will report you to the law enforcing authorities teachers felt that students would refuse to follow their instructions which was one of the reasons behind the desire to continue using corporal punishment this perception generally emerged more often in congolese than in burundian schools students misbehaviour and attitudes made it difficult for some teachers to enter the class without a cane as testified below for example there are three students making noises while teaching you order one student to stand up and shift to another chair but he refuses to shift and tells you that he will not shift therefore i cannot advise a student like that instead i cane him even if the programme does not allow us to use corporal punishment there are types of misbehaviours which when they exceed the limit i cannot tolerate them any student who goes beyond the teachers instructions will get strokes of the cane that is why i am saying that i do not accept other disciplinary methods some empateach coordinators reported that parents also supported corporal punishment as they believed it to be a good way of disciplining students it is from parents who said that if you dont beat your child you discipline himher in a bad way and will not understand what you are telling him teachers reported that using noncorporal punishment was perceived by parents as an insufficient way of disciplining students who would not understand what was being taught to them without use of violence discussion the study findings revealed how behavioural change interventions can facilitate change among schoolteachers in disciplining students teachers declared to have attended several empateach sessions facilitated by group coordinators and acknowledged the positive role that the intervention played in influencing the way they disciplined students and behaved in class teachers reported using a variety of alternative discipline strategies learnt during the sessions including teaching practices to keep students focused reward and praise methods to reinforce positive student behaviours they also perceived the techniques for managing stress and controlling their own emotions as beneficial in facilitating avoidance of corporal punishment although we know from our trial analyses 15 that the intervention overall did not lead to a reduction in students experiences of corporal punishment this process evaluation shows that school staff felt that there had been positive changes in their disciplinary approaches including their relationships and communication with students students responses also depicted a generally positive picture although their experiences were less consistent and less clearly linked to the intervention itself these findings are generally consistent with our previous study results 15 specific techniques were not consistently mentioned and teachers accounts of new strategies were sometimes vague and not always linked to empateach content this suggests that while the intervention may have fostered improvements in the school environment among school staff it was not successful at consistently developing teachers skills along all the intervention components the study offers important insights into student and teacher experiences of the intervention and represents a first attempt to reflect on the implementation and pathways of a schoolbased violence prevention intervention in a fragile setting data collection was delayed by covid19 restrictions in the camp which may have affected participants ability to respond adequately to all sections of the interview due to a lack of continuity in practising what they learnt in the intervention sessions it is important to note that while the empateach intervention helped to change some teachers behaviour and attitudes towards the use of corporal punishment during the implementation of the intervention there were challenges difficulties in balancing coordination responsibilities alongside teaching and the rainy season which interfered with timely and effective delivery of intervention activities may have prevented teachers from fully engaging with the intervention content lack of external continued support and supervision may have contributed to lack of clarity of certain strategies and compromised the internalisation of specific techniques this study plays a crucial role in intervention evaluations by providing detailed information on how the intervention was perceived and experienced through indepth exploration contextual understanding and ability to uncover underlying mechanisms qualitative research offers valuable insights that quantitative methods alone cannot produce additionally conducting research with the support of research assistants who shared the cultural and linguistic background of the participants greatly enhanced the quality of the data collected during the evaluation ensuring smooth communication and facilitating the acquisition of rich data in this process evaluation of the empateach intervention valuable insights were obtained by directly engaging with stakeholders open access including teachers and students who were directly involved in the environments where violence may occur however the study counts some limitations as it recruited a small sample size that prevents the generalisation of study findings finally recruitment or replacement of new study participants at midline and endline made it difficult to capture continuity in the stories as related to the empateach intervention the study faced additional limitations such as an incomplete exploration of the intervention theory and contextual factors in interviews with students and teachers which hindered a comprehensive understanding additionally reliance on participants subjective accounts restricted our ability to assess all potential mechanisms of action within the interventions despite the limitations faced during the intervention implementation our study found that support and facilitation by peers and the selfguided nature of the intervention package may have contributed to the positive responses of school staff whereas the quantitative findings stemming from the trial showed that there was no evidence that students reports of physical violence from teachers decrease on average this qualitative study showed that overall teachers perceived the intervention as useful to improve their teaching abilities and reduce their use of corporal punishment this contrast in findings might be attributable to several possibilities to begin with our trial outcome was the calculated as the proportion of students reporting any experience of corporal punishment in the past week not accounting for frequency or severity second there is some suggestion in our qualitative data of improved relationships between teachers and students and a more positive and friendly classroom environment it is possible that some teachers did use less violence or less severe violence without stopping other studies have shown that participants in uganda for example understand corporal punishment to refer to only excessive beating 10 in reflection empateach is different from other successful violence prevention interventions in its focus on stress reduction and prevention of impulsive violence and because it does not explicitly seek to confront teachers on the use of corporal punishment instead the intervention seeks to enhance teachers repertoire of techniques for classroom management and intended for these to replace the use of corporal punishment other interventions which have some evidence of reductions in corporal punishment are thought to have different mechanisms of effect the icct intervention implemented in tanzania provided training on teacherstudent interaction and guided teachers to reflect on child maltreatment the intervention was found to have resulted 11 in a significant change in the use of physical and emotional violence among teachers to students in intervention schools as reported by both teachers and students the irie classroom toolbox intervention was implemented in jamaican preschools through the provision of training to teachers in classroom behaviour management and focused on creating an emotionally supportive classroom environment preventing and managing child misbehaviour strengthening teacher social and emotional skills promoting individual and classwide behaviour planning 7 in uganda the gst intervention aimed to change the schools operational cultures through the involvement of the school administration teachers and students and surrounding communities the gsts main mechanisms of action appeared to relate to improved teacherstudent relationships which then improved students voices reduced fear through rewards and praise and encouraged good behaviour 10 similar changes have been noted in the empateach intervention whereby the reward and praise were perceived by school staff as a positive mechanism for fostering behavioural change among students however teachers percevied parents to be supportive of the use of corporal punishment as reported in other settings 4 19 attitudes supportive of corporal punishment and old practices continued to coexist alongside new intervention strategies that were implemented our data also highlight the variation in use of corporal punishment across schools and in what teachers perceived as factors responsible for such practice in some schools teachers saw students reluctancy to change or obey to the instructions given and parents belief that beating is the best way to discipline students as the main reasons why corporal punishment continued teachers also perceived that the use of alternative discipline would only be effective for certain students and lazy and misbehaved students were thought to only respond to corporal punishment similar perceptions were reported in other contexts 20 21 as such there is a need for further contextual analysis of what is perceived as violence whose findings will inform specific strategies for intervention development for future testing of the intervention there is a need to critically review the components of empateach including the sessions content delivery modality contextual characteristics and duration conclusion the empateach intervention to reduce physical violence from teachers to students was widely accepted by teachers in nyarugusu refugee camp some intervention techniques especially alternative discipline practices and classroom management strategies were widely implemented and teachers were familiar with stress reduction and emotional regulation methods however it appears that the norms sustaining the use of corporal punishment persisted among teachers as they kept referring to their past personal experiences of school violence from when they were studying and to the belief that physical violence is the best way to discipline students these qualitative findings revealed high acceptability among teachers and coordinators of the alternative disciplinary and classroom management methods included in empateach thus we recommend for the intervention to be further adapted and tested potentially also in nonhumanitarian settings ethics approval this study involves human participants and was approved by medical research coordinating committee of the national institute for medical research in tanzania and the london school of hygiene ethics committee in the uk participants gave informed consent to participate in the study before taking part provenance and peer review not commissioned externally peer reviewed data availability statement data are available upon reasonable request fully anonymised quantitative data are available on request from the lshtm data repository for researchers who meet the criteria for data access and whose intended analyses fall under the scope of the pvac study the lshtm research data manager based in the library and archives service is responsible for managing data in the repository and can be contacted at rese arch data mana gement lshtm ac uk

objective we explored the experiences and perceptions of school staff and students with the empateach intervention to prevent teachers violence against school students design this qualitative study involved indepth interviews with 58 and 39 participants at midline and endline respectively with burundian and congolese intervention schools in nyarugusu refugee camp they comprised three education coordinators of primary and secondary schools 29 empateach intervention coordinators 14 stakeholders including headteachers and discipline teachers 25 classroom teachers and 26 students thematic analysis was used to develop codes by examining the content of quotes to capture key themes in line with the key elements of the programme theory results coordinators and teachers widely reported positive experiences with the empateach programme the intervention sessions enabled teachers to reflect on their own values and experiences of corporal punishment and equipped them with useful and acceptable classroom management and alternative discipline strategies teachers adopted the use of counselling praise and reward and joint discussions with students and parents on the other hand several teachers reported persistent use of corporal punishment which they attributed to childrens mis behaviours and strong beliefs that beating was a positive approach to disciplining students conclusion the majority of coordinators and teachers widely accepted the empateach intervention as it offered useful and relevant knowledge and skills on alternative disciplinary methods students noticed some positive changes on the way they were being disciplined by teachers where nonviolent methods were used further research is needed to understand how violence prevention interventions can successfully lead to reductions in violence in fragile settings trial registration number nct03745573

the national policy perspective in england the implementation of the children and families act 2014 gave all ycs under the age of 18 the right to an assessment of their needs this is a responsibility of the local authority the legislation also placed a duty on local authorities in england to take reasonable steps to identify the extent to which there are ycs within their area who have needs for support hm government moreover the children and families act 2014 together with the care act 2014 hm government set out a preventative focus on supporting children through a whole family approach dedicated support for ycs in england the most frequent support provision for ycs provided by local authorities in england is a referral to a yc service these dedicated support groups provide ycs with a break from their caring responsibilities and offer a range of support which provides opportunities for these children and young people to socialise have fun meet others with similar experiences talk about their concerns receive information receive advice and advocacy and provide support for parents although ycs and their families have access to a range of different health social care and educational support services research by the childrens commissioner for england indicated that the emphasis on identification and assessment in legislation may lead to support for young carers being overlooked and that approximately 80 of ycs may not be receiving support from their local authority however despite the fact that many may not be receiving support the uk remains ahead of other countries with awareness and policy responses for ycs and their families with the existence of dedicated yc projects undoubtedly playing a significant role around a decade ago according to becker the number of yc projects in the uk had grown to more than 350 the current number of dedicated yc services in the uk may have reduced in recent years although a definitive number appears not to be known however the number still remains at over 260 services the hampshire young carers alliance hyca is an alliance of ten yc projects within the english county of hampshire the projects differ in capacity and composition some are local charities working specifically for ycs whereas others form part of broader charitable services with broader remits and one is a national charity for supporting children more generally originally composed of five yc projects the alliance was formed around 2005 in order for the individual services to work closer together share good practice and resources to develop a single countywide voice and to advocate and campaign for ycs within the county hyca projects are currently funded by a broad range of funding streams including funding from the local authority as has taken place nationally over the last ten to fifteen years some of the hyca projects have complemented their general offer of respite activities through clubs and trips with work within schools and a whole family approach to supporting ycs and their families for some of the hyca projects this has involved employing specific staff to work with families and staff to provide targeted work within schools in 2017 hyca projects were in contact with 1856 ycs actively providing support to 1139 ycs and supporting 952 families in 2016 hyca was awarded funding from the big lottery in order to roll out and embed a previously developed 3pronged support model to bring about a more consistent countywide service across the ten districts where the projects operated using an allocation of this funding hyca commissioned the university of winchester to undertake an independent evaluation of the work of the alliance over the three year period from september 2016 to august 2019 this current study carried out between december 2016 and august 2017 was undertaken as a first stage of this evaluation methods the primary study aims were to explore what are the most important changes that the yc services made to ycs and their families and what it is about the services that creates those changes a total of semistructured interviews were carried out between january and march 2017 with three different types of participants ycs aged 917 their parents hyca staff and professionals from other stakeholder organisations in contact with one of the ten local projects questions primarily explored what participants considered to be the most important changes that the yc projects bring about for ycs and their families and what it is about the projects that made these changes additional questions explored the support needs of ycs and families on average the interviews lasted 31 min with 21 of the interviews being in the range of 2040 min interviews were recorded and then fully transcribed before being analysed thematically using three levels of coding sorting exercises each interview was preceded by two short sorting exercises where participants were asked to rank in importance two different sets of descriptors different hyca interventions and statements about how different interventions help ycs and families this exercise was carried out for two reasons firstly as an icebreaker to set participants at ease before the main semistructured interview and secondly as a way of reminding participants about the range of support the projects provided ethical approval and consent ethical approval was granted under the research and knowledge exchange ethics procedures of the university of winchester and informed written consent was obtained from participants from ycs informed verbal consent was obtained in addition to informed parental written consent principles of confidentiality were upheld strengths and limitations limitations of the study need to be recognised and considered firstly since the yc services acted as gatekeepers for the ycs and parents a random sampling of participants was not possible although this is a common practice with this type of research it is potentially problematic since the yc services might be identifying only participants who are known to positively engage with their service and be available to participate this therefore may result in interviewing participants who are more likely to respond positively to interview questions one particular strength of the study is that four different types of participant were interviewed this provides four different perspectives as well as a more comprehensive set of findings a second strength was that ten different services were included which again provided a breadth of perspectives results what ycs need reflecting previous research the ycs reported a wide range of different needs reflecting their individual circumstances these needs fell under four categories emotional support time out and opportunities to relax socialise and make friends support with and understanding of their caring role and knowing they were not alone in being a yc emotional support ycs reported needing emotional support to help them deal with anger stress or with feeling down one yc stated i think the emotional side of it i cant really deal with seeing my mum in pain so that bit i need support on this was reflected also by the other participants who all thought ycs needed to have someone outside the family to talk to for example as one parent said i can talk to our son a lot but i do think it helps that theres somebody outside of the unit that can help and talk to him as well and give their view on things as well time out and opportunities to relax socialise and make friends all participants felt that ycs needed time out from their family situations and caring roles in order to have free time to relax socialise and experience new activities one yc reported that i think the most support that i think would be good would be just relaxing and getting free time to do what we need to do whilst another stated getting a bit of a break i guess it can be a bit overwhelming at home so coming here their yc project its a bit more sort of chilled the importance of being able to make friends and having friendships was strongly emphasised one parent felt that their child needed just like building friendships up really… so its just enabling them to have more more social time really and similarly one yc stated that what they needed was probably like being like getting friends cos sometimes i would like try and make friends but it doesnt always work support with and understanding of their caring role the third category of support need related to the ycs caring role and fell into two camps firstly the need for support with the caring role itself was briefly reported with one yc expressing this need as knowing how to care for them so im making sure that im doing everything right and making sure that theyre happy as well a couple of ycs discussed needing to acquire life skills including skills for dealing with money some participants also felt it was important for ycs to better understand the condition of their family member and to manage their caring roles alongside their education knowing they were not alone in being a yc participants commonly reported that ycs needed an awareness that they were not the only ones and that there were other young people who were in similar situations to themselves one yc expressed it this way because its knowing that youre not alone that youre not the only one whos going through the same situation on a daytoday basis and one parent put it like this and its just nice for him to have somewhere to come with other children and to know that hes not the only one cos i think at times he did feel isolated and felt you know it was difficult to cope with things at times what families need families like the ycs were also found to have a diverse range of needs although the parents themselves were less clear in articulating these support staff were the most consistent in stating that families needed a wider support network including information about support available locally and being signposted to it both ycs and some professionals reported that families needed support with family relationships and managing situations better one professional stated i think they need the support with so to keep together as a family unit the support interventions interventions to support ycs directly through a combination of individual support and group work the projects support ycs through a package of support interventions aimed at providing emotional support respite from caring and opportunities to meet others in similar situations as well as opportunities to develop new skills and experience new activities projects aimed to take a preventative approach with varying frequency according to their capacity projects run both trips and young carer clubs or groups clubs and activity days offer a mix of activities such as cooking sports or crafts eating together as a group a forum to share experiences and have group discussions and free time to relax and chill out with peers through for example playing pool table football or table top games one project had established a yc choir ycs can also access support in school the majority of projects employed staff to work within both primary and secondary schools run dropin sessions during lunch times or support students individually one yc reported that their project gave them information that supported them as a yc interventions to support families in order to improve the situation for ycs the projects also aim to provide a whole family approach the majority of projects achieve this through a dedicated role of family support worker which enables them to support families in a number of different ways such as homevisits referring and signposting to other services and providing direct support and advice to parents on parenting and family relational issues projects commonly initiate wider support for families by working collaboratively with other services support for families had been triggered for example from adults and childrens social care local housing associations and services providing parenting courses projects work flexibly and creatively in order to source and initiate other support as illustrated by one parent if they couldnt support me they would find somebody else that would be able to do it they wouldnt just go oh no we cant support you with that they would find somebody that could support me with that make sure that i felt comfortable with that projects provide support for families with housing and accommodation issues in very practical ways and by initiating support from other agencies to help families with their rent or with changing and modifying accommodation and acquiring vital furniture projects have also helped families with their finances by informing them of benefits they are entitled to and practically with financial documentation in addition some projects provide activities and trips for the whole family to enable the family unit to share experiences and have fun together activities have included family trips to a fireworks display a family picnic and swim and a christmas gala some projects run coffee mornings to enable parents to meet others in similar situations reduce their isolation and find mutual support what projects have changed for ycs positive changes for ycs the interventions by the yc projects led to a diverse range of positive changes for ycs at home with their schooling and with their socialisation as one parent put it the positives that weve seen at home and at school i think really the changes that weve seen its going in the right direction were seeing progress if you like were not stuck in the same place we were you know six months ago we have some positive changes being able to relax and reducing stress the most common change cited by ycs was being able to relax and destress since projects gave them opportunities to relax have space away from their caring role and to feel supported this was highlighted simply by one yc its definitely helped with stress i mean being at home all the time is quite stressful so getting a break is quite relaxing another yc reported before this group i stressed really badly like im stressing 247 but now ive come here im not as stressed i know that theres always someone out there that can help me if i need it ycs make friends and develop social skills being able to meet and make new friends with others with caring responsibilities was also commonly identified by all types of participant as being very important for ycs projects provide the space for ycs to socialise and in contrast to other peers who may not understand the challenges that ycs face the ycs attending the projects had a common understanding of what it is like to be a yc which seemed to help facilitate friendships this is illustrated by one yc all together ive made new friends definitely ive met new people who share similar problems and different problems i mean not everyone has disabled parents several ycs talked about how attending their project had helped them develop their own social skills including increasing their patience being able to be a good sport and developing the ability to ignore others if for example someone was being mean to them improvements in school for some ycs projects also led to improvements in school or with their schooling this was for some as a consequence of joining their project and being able to relax and not worry as much about the person they cared for parents and ycs themselves reported that support led to ycs becoming calmer and being less stressed one yc expressed it like this if this wasnt here i wouldnt like have no support and id like always feel stressed and angry and upset and like i wouldnt have support in school and so the teachers would…id be getting detentions all the time and stuff like that whilst one parent reported that year four was challenging and year five since hes started hes much calmer year five has been a lot better and i do think coming here does help furthermore one yc reported that their exam grades had improved attributing this to the revision they had done with others at their yc club internal changes the projects were also found to bring about more internal changes for the ycs these changes related to how the ycs felt their confidence and how they perceived things how ycs feel being part of and attending the yc projects also helped improve how ycs felt several ycs reported that the fun activities they took part in gave them something fun to do and made them feel happier and parents similarly reported improvements in how their children felt when attending the groups one yc expressed it this way well before i was quite unhappy because i was always busy and stressing at school and stuff but being here ive noticed that quite a big change in emotions as well but for good reasons because made friends had a laugh and done some activities with them participants reported how the projects made ycs feel better about themselves in other ways and used terms such as special valued and normal to describe these positive changes one parent stated i dont know whether its the atmosphere the people i dont know what it is i think you feel special coming to young carers that sounds silly but its good to celebrate im really sic cos they are important and you know they do an amazing job one professional described in this way they feel valued when they go there and you know yeah thats about it i think and a project staff member in this way it just gives them a chance to be themselves and to i dont want to say for them but to feel more normal increased general confidence increased general confidence in ycs as a result of attending their project was reported by parents project staff and ycs themselves which enabled them to take part in activities and helped some to speak out about their caring roles gaining understanding and new perspectives about their situation and themselves as carers a further common change or set of changes that was clearly very important for ycs came from meeting other ycs in similar situations which transformed how they understood and perceived their own situation as a yc knowing they are not alone in being a yc one significant change highlighted by several parents and reflected by project staff and professionals was that the groups enabled ycs to know that they were not alone in being a yc by meeting other children in similar situations they did not feel they were unique in having caring responsibilities for some ycs joining their project was the first time they had met other young people who were carersand this was important to them one yc spoke about meeting others who went to the same school as they did and who they had not previously known was a yc the value of meeting other ycs is illustrated clearly by one yc because its knowing that youre not alone that youre not the only one whos going through the same situation on a daytoday basis and similarly by a parent knowing that theyre not the only ones it is knowing to begin with my children thought that they were the only ones so yeah them knowing that theyre not the only ones there and that theres other people the same as them and they can get on and they can talk to other people and stuff im a young carerbut its ok another important change in perception highlighted by staff professionals and parents was that the projectsby introducing ycs to each otherhelped them to feel that it was ok to be a yc one parent expressed this way but yeah i try and make it more of a positive thing and hes very proud to come he loves coming and hes the first one to show off and say im a young carer and when we get into places well you know hell say im disabled im a carer yeah im a young carer i go to yc project so hes very proud of it he wears it almost like a badge it was suggested by one professional the realisation that it was ok to be a young carer was foundational and important in reassuring ycs that no ones going to take them away projects gave them a licence to be a yc and to feel comfortable about being a carer a greater understanding and confidence about their caring role and what to expect being part of a project helped change the perception that ycs held of their caring roles some described how seeing others in similar circumstances to their own seeing them cope talking with them and learning about their experiences had helped them gain fresh insight and confidence about their specific family circumstances and in their own capabilities to care for family members this is expressed by one yc i think im more confident about my mums disability when i was younger i didnt officially understand it and now i think because there are more people who have shared similar experiences i can understand like and what to expect or how to deal with these problems because theyve experienced the same sort of thing maybe before me so i can see what might be coming which is good another yc highlighted how information and support helped them when i come here i get more support and information of like what to do and how to control stuff what projects have changed for families positive changes for families families also experienced a diverse range of positive changes as a result of project support parents themselves benefitted directly from knowing their child was receiving support they were pleased and reassured that their child was meeting other ycs and having a break from their caring roles and being able to socialise and have fun this is illustrated by one parent one of the biggest changes that have made for me is seeing a smile on my childrens face which means theres a smile on my face projects help to improve family relations and have fun together both ycs and parents credited the projects for improving and stabilising family relations calming their households and keeping or bringing their family closer together parents felt that when their children had respite at the clubs and on trips they became calmer which calms the whole house down and breaks things up so its more manageable one yc stated that the biggest change the service had made to their family was that there were not as many arguments and when asked how else the project helped them and their family one yc replied i dont know theyve just brought us together more yeah brought us together through the projects families simply had opportunities to have fun together as a family unit which as some ycs indicated was often not usually possible due to their family situation access to further support and parents knowing there is support to turn to projects enabled families to access a range of additional support interventionseither directly from projects themselves or from other services facilitated by the projects or indirectly for example from being referred to the early help hub the direct support that parents received from projects also enabled them to move from a place where they had felt alone to knowing that they were not alone and knowing that there was support out there for them if they needed it this was expressed simply by one parent its just knowing that were not alone this assurance of a support network for them and their family and access to someone who they could talk to was highly valued by parents as illustrated its knowing that theyre at the end of the phone so if i am having a bad day theyre always willing to to talk to me things and like theres the facebook page so i can message them privately so you know at some point they can they will respond or signpost me to the right people if if its something out of their remit sort of thing so yeah its been you know valuable all the way through the important features of the yc services for facilitating change a number of different features of the yc projects were identified as being important for helping to bring about the changes these relate to how projects are staffed how they operate and the environment that projects create a how projects are staffed ycs and parents strongly emphasised the significant and positive role played by project staff who were viewed as extremely helpful and supportive to both ycs and parents participants stressed the importance of the character of staff and described them for example as being really nice caring kind and having compassion and loyalty how staff engaged with the ycs was also highlighted as playing an important role as well as their personalities which were described as fun and laid back it was clear that the staff brought a positivity to the groups which encouraged and enthused ycs to take part and enjoy activities one parent stated i just think that theyre an amazing bunch of people and theyre always theyre supportive if i walked in today and say ive got this problem that problem and theyd say right well lets try and sort it can i help and one yc expressed their view of the staff simply as theyre amazing they really are yeah staff understand ycs and families the skills knowledge and experience that staff brought to the role were also clearly valued by ycs and parents but particularly by professionals it was recognised that since projects provided dedicated support for ycs staff had a deep understanding of yc issues their needs and their families needs consequently ycs and parents had confidence in staff and felt comfortable and safe being supported by them one parent put it like this again its someone that knows and they might have been through those things with other people and i havent been there so its always good to have someone with more experience than i have b how projects operate projects are relational another key feature of projects is their relational nature relationships are built not only between the ycs but the project staff also had time to get to know the ycs and families and build positive relationships with them this in turn supports engagement with the projects two parents gave clear examples of this my daughter has anxiety issues and if she didnt have that onetoone relationship with them staff she wouldnt feel comfortable and she wouldnt want to come so which meant that she wouldnt get a break from me i know that theyre being well looked after they staff get to know the children very well so if they can pick up very easily if theres anything wrong i know its confidential as well its just having yeah theyve enabled us to build up trust in them which is quite difficult to gain sometimes consistent support the consistent support that projects provided over a number of years and the consistency of staff was identified as helpful in building the confidence of families and in the ability of projects to help them this also helped enable staff to get to know the young people and build relationships with them furthermore the consistency of support groups throughout the year and especially throughout the school holiday periods was further recognised a diverse range of early intervention and support initiatives participants highlighted the importance of the diverse and unique range of interventions and opportunities offered by projects to meet the diverse needs of ycs as well as their early intervention approach specialist and tailored support finally there was both recognition of the importance of projects providing specialist and tailored support for ycs and how projects targeted the support needs of individuals in responsive way through bespoke activities this ability of at least some of the services to be responsive flexible and to offer bespoke and creative interventions targeted at the needs of individual groups of ycs was summed up by one project manager if they have any particular issues then we can do work on that so selfharming or anything else thats going on focus sort of focus groups we got sexual health to come in to talk to the kids because we had quite a few who were struggling with that so whatever the need is we can tailor it and pretty much do anything… c the environment that projects create the environment created by the projects was clearly another significant factor in facilitating the positive changes facilitated by projects a safe accepting and supportive environment all the ycs and parents staff and professionals agreed that the groups were somewhere safe and supportive for ycs one reason for this was that projects had guidelines in place and group contracts were developed to ensure confidentiality one yc reported that there was never any bullying in their group being with other young people who understand the value of ycs being with others similar situations who understand or know each others background was commonly reported simply knowing that others within the group understand seems to be extremely important for the ycs and helps them to feel comfortable relax make friends and talk to each other about their lives without the fear of being judged as one yc stated the carers themselves because we all doing a caring role being able to relax together and just having a break all in all knowing that we have sort of similar roles its quite nice to know services build trust with ycs and families the trusting atmosphere that the projects engendered was another important factor ycs felt they could open up to others with confidence that what they said would not be discussed outside this is expressed clearly by one yc knowing that everythings confidential knowing that people arent going to judge on you and judge on the situation that youre in with your family similarly the importance of trust built up between the services and families was also commonly recognised a balance of structure and freedom ycs valued the fact that the club activities were not forced on them but were offered as a choice the importance of achieving a balance or combination of structure and free time within the sessions where ycs could talk about issues simply be children and have fun with peers was highlighted by project staff how do the hyca services help facilitate change for ycs in addition to these important key features of yc projects above a small number of factors or key dynamics were found to be particularly significant in helping to bring about the positive changes experienced by ycs talking to others helps ycs as well as being something that has changed for ycs being able to talk to someone outside of the family about issues concerns or things they were struggling with was commonly highlighted as extremely important for the ycs and a key dynamic for facilitating change talking with others encompassed talking with peers talking with staff and talking in structured groups different terms were used by participants to describe the benefits of talking including having emotional support offloading having an outlet sharing and having a listening ear even simply knowing that they can talk if needed was helpful as expressed by one yc its just knowing that you can talk about that if you want to and not having to hesitate and divert around the conversation having mutual support the majority of ycs reported the benefit of mutual support within their projects that they experienced with other young people this was often articulated by ycs as being able to talk to others about problems but it also included supporting each other with revision and gaining ideas that supported them in their own caring role project managers discussed how ycs looked out for and supported each other and the close bonds they formed being a child or young person having fun and having something to look forward to participants highlighted the value of how projects provided ycs with opportunities to have a break from and to forget about their caring role projects enabled ycs to take part in activities and to simply be children or young people and have fun as expressed by one professional by accessing ycs the project they have had opportunity to be a young person undertake all those things that young people do and to just shelve the responsibilities as a carer for some time finally the value of projects enabling ycs to have something to look forward to was emphasised as illustrated by one yc its a bit of a change its something to look forward to something new and exciting usually discussion the main focus of the study was to explore what were the most important changes that the yc services made to ycs and their families and what it is about the services that creates those changes interviews initially also explored the support needs of the ycs and families the needs of ycs and families ycs were found to have the following broad range of needs that fell under four categories emotional support time out and opportunities to relax socialise and make friends support with and understanding of their caring role and knowing they were not alone in being a yc similarly families also have a range of needs although parents tended to focus primarily on their childrens needs for them it was important to know their children were being supported had opportunities to forget about their caring roles and were able to be children the diverse needs or support needs of ycs identified in the study clearly reflect that of previous research aldridge et al for example found that almost all the ycs and families in their study agreed that emotional and social support as well as practical support and information would be of value this range of needs is to be expected since the ycs are not a homogenous groupthey are different ages have different caring roles and different backgrounds and have been caring and accessing support from the projects for varying lengths of time it is also likely as points out that support needs change over time as joseph et al assert that the policy targets for all young people will not be the same the ongoing need for effective and timely needs assessments is therefore evident as well as a support offer that responds to changing needs over time a diverse range of support the services were found to offer a diverse range of support interventions for ycs providing emotional support respite from caring opportunities to meet others in similar situations opportunities to develop new skills and experience new activities and access support in schools services provide support for families through a whole family approach which includes initiating further support through other agencies this diverse interventions approach provides a logical response to the above findings that ycs accessing the projects have a range of needs it also aligns with the propositions of others for multifaceted policy and support responses joseph et al for example posit a model of caring using three concentric circles that relate to differing intensities of caring young people from each of these groups they propose have their own distinctive needs having recognised this they state that policy targets can be more nuanced and responsive to the needs in families they also advocate the analytical framework proposed by purcal et al that categorises yc support services in order to provide a structure for assessing their effectiveness their framework groups the goals of yc support into assisting young people who provide care mitigating the caregiving responsibility and preventing the entrenchment of a young persons caring role the interventions delivered by the projects within this study clearly aim to meet all three of these goals matzka and naglcupal identified two sets of psychosocial resources used by ycs to respond to the care burden again the project interventions in this present study support both these types of resources for example by enabling leisure time and fostering meaningful friendships including promoting cohesion within the nuclear family positive changes from accessing projects a diverse range of positive changes took place for both ycs and families with ycs themselves experiencing positive changes at home at school and in their social life knowing other children with caring responsibilities making friends and having regular groups to attend helped reduce isolation ycs felt more relaxed less stressed and happier they gained understanding new perspectives and were more confident about being a yc and about their family situation families felt better from knowing that the yc services were there to support them if needed as well as from the additional support that is facilitated by the services family relations are improved and parents gain comfort from knowing their children are supported and able to socialise this identification of a diverse range of positive changes for ycs accessing these projects is significant considering these dedicated services are the ycs primary source of support for ycs indeed the value of dedicated yc services has been consistently found in studies dearden becker 2000price jarvis 2017 moreover many of the positive changes reflect the diverse range of needs of ycs and their families which implies that this type of project support is indeed effective key project features a large number of project features were identified that appear to facilitate the positive changes experienced by ycs these included the diverse range of support interventions the specialist nature of the services a safe accepting and supportive environment the significant role played by staff the relational nature of the services the consistency of the support provided by individual services and the early intervention approach what is significant about this finding is the large number of features associated with the projects that appear to be important in enabling their effectiveness and facilitating change several of these features stem from the specialised nature yc projects such as their understanding of yc needs and the skills of staff as well as being able to provide a forum for ycs to meet others in similar situations these features should be recognised in the commissioning and development of services as should the importance of the relational nature of yc projects which previous studies have also identified this holds especially true during times such as experienced in the covid19 pandemic in 2020 key dynamics a small number of factors or key dynamics were found to be particularly important in facilitating change for ycs these were having mutual support talking to others being a child or young person having fun and having something to look forward to again these have previously been found to be important to ycs what is important to recognise here is that there is nothing unusual or exceptional about these dynamics indeed this recognition mirrors the assertion made by that what allows ycs and their families to deal with the challenges they face are basic yet effective human adaptational systems that may be cultivated and promoted with systemic support the fact that these dynamics have been identified in this study as being key for facilitating change for ycs implies that they are not being sufficiently enabled for these young people within other environments such as at home or in school mutual support for example may be enabled at a yc project because of the trust between ycs who understand each other and who feel safe accepted and supportedwhereas in school this may not be the case gough and gulliford recently identified three factors associated with adjustment outcomes for ycs which the findings in the current study resonate with the key dynamic of mutual support in the present study reflects the social support that gough gulliford identified whilst the finding that ycs gain greater understanding and confidence about their caring role echoes their perceived selfefficacy taken together these findings have led to a threetiered conceptual framework that attempts to differentiate between the key features of the yc projects that underpin and enable an environment in which key dynamics are able to bring about positive changes for ycs this framework that focuses solely on facilitating change for ycs holds potential to be used in the evaluation of support services it may well be argued that certain features set out in a particular tier could be placed in another for example young carers being able to talk or young carers just having fun could be viewed as changes in themselvesrather than the dynamic that engenders a change conversely it could be reasoned that young carers gaining new understanding and new perspectives about their caring role eg know they are not alone in being a yc might also be a key dynamic for change and included in tier 2 furthermore it is not proposed that the lists contained within the framework are comprehensive they are however the main changes dynamics and important features of yc services found within the present study projects giving information to ycs or enabling participation are examples of additional features that could also be included conclusion through a range of interventions the yc projects bring about a diverse range of positive changes for ycs and families that reflect their diverse needs that were identified key features of these projects that are important in enabling these changes and key dynamics that facilitate these changes were also identified together these findings are important for understanding the impact and potential that dedicated yc services can make to the lives of ycs and their families a conceptual framework has been developed to contribute an additional perspective to the existing frameworks that categorise yc support interventions and resources used by ycs to improve their outcomes this attempts for the first timeas far as the author is awareto set out and differentiate between the key features of yc projects the key dynamics that engender change and the actual changes experienced by ycs the findings have implications for the development commissioning and evaluation of interventions and services for ycs and families and how service providers promote their support provision the findings also reemphasise the importance of ongoing refinement of assessment tools to identify the varying needs of ycs and families future research should further explore the diverse needs of different yc populations and the different factors that enable services to bring about successful outcomes for ycs publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

in 2016 the childrens commissioner for england reported that the most frequent provision for young carers ycs comes from dedicated yc services this study formed one part of a threeyear evaluation of support for ycs and their families provided by the hampshire ycs alliance hyca a countywide collaboration of ten yc services in the uk it set out to explore the following primary questions a what are the most important changes that the yc services made to ycs and their families b what is it about the services that creates those changes semistructured interviews were carried out in 2017 with ycs aged 917 n 8 their parents n 5 hyca staff n 6 and professionals from other stakeholder organisations n 5 and a thematic analysis was undertaken reflecting previous research that ycs and their families have a broad range of needs findings also reveal how yc services support them through a diverse range of interventions support led to a diverse range of positive changes for ycs and their families a number of service features that facilitate change for ycs as well as key dynamics important in facilitating change were identified these findings have led to a conceptual framework of how yc services facilitate change for ycs and are important for understanding the impact these dedicated services can make to the lives of ycs and how they facilitate change together they have implications for the development and commissioning of interventions for ycs and families and how service providers promote their support provision